#140 Management of Abnormal Cervical Cancer Screening Test Results and Cervical Cancer Precursors Flashcards
Is HPV infection more likely to be transient or permanent?
Transient
Persistence of HPV for how long strongly predicts subsequent risk of CIN3?
1-2 years
Which HPV genotype has the highest carcinogenic potential?
HPV 16
What percentage of cervical cancers are caused by HPV 16 worldwide?
Approximately 55-60%
What is the second most carcinogenic HPV genotype?
HPV 18
What percentage of cervical cancers are caused by HPV 18?
10-15%
What are risk factors known to increase likelihood of HPV persistence?
Cigarette smoking, compromised immune system, HIV infection
At what age range is HPV infection most common?
Teenagers and early 20s
What is the lifetime risk of HPV infection?
80%
In what time frame do young healthy women typically clear HPV infection?
Average of 8 months.
In the young population, does clearing of HPV also lead to spontaneous resolution of cervical neoplasia?
Most of the time
What is CIN1?
Manifestation of acute HPV infection
How is CIN1 managed?
Usually can be managed expectantly
What is the typical time course of progression from CIN 3 to invasive cancer?
Between 8.1 to 12.6 years
What %tage of women with LSIL will have CIN2-3?
28%
Is HPV testing more or less sensitive to cytology testing?
More sensitive. Less specific.
What increases the sensitivity of colposcopy?
Additional biopsies. Increased detection with random biopsies in addition to directed biopsies
What techniques can be used for endocervical sampling during colposcopy?
Sharp curette, vigorous endocervical brushing, or both. Curette followed by brush.
When should endocervical sampling be performed at time of colposcopy?
- Women with ASCUS or LSIL with no lesion on colposcopy, unsatisfactory colposcopy, previous excision or ablation of transformation zone
- Women with ASC-H, HSIL, AGC, or AIS ECC should be considered part of initial colpo exam, unless excision is planned
How frequent do you perform cervical cytology screening?
q3 years
How frequently do you perform cervical cotesting?
q5 years
How long after treatment do women with hx CIN2+ have increased risk of recurrence?
Up to 20 years
At what age do you start cervical cancer screening for general population?
21 years old
What does LSIL represent?
Productive HPV infection, majority transiet and unlikely to progress to cancer. CIN1
What does HSIL represent?
Precancerous lesions. CIN 2 and CIN 3
How do you manage an unsatisfactory cervical cytology test result and no, unknown, or negative HPV?
Repeat cytology in 2-4 months
How do you manage unsatisfactory cervical cytology with positive HPV co-test (>30yo)?
Repeat cytology in 2-4mo or colposcopy
How do you manage two consecutive unsatisfactory cervical cytology test results?
Colposcopy
How do you manage negative cytology test results with absent or insufficient endocervical-transformation zone component (age 21-29)?
Routine screening recommended. HPV testing is unacceptable.
How do you manage negative cytology test results with absent or insufficient endocervical-transformation zone component and no or unknown HPV testing (age >30)?
HPV testing is preferred. Repeat cytology in 3 years if HPV testing not performed.
How do you manage >30yo NILM, HPV neg with absent or insufficient endocervical-transformation zone?
Return to routine screening
How do you manage >30yo NILM, HPV+ with absent or insufficient endocervical-transformation zone?
Repeat cotesting in 1 year is acceptable. Genotyping is acceptable, if HPV 16 or 18, colposcopy is recommended. If 16, 18 negative, repeat cotesting in 12 mo
Do women with insufficient endocervical-transformation zones sampling on pap have an increased risk of having CIN2+?
No
How do you manage a 30+ year old with cytology negative, HPV positive pap smear?
Option 1: HPV genotyping, HR HPV -> colposcopy
Option 2: cotesting 1 year
Next step in pap management:
30+ year old w/ NILM, HPV+ pap, repeat cotesting in 1 year is NILM, HPV neg
Repeat cotesting in 3 years
What pap result on cotesting 12 months after 30+ yo w/ NILM, HPV+ pap would lead you to do colposcopy?
HPV+ with any cytology.
ASCUS or greater
What is the % chance of CIN2+ with normal cytology and single HPV positive result?
2.2 - 6.1% risks
What is the risk of CIN3+ over the next several years in woman with HPV16?
Approaches 10%
What is next step in management: 25+yo ASCUS, HPV negative?
Repeat cotesting in 3 years
What is next step in management: 25yo+ ASCUS, HPV+
Colposcopy
What is next step in management? 25yo+ ASCUS, HPV+ with negative colposcopy
Cotesting at 12 months
What is next step in management? 25yo+ ASCUS, HPV+ > negative colpo > HPV+ at 12mo cotesting
Repeat colposcopy (colposcopy for anything ASCUS or higher or persistent HPV)
What is next step in management? 25yo+ ASCUS, HPV+ > negative colpo > Cotesting ASCUS HPV-
Repeat colposcopy (colposcopy for anything ASCUS or higher or persistent HPV)
What is the next step in management? 25yo+ with ASCUS and no HPV testing?
