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Boards - Cervical Cancer
OBGYN Qualifying Exam
152
Other
Post-Graduate
02/23/2020

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Cards

Term
what percent of women have never had cervical cytology
Definition
50%
Term
what percent of women have not had cervical cancer screening in >5y
Definition
10%
Term
HPV is associated with cancers where and the incidence
Definition
vulva 50%
vaginal 50%
penile 40%
anal 90%
oropharyngeal 25%
Term
what percent of HPV are in the vaccine
Definition
87%
Term
what percent of women will get HPV within 2y of coitarchie
Definition
75%
Term
what type of virus is HPV
Definition
papovavirade family DS DNA
Term
what does HPV target
Definition
E6 - inhibits p53 (involved in apoptosis)
E7 - binds Rb (release E2F TF which causes cell proliferation)
Term
HPV 16/18 are associated with what percent of HPV cancers
Definition
70% overall
16 - 60%
18 - 10%
Term
what are the #3 and #4 HPV that cause cancers and what percent
Definition
together 33+39 cause 4%
Term
what HPV cause 90% of condylomas
Definition
6 and 11
Term
what HPV cause verruca pantaris
Definition
1, 2, 4
Term
what HPV cause verruca vulgaris
Definition
2, 4, 29, 38
Term
what HPV cause verruca plana
Definition
1, 20, 28
Term
when <21yo on average how long does it take to clear HPV
Definition
8mo
Term
what percent of HPV clear in 1 and 2y
Definition
1 - 70%
2 - 90%
Term
what is the risk of cancer in CIN3
Definition
30% in 30y
Term
what is the average time of CIN3 to cancer
Definition
10y
Term
what percent of ASCUS will have CIN3 and cancer
Definition
CIN3 - 10%
cancer 0.2%
Term
what percent of ASCH will have CIN 2-3
Definition
40%
Term
what percent of LSIL have high risk HPV subtypes on testing
Definition
80%
Term
what percent of LSIL have CIN2-3
Definition
15%
Term
what percent of LSIL will regress
Definition
80%
Term
what percent of LSIL will progress to cancer
Definition
0.3% in 2y, 1.6% in 5y
Term
what percent of HSIL will have CIN2-3
Definition
60% on copo, 90% on LEEP
Term
risk factors for HPV infection
Definition
smoking, immune compormise, HIV, AA, hispanic, alcohol, more partners, early coitarchie, SLE, low SES, high parity, long term OCPs
Term
what type of cervical cancer do long term OCPs increase the risk of
Definition
adenocarcinoma
Term
why do we cotest at >30yo
Definition
<30yo detects too much transient HPV causing non-indicated procedures

