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Gynecology [CERVICAL CANCER]

Intro and Etiology


Reproductive Aged
Cervical cancer is caused by the Human Papilloma Virus. Its
carried in asymptomatic males and infects a woman during sex.
While not all cervical cancer is HPV related, for our purposes its 11 Menses + Sex 51 Virus stays with her,
ok to assume it is. Therefore, it occurs in sexually active females. risk never ends
HPV causes an infection of the cervical mucosa, transforming the
cells of the cervix through inflammation. The cells with a nucleus
are located at the basement membrane; this is where cells will be
first transformed (CIN I). As cancerous cells grow and fill the
epithelial layer (Carcinoma In-Situ) they eventually penetrate
the basement membrane and become full blown cancer. HPV
causes cancer (subtypes 16, 18, 30s, 45) and genital warts
(subtypes 6, 11). Risk factors are number of sexual partners, HPV, Endocervical
smoking, and history of STDs. Carcinoma
CIN I CIN III Ectocervical
Symptoms and Patient Presentation
Dysplasia Carcinoma In situ Carcinoma
Asymptomatic screening is the preferred method of diagnosis.
Screening is with Pap Smears (start 21, stop 65). In any patient 16,18,45
HPV
Dysplasia/CIS
Squamous Cell
who has post-coital bleeding, consider cervical cancer. Do a
pelvic and stage staging is clinical, not by imaging. In a post- h/o sex partners pap smear q1y surgery or
menopausal woman, its likely secondary to vaginal atrophy. That other STDs, HPV chemo
said, all women who bleed after sex deserve a pelvic (and soon.) smoking
(LSIL) (HSIL) (Cancer)
Diagnosis and Treatment
If a mass is identified on exam the diagnosis is made by biopsy
of that mass. The patient must then be staged. Cervical cancer is Stage IV
the only cancer that is clinically staged rather than surgically a- Bowel/Bladder
b- Distant Mets
colpo, rectal, vaginal exams. The further down the vagina the Ia: Microscopic
higher the grade. B classification denotes involvement of the Ib: Macroscopic
cardinal ligament or the pelvic sidewall. Involvement of the IIa: 2/3 vagina
bowel, bladder, or distant mets makes it stage 4. In addition to the Stage I IIb: Parametrial
physical a CT scan can be used to stage. Cancers that are IIa or IIIa: 1/3 vagina
better are cured surgically. Cancers that are IIb or worse are III b IIb
IIIb: Sidewall
treated with debulking and chemo. Stage II a IVa: Adj Organs
IVb: distant mets
Screening

Stage III a
The most high-yield topic for cervical cancer is screening. A
woman should receive a pap annually starting at 21 years old
(regardless of when she began having sex). If theres ever an
abnormal pap (other than ASCUS) do a reflexive colposcopy.
From the colpo we get a sampling of two things: ectocervical
biopsy and endocervical curettage. If Ecto and Endo the Asx Screen
problem is on the outside of the cervix and a local destruction
can be done: LEEP, Cryo or laser. If the Ecto and the Endo
or couldnt be sampled, it must be assumed its in the endocervix; ASCUS Anything but ASCUS or
Pap Smear a normal pap
a cone biopsy is required. Both local destruction and cone biopsy
are curative. If the original pap showed ASCUS, dont do a colpo.
Either repeat the pap q3month to watch for resolution or do an
HPV DNA to confirm its high risk HPV. If the patient is ASCUS Abnormal
pregnant a colpo or cone biopsy may harm the pregnancy - it can
be deferred until after delivery (preferred 6 weeks postpartum).
Remember, it takes 3-7 years to develop cancer from precancer, Colpo
so 9 months of pregnancy wont make a huge difference.
Repeat at 6 HPV DNA
months
Prevention
Everyone (including males) should get the HPV vaccine. A hard ASCUS and HPV + Colpo
yes is recommended for females 13-26 + males 12-21. Some say ASCUS and HPV - q3y Ectocervix Endocervix
as early as 9 (for boys and girls) and as late as 26 (for men). The ASCUS and + repeatColpo Only + Ecto
CDC recs starting @ 11; the key is before theyre sexually active. ASCUS and repeat q3y
Local Cone
Destruction
(LEEP, Cryo)


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