Repeat cytology at 1 year
What is the next step in management? 25yo+ ASCUS (no HPV testing) > 12mo cytology = ASCUS or higher
Colposcopy
What is the next step in management? 65yo+ (for whom you were planning to discontinue screening) w/ ASCUS results?
Consider abnormal, repeat testing in 12 months, cotesting preferred
What is the next step in management? 25yo+ LSIL, HPV negative?
Option 1: cotesting at 1 year (preferred)
Option 2: colposcopy (acceptable)
What is the next step in management? 25yo+, LSIL, HPV positive
Colposcopy
What is the next step in management? 25yo+ LSIL, HPV negative > repeat cotesting (1 yr) LSIL
Colposcopy. Colposcopy if repeat cotesting ASCUS or greater or HPV+
What is the next step in management? 25yo+ LSIL, HPV negative > repeat cotesting (1 yr) NILM, HPV-
Repeat cotesting in 3 years
What is the next step in management? Postmenopausal LSIL and no HPV testing?
Option 1: obtain HPV testing
Option 2: cytology at 6 and 12 months
Option 3: colposcopy
What is the next step in management? Age 25-29 LSIL, no HPV testing?
Colposcopy
What percentage of women with LSIL have CIN2+ on colposcopy or will develop CIN2+ within the next 2 years?
27.6%
What percentage of patients with LSIL are HPV positive?
77%
How to manage patients 21-24yo with ASCUS?
Option 1: cytology alone at 12 months (preferred)
Option 2: Reflex HPV testing (acceptable)
What is next step in management? 21-24yo with ASCUS, HPV negative?
Repeat cytology in 3 years
What is the risk of cervical cancer in the 21-24yo age group?
1.4/100,000
What is the initial approach for woman 25+yo with ASC-H pap?
Colposcopy. Reflex HPV testing NOT recommended
What is the 5 year invasive cancer risk for a patient with HPV negative ASC-H pap?
2%
What is the initial management of 25yo+ with HSIL pap smear?
Option 1: Immediate LEEP
Option 2: Colposcopy > diagnostic LEEP if inadequate
What percentage of women with HSIL will have CIN2+ on directed biopsy on colposcopy?
60%
What percentage of women with HSIL will have cervical cancer on colposcopy?
2%
What is the 5 year cervical cancer risk for patients (30+yo) with HSIL on pap?
8%
What is the next step in management? HSIL cytology in a woman who has completed child bearing?
Immediate excision of the transformation zone. “see and treat” vs colpo with endocervical assessment
What is the 5-year risk for CIN3+ for woman with HSIL, HPV neg pap?
29%
What is the 5-year risk for invasive cancer for woman with HSIL, HPV neg pap?
7%
Is triage with HPV testing recommended for HSIL cytology?
No, HPV status does not change recommendation
What is the next step in management for 21-24yo with HSIL or ASC-H cytology?
Colposcopy recommended. Immediate treatment (see and treat) is unacceptable
What is the next step in management for 21-24yo w/ HSIL cytology, colposcopy negative or CIN1?
Cytology and colposcopy testing q6 months for up to 24 months. Return to routine if two consecutive negative cytology and colposcopy results Provided that colposcopic exam is adequate and endocervical assessment is negative or CIN1
What is the next step in management in 21-24yo w/ persistent HSIL for 24 months without identification of CIN2+ on colposcopy?
Diagnostic excisional procedure is recommended
What is the next step in management in 21-24yo with persistent HSIL for 1 year with negative colposcopy?
biopsy
What is the next step in management for 21-24yo w/ HSIL cytology and inadequate colposcopy?
Diagnostic excisional procedure
What is the next step in management for 21-24yo w/ HSIL cytology and CIN2+ on endocervical sampling?
Diagnostic excisional procedure
What is initial work up for women with atypical glandular cells on pap cytology?
Colposcopy with endocervical sampling. Add endometrial sampling in 35yo and older. (younger if at risk)
What is the initial work up for women with adenocarcinoma in situ on pap cytology?
Colposcopy with endocervical sampling. Add endometrial sampling if 35yo or older. (younger if at risk)
What is the initial work up for woman with atypical endometrial cells on pap cytology?
Initial eval limited to endocervical and endometrial sampling preferred. Colposcopy acceptable at time of initial sampling. Colposcopy recommended if no endometrial abnormality identified
What is the next step in managment for woman with atypical glandular cells-not otherwise specified on pap with CIN1 or less on colposcopy?