better at detecting CIN 2 and cancer
Term
how should you biopsy on colpo
Definition
directed or 4 quad - 4 quad detects 25% of missed CIN
Term
how does acetic acid show HPV
Definition
desiccant reducing cytoplasm to enhance prominent nuclei causing acetowhite change
Term
how does lugols show HPV
Definition
stains glucogen which is lower in HPV causing non-stained areas
Term
signs of HPV on colpo
Definition
mosacism, punctation, vascular changes on green filter
Term
sings of CIN 1 on colpo
Definition
acetyl white plaques, clear demacration, fine punctations, better seen with acetic acid
Term
signs of CIN 2-3 on colpo
Definition
dull white plaques, cobblestoning, coarse punctations, atypical vessles, mosacism
Term
indications for ECC
Definition
no lesion on colpo, unsat colpo, prior ablation of TZ, lesion at TZ, ASCH, HSIL, ACG, AIS
Term
screening schedule
Definition
<21yo no screening
21-29yo cytology q3y
>30yo cotesting q5y or cytology q3y
>65yo no screening
Term
criteria to DC paps
Definition
>65yo and no history of CIN2+ for 20y and adequate screening (2 pap with cotest, 3 pap cytology alone one being in last 5y)
Term
why are there false positive paps after 65yo
Definition
epithelial atrophy
Term
screening pap schedule post hysterectomy
Definition
DC if no CIN2+ for 20y and adequate screening (2 cotest or 3 cytology one being in last 5y)
Term
what is the risk of abnormal cuff cytology in someone who had CIN3 before hysterectomy
Definition
14%
Term
how does CIN 2 correlate with HSIL/LSIL
Definition
p16 negative - LSIL
p16 positive - HSIL
Term
what are the requirements for laser or cryo cervical ablation
Definition
exclusion of invasive cancer, has never had treatments before, negative ECC, adequate colposcopy
Term
what cervix treatment has lowest and highest risk of PTD
Definition
laser - lowest
LEEP - 1.5x risk, 4.5%
CKC - 2.5x risk, 7.5%
Term
what is the recurrence after LEEP, laser, CKC
Definition
leep = 13%
laser = 13#
CKC = 19%
Term
how deep does cervix laser ablation go
Definition
5-7mm
Term
other than PTD, what other pregnancy issues is cervical excision/ablation associated with - 3
Definition
low birth rate, c-section, cervical stenosis 3%
Term
what do you do if someone has positive margins on LEEP
Definition
screeneing per protocol
Term
what are the indications for a CKC
Definition
microinvasive disease, preference, AIS
Term
after hyst what percent will continue to have abnormal cytology if had pre-cancer lesion
Definition
15%
Term
how does the HPV vaccine work
Definition
virus like particles in saccharomyces cervisiae, L1 proteins self assemble into virus like particles
Term
what is in the bivailent HPV vaccine, what is the cIN and cancer protection rate
Definition
16, 18
CIN nearly 100%
cancer 30%
Term
what is in the quadrivalent HPV vaccine, waht is the CIN and cancer protection rate
Definition
16, 18, 6, 11
cancer 30%
CIN nearly 100%
Term
what is in the 9 vailent HPV vaccine what is the cancer and CIN reduction rate
Definition
16, 18, 6, 11, +5 more
cancer 50%
CIN nearly 100%
Term
who should get the HPV vaccine
Definition
9-26yo males and females (generally 11-12yo), >26yo off label but can be indicated
Term
who should get the two dose HPV vaccine and who the three dose
Definition
two dose - <15yo, interval between doses <5mo

three dose - all with immune suppression, everyone else, <15yo with >5mo break
Term
what should you do if someone misses a HPV vaccine dose
Definition
pick up where you left off
Term
contraindications to HPV vaccine
Definition
allergy to yeast, current pregnancy, safe in breast feeding, moderate to severe current febrile illness wait until after
Term
side effects of HPV vaccine
Definition
pain 83%, swelling 25%, erythema 24%, pruritis 3%, fever 10%, nausea 4%, dizziness 2%
*placebo had same SE but approx 10% less for each, half the rate of the ones <10% initially
Term
what is the benifit of giving the HPV vaccine to patients who are already HPV positive
Definition
about 45% effective but can decrease progression
Term
how much more effective is the 9 vailent HPV vaccine then the others
Definition
96%
Term
what strains are not covered unless your get the 9 vailent HPV vaccine
Definition
52, 58 - not covered in direct or cross protection
they dont directly cover other types but do cross cover
Term
HPV vaccine prevents ___% anogenital warts
Definition
nearly 100%
Term
what should you do with an unsat pap cytology, what if it is unsat HPV positive
Definition
repeat in 2-4mo, if it happens again colpo

if HPV positve and <30yo routine screening

if HPV positive and >30yo colpo if recurs twice or if 16/18 positive
Term
what should you do if pap cytology returns not unsat, but insufficient/absent tZ, what if it is HPV positive
Definition
routine screening

if HPV pos and <30yo routine screening

if HPV pos and >30yo colpo if 16/18 pos, cotest in 1y otherwise
Term
histology of AIS
Definition
skip lesions, precursor for adenocarcinoma
Term
management of AIS - non-fertility sparing
Definition
cone to rule out other pathologies, extrafascial hyst regardless of margins
Term
management of AIS - fertility sparing
Definition
cone neg margins neg ECC - colposcopy and cotesting q12mo

