Abnormal CST results

Question 1

“24F presents following a positive CST showing CINII and HPV.A 35-year-old woman has an abnormal Pap smear result. Discuss management.

GP case: A 35-year-old has abnormal Pap smear. Her previous Pap smears have been unremarkable. She is concerned. Discuss.”

Answer 1

Impression
Postive CST result in concerned younger female patient of reproductive age.

Current test is 5-yearly PCR for HPV viral DNA, with reflex cytology or colposcopy if oncogenic strains (16, 18) are detected. New terminology categorises either high grade squamous intraepithelial lesions (HSIL) which encompasses CIN2 and 3 lesions, or low-grade (LSIL) encompassing CIN1 lesions.

Would want to establish if any clinical signs/symptoms of cervical cancer or other gynaecological pathology with thorough H/E/I, counsel woman about findings and management options available, initiate appropriate management pathway.

Question 2

Abnormal CST - History

Answer 2

History
Ask about red flags for cervical cancer:
- sx: PV bleeding, intermesntrual bleeding, vaginal discharge, dyspareunia, dysmenorrhoea, fevers, weight loss, night sweats. HPV infection history
- obstetric history (multiple pregnancies is risk factor)
- PMHx: Gardasil injections, previous STI’s
- Sexual history
- SNAP

Question 3

Abnormal CST - Examination

Answer 3

Examination

• general observation + vital signs
• pelvic examination: adnexal masses, cervical bleeding, tenderness (not recommended for screening, only if suspicious based on hx)
• lymph nodes assessment: inguinal (for mets)

Question 4

Abnormal CST - Investigations

Answer 4

Investigations
- key/diagnostic: HPV PCR test +/- reflex cytology depending on results, colposcopy +/- biopsy (cone), LLETZ

other:

• cystoscopy (bladder extension, staging)
• Imaging: PTE, MRI, CT CAP - staging

otherwise:
- opportunistic STI screening

Question 5

Abnormal CST - Management

Answer 5

Management
Patient education and counselling
- first gauge patient’s understanding of the test and what the result signifies
- Explain how the test works
- emphasise that abnormal result does not mean cancer: HPV is common sexually transmitted infection, 80% will have it at some point in their lifetime, most people clear it in 1-2 years
- Explain further investigational modalities (will depend on course of management depending on actual test result)
o repeat CST on speculum examination
o colposcopy: visualisation of cervix and staining for abnormal cells. explain the full procedure, biopsy of any abnormal areas.
o biopsy: punch, cone, LLETZ - are diagnostic +/- therapeutic, may or may not be indicated

Specific management depends on CST results;

• if HPV 16/18 positive, then straight to colposcopy
• if positive for other HPV types, then reflex cytology is performed on CST sample
• HSIL goes for colposcopy, otherwise goes for repeat screening in 12 months time