Cotesting at 12mo and 24mo is recommended. If both negative, repeat cotesting in 3 years. Colpo if any test abnomormal
What is the next step in management for woman with atypical glandular cells - favor neoplasia on pap, if no invasive disease on initial colpo?
Diagnostic excisional procedure recommended - CKC for intact margins, endocervical sampling after excision preferred
What is the next step n management for woman with endocervical adenocarcinoma in situ cytology result with no invasive disease on initial colpo?
Diagnostic excisional procedure recommended - CKC for intact margins, endocervical sampling after excision preferred
What is the reporting rate of atypical glandular cells on pap in the US?
0.4%
Is atypical glandular cells on pap typically a reproducible interpretation?
Poorly reproducible
What non cancerous lesions often cause an atypical glandular cells result on pap?
reactive changes, polyps
What concerning etiologies can result with atypical glandular cells on pap?
Squamous dysplasia, adenocarcinoma of cervix, endometrium, ovary, or fallopian tube
What percentage of women with pap result atypical glandular cells have CIN2+?
9-38%
What percentage of women with pap result atypical glandular cells have invasive cancer?
3-17%
Is an atypical glandular cell cytology result more commonly associated with squamous or glandular lesions?
Squamous
How should an asymptomatic premenopausal woman with endometrial cells found with cervical cytology testing be managed?
No further eval for benign endometrial cells, endometrial stromal cells, or histiocytes
How should postmenopausal women with endometrial cells on cervical cytology testing be managed?
Endometrial assessment regardless of symptoms
What are defined as “lesser abnormalities” on pap smears?
HPV 16 or HPV 18 positivity, persistent untyped oncogenic HPV, ASC-US, and LSIL
What is the next step in management for 25yo+ w/ lesser abnormalities on pap with no lesion or bx confirmed CIN 1 on colpo?
Cotesting at 1 year
What is the next step in management for 25yo+ w/ lesser abnormality on pap, neg colpo, then cotesting at 1 year neg?
Age-appropriate retesting 3 years later (cotesting 30yo+)
What is the next step in management for 25yo+ w/ lesser abnormality on pap, CIN1 colpo persistent for 2 years?
Follow-up or treatment (ablative or excisional methods [preferred if colpo inadequate, pos ECC, or previously treated])
What is next step in management of 25+yo w/ ASC-H or HSIL pap and no lesion or CIN1 on colpo?
Option 1: diagnostic excisional procedure
Option 2: Observation with cotesting at 12 and 24 months (as long as colpo adequate and endocervical sampling neg)
What are reasons to not identify CIN2+ lesion in women with ASC-H or HSIL cytology?
Cytologic abnormality may be caused by a vaginal lesion, presence of occult CIN2+ not identified because of insensitivity of colpo, or over reading of a non-high-grade cytology specimen by the cytologist
How can you identify a vaginal lesion? (what solution?)
Both 3-5% acetic acid and Lugol solution
Should women with ASC-H on pap be managed similar to women with HSIL or LSIL on pap?
HSIL
Is pap cytology subjective or objective?
Subjective
Next step in management for woman with HSIL or ASC-H cytology, no lesion or CIN1 colpo, neg cotesting at 12 and 24 mo
Age-appropriate retesting 3 years later (cotesting 30yo+)
Next step in management for woman with HSIL or ASC-H cytology, no lesion or CIN1 colpo, neg cotesting at 12mo, any LSIL at 24mo
Colposcopy
Next step in management for woman with HSIL or ASC-H cytology, no lesion or CIN1 colpo, cotesting at 12mo HSIL
Diagnostic excisional procedure
Next step in management 21-24yo with CIN1 after ASC-US or LSIL pap?
Repeat cytology at 12 months
Next step in management 21-24yo with CIN1 after ASC-US or LSIL pap, cytology at 12mo ASC-H?
Colposcopy
Next step in management 21-24yo with CIN1 after ASC-US or LSIL pap, cytology at 12 months NILM?
Repeat cytology at 12mo. (return to routine screening after two consecutive negative cytology)
Next step in management 21-24yo with CIN1 after ASC-US or LSIL pap, cytology at 12mo NILM, cytology at 24mo ASC-US?
Colposcopy. Colpo for ASC-US or worse.
Recommended management for women with recurrent CIN2+ (25yo+, non pregnant)?
Diagnostic excisional procedure
What percentage of CIN3 regresses if left untreated?
32%
What percentage of CIN3 persisted if left untreated?
56%
What percentage of CIN3 progressed to CIN3+ if left untreated?
14%
What percentage of CIN2 regresses if left untreated in adults? In adolescents?
43% in adults. Up to 65% in adolescents.
What percentage of CIN2 persists if left untreated?