cone pos margins pos ECC - reexcision then cplpo and cotest q12mo
Term
recurrence rates AIS
Definition
10% negative margins after cone
60% positive margins after cone
Term
rate of residual disease after cone in AIS
Definition
negative margins 30%
positive margins 60%
Term
what are atypical glandular cells of the cervix associated with
Definition
reactive changes
polyps
squamous dysplasia
adenocarcinoma of the cervix
adenocarcinoma of the endometrium, ovaries, tubes
Term
when someone has atypical glandular cells on pap what percent have CIN2+ and cancer
Definition
15% cancer
30% CIN2+
Term
what is the cause of atypical glandular cells (not the associated conditions)
Definition
HPV 18 usually
Term
what do you do when you get atypical glandular cells on a pap now
Definition
colposcopy WITH ECC
EMBx if >35yo or risk factors
HPV testing not indicated does not change management
Term
what do you do when you get a pap with benign glandular changes
Definition
pre-menopause - nothing
post-menoause - EMBx
post-hyst - nothing
Term
what do you do when you get a pap with normal endometrial cells
Definition
pre-menopause - nothing
post-menopause - EMBx
post-hyst - nothing
Term
after you do an excision or ablation of the cervix what is the follow up
Definition
cotesting in 12 and 24mo then at 3y

if had positive margins do ECC at 4-6mo in addition
Term
who are considered high risk patients when it comes to cervical cancer screening
Definition
HIV, immune compormised, DES exposure in utero, history of CIN2+, history of cervical cancer
Term
cervical screening if history of DES exposure in utero
Definition
yearly cytology
Term
cervical cancer screening for high risk patients
Definition
cytology within 1y of sexual activity or 1y of diagnosis of risk factor

do not discontinue at 65yo

anal cytology at same time
Term
HIV cervical cancer screening
Definition
<30yo - cytology yearly until 2 consecutive negative then cytology q3y

>30yo - cytology or cotesting, annual until 3 consecutive negative then q3y regardless of method

history of CIN 2-3: annual cotesting x2 then annual cytology
Term
when should someone with HIV get anal cytology
Definition
CD4 <200, history of STI other than HPV, current abnormal cervical cytology
Term
how is management of abnormal pap results different in HIV
Definition
LSIL - directly to colposcopy
ASCUS >21yo - directly to colposcopy
ASCUS <21yo - cytology in 6mo
CIN 2+ - directly to excision or ablation
Term
what percent of pregnancies have cervical dysplasia
Definition
5%
Term
what if you need to colpo during pregnancy
Definition
you can wait until 6wk pp for ASCUS but its fine in pregnancy as long as no ECC, need to do if > ASCUS

