5. Pap Smear Flashcards
How has screening affected the incidence of cervical cancer?
Decreased incidence by more than 50% in the past 30 years.
Cervix has what kind of epithelium?
- 1. Columnar
- 2. Stratified nonkeratin squamous epithelia
Where does most cervical cancer occur and what causes it?
- 90% happens at squamocolumnar junction
- 90% caused by HPV
Most cervical cancer is __________ carcinoma.
Squamous cell carcinomas (80%)
Know the RFs for cervical neoplasia and cancer.
- Multiple sexual partners or partner w/ multiple
- Young age @ first intercourse or pregnancy
- Smoking
- HIV/STIs/Organ transplant
- DES exposure
- Infrequent or absent pap screening tests
- High parity
- Lower SES
List the pap smear/cytology screening guidelines.
- Start at 21
- 21-29: cytology (pap smear) alone every 3 years
- 30-65: HPV and cytology every 5 years
- 65 and older: no screening following adequate negative prior screening
- After hysterectomy: no screening
Know the management of a patient with an abnormal pap test.
- Pap smear or colposcopy
Describe the symptoms and PE findings of a patient with cervical cancer.
How does it spread?
-
Symptoms:
- Post-coital bleeding (most common sx)
- watery vaginal bleeding
- intermittent spotting
- Spread by direct invasion and lymphatic spread
As we age, how does the SQJ and TZ change?
Neonate and postmenopausal: located inside; located out at other times
Which strains of HPV cause the majority of cancers?
HPV 16*, 18*, 31, and 45
* = 70% of cervical cancers
What are the pap smear screening guidelines following hysterectomy?
No screening
is cervical cancer hereditary
no
If 40 y/o patient had an HPV status that was unknown on her last pap result when would she need another pap?
3 years when unknown
What can the 2001 Bethesda System tell us about a pap smear?
- Specimen type (conventional or liquid-based)
- Specimen adequacy = satisfactory for eval or unsatisfactory (not enough cells)
-
General categorization: negative/abnormal/other
1. - Organisms
2. - Other non neoplastic findings: inflammation, radiation, IUD
3. - Epithelial cell abnormalities
-
General categorization: negative/abnormal/other
In the 2001 Bethesda System, what does general categorization tell us about the pap smear?
- Negative for intraepithelial lesions or malignancy
- Abnormality of epithelial cell: see interpretation/result for details
- Other: see interpretation/result (endometrial cells in a W older than 40YO)
What are common organisms that Bethsda system can detect?
- Trichomonas
- Fungal organisms consistent w Candida
- 3. Bacterial vaginosis suggested by shift in flora
- Actinomyces bacteria
- HSV
What type of squamous epithelial cell abnormalties can 2001 Bethesda System detect?
-
Atypical squamous cells (ASC-US/ASC-H)
- -US = undetermined significance
- -H: cannot exclude high grade
- LSIL (low grade squamous intraepithelial lesions)
- HSIL (high grade squamous intraepithelial lesions)
- Squamous cell carcinoma
What type of glandular epithelial cell abnormalties can 2001 Bethesda System detect?
- Atypical (endocervical, endometrial (favor neoplastic), glandular (favor neoplastic))
- Adenocarcinoma (endocervical, endometrial, extrauterine, not otherwise specified)
Cervical changes from NL => cervical cancer
- NL
- LSIL
- HSIL
- Cervical cancer
Managment of a women w/ atypical squamous cells of undetermined significance (ASC-US) on cytology
-
Repeat cytology at 1 year
- (-) => back to routine screening
- ASC => + colposcopy
-
Do HPV testing
- (-): repeat cotesting @ years
- (+; managed same as LSIL): coloscopy
What are the guidelines for managment of a women w/ LSIL pap smear?
- LSIL with (-) HPV test
- LSIL with no HPV test
- LSIL with (+) HPV test
What are the guidelines for managment of a women w/ LSIL and (-) HPV test?