35%
What percent of CIN2 progresses to CIN3+ if left untreated?
22%
Next step in management for “young women” with CIN2 on colpo?
Observation preferred (colpo and cytology q6mo for up to 12 months) Treatment acceptable
Next step in management for “young women” with CIN3 on colpo?
Treatment recommended
How does the ASCCP define “young women” in context of cervical cancer screening/management?
Women who, after counseling by their clinicians consider risk to future pregnancies from treating cervical abnormalities to outweigh the risk of cancer during observation of the abnormalities. No specific age threshold.
Should CIN3 be treated regardless of age or fertility concerns?
Yes, because it is a definite cervical cancer precursor
When are ablative treatments appropriate for treatment of cervical abnormalities?
When invasive cancer is excluded. CANNOT USE ABLATION IF: endocervical assessment with CIN, inadequate colpo, cytology or colpo results suggest cancer, after prior therapy
What is the efficacy of excisional procedures (LEEP, laser conization, CKC) for CIN?
90-95%
When do most treatment failures occur after cervical excisional procedure for CIN?
Within first 2 years after treatment
What must be included in cervical excisional procedures for CIN?
Entire transformation zone must be encompassed
Which cervical abnormalities necessitate careful attention to margins of excision (consider CKC over other options)?
Microinvasive cnacer and adenocarcinoma in situ
What is the management for women with CIN2, CIN2,3 or CIN3 after excisional procedure?
Cotesting at 12 and 24 months
What is the next step in management for women with negative cotesting x 2 after excisional procedure for CIN2, CIN2,3 or CIN3?
Retesting in 3 years
For how long after an excisional procedure for CIN are women at risk for cancer?
Cases of cancer have been found as late as 20 years after initial therapy
After excisional procedure for CIN, is HPV testing more sensitive and/or specific than cytology?
HPV testing is more sensitive, but less specific. May result in earlier diagnosis of persistent or recurrent disease
What is the sensitivity of HPV testing to predict treatment failure after excisional procedure for CIN?
Averaged 94.4%
If CIN2,3 is identified at the margins of an excisional procedure or post-procedure ECC what is the preferred follow up? What is acceptable follow up?
cytology and ECC at 4-6 months is preferred. Repeat excision is acceptable and hysterectomy is acceptable if re-excision is not feasible
What is the recurrence rate of CIN2+ after standard treatment in HIV+ women?
Greater than 50% recurrence rate
How does HIV status and use of antiretrovirals affect managment of CIN2+?
It does not. Use same management.
What is the recommended cervical screening for women who are HIV+?
Annual cytology alone
What is the management for women with adenocarcinoma in situ on diagnostic excisional procedure?
Hysterectomy preferred if completed childbearing
Conservative acceptable if desire future fertility - If margins involved or endocervical with CIN or AIS reexcision preferred; reevaluation at 6mo w/ cotesting and colpo with endocervical sampling
Is adenocarcinoma in situ or CIN2,3 associated with skip lesions?
AIS
What is important for diagnostic excisional procedure for adenocarcinoma in situ?
Intact, deep excision with interpretable margins since AIS frequently extends for a considerable distance into the endocervical canal and has skip lesions
Do negative margins for diagnostic excisional procedure for adenocarcinoma in situ mean lesion is completely excised?
Not necessarily as AIS is multi focal with skip lesions.
What is the risk of persistent adenocarcinoma in situ after deep conization with negative margins?
Up to 10%
If performing hysterectomy for persistent CIN2+, what route is preferred?
Vaginal approach is preferred when feasible (balance safety and patient recovery). Only perform after exclude possibility of invasive cancer.
What part of colposcopy cannot be performed during pregnancy?
endocervical curettage
For which pap cytology that you would perform colpo for, can you defer to the 6wk postpartum visit?
ASC-US and LSIL (although preferred for LSIL is to perform during pregnancy, postpartum is ‘acceptable’)
When would you repeat a colposcopy during pregnancy? At what interval?
Acceptable to do colposcopy and cytology in with w/ CIN2, CIN3, CIN2,3 at intervals no more frequent than q12wks. Repeat bx only if appears worse or cytology suggests invasive cancer
When is a diagnostic excisional procedure recommended during pregnancy?
Suspected invasive disease
Does management of LSIL and HPV-positive ASC-US pap during pregnancy change compared to non pregnant women?
No
Do you treat CIN during pregnancy?
No
What are risks of diagnostic excisional procedure during pregnancy?
Fetal loss, preterm delivery, maternal hemorrhage
For women with CIN2 during pregnancy, what is the risk of microinvasive cancer at the postpartum visit?
Negligible
For women with CIN3 during pregnancy, what is the risk of microinvasive cancer at the postpartum visit?
Substantially less than 10%, deeply invasive types of cancer are rare