limit biopsies to suspicious lesions only

if CIN2+ do colposcopy q12wk or defer to PP, repeat biopsy only if worsened lesion
Term
what are the criteria for expedited cryotherapy of the cervix in low resource settings
Definition
>75% of the cervix is positive on colpo, TZ is completely visualized, and there is no extension into the canal
Term
what is the success rate for early cryotherapy of the cervix in low resource settings
Definition
80% success for CIN3 over 3y monitoring
Term
what are the types of cervical cancer and the incidence
Definition
squamous cell 80%
adenocarcinoma 25%
adenosquamous
neuroendocrine 1-2%
Term
what are the typs of squamous cell cervix cancer
Definition
squamous cell carcinoma 70% of all cervix cancers
large cell keratinizing
large cell non-keratinizing
Term
what are the types of adenocarcinomoa of the cervix
Definition
adenocarcinoma
mucinous - common
endometroid - rare
clear cell - DES
Term
what are the types of adenosquamous cancer of the cervix
Definition
malignant glandular
malignant squamous
Term
what the neuroendocrine carcinomas of the cervix
Definition
small cell - most common neuroendocrine
large cell
typical carcinoid
atypical carcinoid
Term
signs of cervical cancer
Definition
bleeding, post coital spotting, AUB, PMP bleeding asymptoamtic, foul smelling yellowish discharge, back pain, lethargy, nausea, vomiting, fistula, leg swelling, renal failure
Term
how is cervix cancer stage 1 broken up
Definition
1A1 - confined to cervix <3mm depth
1A2 - confined to cervix 3-5mm depth
1B1 - >5mm depth, <2cm dimension
1B2 - >5mm depth, <4cm dimension
1B3 - >4cm dimension
Term
how is cervical cancer stage 2 broken up
Definition
2A1 - upper 2/3 vagina, <4cm
2A2 - upper 2/3 vagina, >4cm
2B - parametrial involvement
Term
how is cervical cancer stage 3 broken up
Definition
3A - lower 1/3 vagina
3B - pelvic wall, hydronephrosis
3C1 - pelvic nodes
3C2 - paraaortic nodes
Term
how is cervical cancer stage 4 broken up
Definition
4A- pelvic organs
4B - distant organs
Term
what stages of cervix cancer can undergo fertility sparing management
Definition
1A1 - 1B2
Term
what stages of cervical cancer require cone vs trachelectomy for fertility sparing management
Definition
1A1 - cone
1A2 - either
1B1 - 1B2 - trachelecotmy
Term
what stages of cervical cancer are best treated with extrafascial hysterectomy
Definition
1A1
Term
what stages of cervical cancer are best treated with radical hysterectomy
Definition
1A1 with LVSI
1A2
1B1
1B2
NOT 1B3
2A1
Term
what stages of cervical cancer are best trreated with ERBT and cisplatin rather than hysterectomy
Definition
1B3
NOT 2A1
2A2 and up
Term
if someone is a poor surgical candidate and they have cervical cancer what do you do
Definition
ERBT and brachytherapy +/- cisplatin
Term
what is the survival rate of stage 1A cervical cancer
Definition
95%
Term
what is the survival of stage 1B cervical cancer
Definition
80%
Term
what is the survival of stage 2 cervical cancer
Definition
60%
Term
what is the survival of stage 3 and 4 cervical cancer
Definition
3 - 40%
4 - 15%
Term
when should you consider primary chemo rads rather than hyst for cervical cancer (characteristics not stage)
Definition
>4cm, positive nodes, positive margins, parametrial extension, stage IIB+
Term
what are the citeria for fertility sparing management in cervical cancer
Definition
<40yo
<2cm lesion
no upper endocervix extension
stage 1A with LVSI or 1A2 or 1B1
no evidence of nodal mets
Term
what is the recurrence date of cervical cancer after trachelectomy
Definition
4%
Term
what is the risk of fetal loss after trachelectomy
Definition
10% 2T loss
Term
what are peters criteria
Definition
positive nodes, margins, parametria -> chemo rads after surgery
Term
what are sedlis criteria
Definition
evaluates stromal invasion, tumor size, LVSI to determine if chemo rads after surgery
Term
what is the risk of nodal mets in 1A1 cervix cancer
Definition
0.1%
Term
what is the risk of nodal mets in 1A2 cervix cancer
Definition
2-8%
Term
what is the best way to look at nodes in cervix cancer
Definition
PET scan
Term
how does LVSI and microinvasive perdict nodal meds in cervix cancer
Definition
microinvasion not associated unless LVSI, LND is not required for microinvasion
Term
what are the 1st nodes involved in cervix cancer
Definition
obturator
Term
what is a modified radical hysterectomy
Definition
1-2cm vagina, 1-2cm parametria, 1-2cm rectouterine
Term
what is a radical hysterectomy
Definition
1/3 vagina, parametria to internal iliacs, rectouterine 2cm
Term
what is a simple trachelectomy
Definition
leave 5mm cervix for cerclage, resect parametria to cervix border, divide rectouterine at cervix border
Term
what is a radical trachelectomy
Definition
leave 5mm of cervix for cerclage, resect 1-2cm vagina, unroof urethra from cervix, resect parametria to ureter, resect 1-2cm rectouteirne
Term
what are the risks and incidence of them for radical hysterectomy
Definition
bladder dysfunction 10%, ureter injury <2%, bladder injury <1%, fistula <1%, PE, blood transfusion
Term
what are the risks of pelvix exenteration
Definition
5% mortality
40% complication - hemorrhage, infection, abscess, SBO, fistula
high EBL 1-3L
Term
poor prognostic factors associated with pelvic exenteration
Definition
chemo within last 2y, positive paraaortic nodes, smokers, >70yo, primary site of disease, time to recurrence
Term
benifit of chemo in cervical cancer
Definition
30-50% decreased risk of death
Term
benifit of bevacizumab in cervical cancer
Definition
4mo survival advantage, higher response rate to chemo
Term
response rate to cisplatin in cervix cancer
Definition
30%
Term
borders for radiation in cervix cancer
Definition
16x16cm
L4-5
1cm lateral to bony pelvis
obturator foramen
covers internal and external iliac nodes
Term
surveillance in fertility sparing cervical cancer patients
Definition
stage 1- imaging based on symptoms, 1B3 and had adjuvant chemo rads then PET q3-6mo

