Overview

• Human papillomavirus-related malignancy of the uterine cervical mucosa.
  • Divided into squamous cell carcinoma (80%) and adenocarcinoma (20%).
  • 3rd most common cancer worldwide.
• Human papillomavirus (HPV) is most important risk factor.
  • Main association with HPV 16 and 18.
  • Other Risk Factors → smoking, HIV (hence very high incidence of cervical cancer in Africa), early first intercourse, multiple sexual partners, high parity, lower socioeconomic status, COCP (increases risk of breast + cervical).
  • Transformation zone of cervix most vulnerable.
• CERVICAL SCREENING ⇒
  • 25-49 years old → every 3 years and 50-64 years old → every 5 years.
    • Exceptions → women with HIV are screeened annually.
    • Pregnancy → wait until 12 weeks postpartum for smear. If a smear has been abnormal in the past and a woman becomes pregnant then specialist advice should be sought. If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.
  • Outcomes →
    • Negative HPV Test → returned to routine call.
    • Positive HPV Test → cytological testing.
      • Abnormal Cytology → referred to colposcopy. (Low Grade = refer within 6 weeks. High Grade = refer within 2 weeks.)
      • HPV Positive + Negative Cytology = repeat HPV test in 12 months and again at 24 months if still positive. If still positive at 24 months, refer for colposcopy.
    • Inadequate Cytology → repeat smear in 3 months. (If two consecutive inadequate samples → do colposcopy)
  • Girls and boys 12-13 receive HPV vaccine as part of NHS programme.
• Cervical Intraepithelial Neoplasia (CIN) → precancerous changes to cervical lining (dyskaryiosis of cervical cells). Diagnosed with colposcopy (not screening). Most common in late 20s / early 30s.
  • Diagnosed via colposcopy biopsy.
    • CIN I (Mild - lower 1/3 of epithelium) / CIN II (Moderate - lower 2/3 of epithelium) / CIN III (Severe - full thickness of epithelium).
    • CIN I → observation and follow-up smear in 12 months. CIN II/III → LLETZ (+ test of cure in 6 months).
    • Hysterectomy + CIN → vault smear at 6 months and 18 months.
  • LLETZ (Large Loop Excision of the Transformation Zone) → removal of abnormal cells. Outpatient procedure with LA.
    • Increased risk of midtrimester miscarriage and preterm delivery.
    • Repeat smear in 6 months → test of cure. (Test of cure negative → recall in 3 years, regardless of age. Then go back to normal age routine calls.)

Making Diagnosis

Clinical Features

• Abnormal PV bleeding (intermenstrual / postcoital / postmenopausal) + PV discharge.
• Postcoital bleeding.
• Dyspareunia.
• Patients who have had gynaecological symptoms which could be suggestive of cervical cancer (such as IMB and PCB) should be examined and referred for review at gynaecology clinic.

Investigations

• 1st Line → Colposcopy (procedure to visualise cervix) + Biopsy.
  • Presence of ‘egg-white’ lesions following acetic acid application indicates the presence of an abnormal nuclear:protein ratio within cells. Lugol’s iodine is then used to stain the cervix. The iodine binds to glycogen, resulting in a chemical reaction that turns cells brown. Abnormal cells lack glycogen, and so remain yellow.
• Speculum → changes in appearance that may suggest cervical cancer include ulceration, inflammation, bleeding or visible tumour. This indicates urgent cancer referral for colposcopy.
• LLETZ → using a loop of wire with electrical current (diathermy) to remove abnormal epithelial tissue on the cervix. Used for diagnosis + treatment of CIN.
  • Bleeding and abnormal discharge can occur for several weeks following a LLETZ procedure.
  • Intercourse and tampon use should be avoided after the procedure to reduce the risk of infection.
  • Procedure may increase the risk of preterm labour.
• CT and MRI → staging.