- Repeat co-testing at 1 year (preferred), but colposcopy is acceptable
- @ co-testing:
- If cytology and HPV negative => repeat at 3 years
- If ≥ASC or HPV positive => then colposcopy
- @ co-testing:
What are the guidelines for managment of a women w/ LSIL and no HPV test or a (+) HPV test?
Colposcopy
What are the guidelines for managment of a women w/ HSIL?
- Immediate loop electrosurgical excision
- Colposcopy (w/ endocervical assessment)
Gold standard for diagnosis and treatment planning of abnormal pap smear
Colposcopy w/ directed biopsy;
cervix is washed w 3% acetic acid, which dehydrates cell and large nuclei of abnormal cell turns white (acetowhite changes)
To be adequate, what must be seen on coloscopy?
SQJ
What are the abnormalities you are looking for on Colposcopy?
- Acetowhite changes
- Punctuations (tiny blood vessels)
- Mosaicism
- Abnormal blood vessels
- Masses
What is CIN for:
- Acetowhite changes
- Punctuations (tiny blood vessels)
- Mosaicism
- Abnormal blood vessels
- Masses
- Acetowhite changes: CIN 1
- Punctuations (tiny blood vessels/dots): CIN 2, maybe 3
- Mosaicism: BAD; almost always CIN 3
- Abnormal blood vessels
- Masses
What is seen in high grade lesions (CIN 3)?
- LOTS of acetowhite changes
- Mocaicism
What are the 2 main treatment options for abnormal pap smears?
Mark most common
- Ablative (cryotherapy or laser) = destroy cervical tissue
- Excisional (CKC or LEEP) ***
What are the 2 types of exisional procedures?
- CKC = cold knife cone
- LEEP = loop electrode excisional procedure
WHEN are excisional techniques done? (3)
- (+) ECC (endocervical curettage) => perform CKC
- Unsatisfactory colposcopy (NO SCJ)
- Discrepancy between pap and biopsy (High grade pap, but negative colposcopy)
4 risks of with excisional procedures for cervical neoplasia?
- ↑ risk of cervical incompetence causing pregnancy loss in 2nd trimester
- ↑ risk of preterm premature rupture of membranes (PPROM)
- Cervical stenosis
- Operative risks (bleeding, infection)
Median age of diagnosis of cervical cancer
When do precursor lesions precede invasive carcinoma?
- 47 YO
- 10 years before
How is cervical carcinoma staged?
- Clinically by:
- PE
- Radiologic exams –> CXR and skeletal XR’s + intravenous pyelogram
- Cystoscopy
- Sigmoidoscopy
- Liver function studies
How is microinvasive cervical carcinoma managed clinically?
Invasive?
- Cold knife cone or hysterectomy
- Radical hysterectomy w/ LN dissection
Prevention of cervical cancer (4)
- Abstinence/ decrease partners
- Contraception
- Regular exams and pap smears (dec by 40%)
- HPV vaccine
HPV vaccine recommendations
- All M/F 9 to 45 YO
How many injections are in a series of HPV vaccine and what is the recommendation for scheduling?
3 injections:
- 1st dose
- 2nd dose 2 months later
- 3rd dose 6 months from the first (can still be given if interval varies)
In children <15 YO: give 2 doses separated by 6-12 month
If a patient already has an abnormal pap can they receive an HPV vaccine; what about during pregnancy and breast feeding?
- YES: abnormal pap or breastfeeding
- NO: pregnancy
What are the 2 Gardasil vaccines?
- 4 strain (6, 11, 16, 18): protects against 70%
- 9 strain (+ 31, 33, 45, 52, 58)
What drug is NO longer on the market for girls 9-25 and protects against 16 and 18?
Cervarix
List 6 AE’s associated with HPV vaccination?
- Syncope** (most common)
- Dizziness
- HA + fever + nausea
- Injection site rxns (pain, swelling, and redness)
If a patient has a + pap smear (HSIL), but a (-) colopscopy, what do you do?
Exision
If a patient has a unnsatisfactory colposcopy, and the SQJ cannot be be seen. What do we do?
Excisiojn