stage 2+ - PET and MRI 3-6mo after therapy
Term
contraindications to fertility sparing treatment, other than staging, for cervix cancer
Definition
neuroendocrine tumors, gastric type adenocarcinoma, adenoma maligum
Term
how is invasive cancer treated in pregnancy if desires to keep pregnancy
Definition
can do CKC
chemo is ok
radical trachelectomy can be done - only a few cases
can have SVD if no visible tumor

1B1 - rad hyst at time of lung maturity or CKC

1B2-2 - CD after lung maturity then chemo/rads

2B-4A - CD after lung maturity, chemo during pregnancy

4B - pallative systemic chemo
Term
how is invasive cancer treated in pregnancy if desires to terminate pregnancy
Definition
<24wk 1B-2A - rad hyst and nodes with fetus in situ

<24wk 2B-4A - pelvic ERBT and chemo
Term
surveillence after survical cancer
Definition
q3-6mo for 2y, q6-12mo for 3-5y then annual visits

cytology annually

imaging based on symptoms, PET best, some say annual CXR
Term
risks for rrecurrence of cervical cancer
Definition
stromal invasion >15mm
LVSI
tumor >4cm
Term
when do cervical cancers recur
Definition
usually within 2-3y
Term
where do cervical cancers recur
Definition
local - vaginal apex
regional - pelvic sidewall
distant - #1 nodes
Term
management of small cell cervix cancer
Definition
rad hyst with LND if early stage
cistplatin etoposide if 1B+
Term
poor prognostic signs in small cell cervix vancer
Definition
early hematogenous dissemination
LVSI and nodal mets
large tumor
advanced stage
pure small cell histology
Term
what percent of small cell cervix cancer will have nodal mets
Definition
60%
Term
5y survival small cell cervix cancer
Definition
11-50%, 30% if limited to pelvis
Term
#1 cancer in pregnancy
Definition
cervical
Term
#1 GYN cancer in the world
Definition
cervical
Term
what do you do if not meeting criteria for expedited cryo in a low resource setting
Definition
LEEP/cone
Term
how much is cervical cancer decreased by expedited cryo in low resource settings
Definition
50%
Term
ASCUS to HSIL - risk of CIN2+
Definition
ASCUS- 0.04, NILM- 0.08, NILM+ 2.6, ASCUS+ 7, NILM++ 10, LSIL 28, ASCH 40, HSIL 60
Term
what is the screening schedule for DES exposure
Definition
yearly cytology starting at 21yo
Term
what is the screening schedule for someone who had CIN2+ before
Definition
cytology q3y
Term
what is the screening schedule for HIV <30yo - no abnormal history
Definition
yearly cytology x3y then cytology q3y
Term
what is the screening schedule for HIV >30yo - no abnormal history
Definition
yearly contesting x3y then contesting q3y
Term
what is the screening schedule for HIV with history of CIN2+
Definition
contesting x2y then cytology yearly
Term
indications for anal cytology - 5
Definition
CD4 <200, HIV with STI, abnormal cervix cytology (esp high grade), hx of vulvar/cervical cancer, other immune compormise
Term
cervix treatments from lowest to highest risk of PTD
Definition
laser < cryo < LEEP < CKC
Term
indications for ECC
Definition
no visible lesions, prior cryo/LEEP, cant see TZ, lesion at TZ, ASCH, HSIL, AIS, AGS
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