Abnormal paps Flashcards
A visibly anxious 38 year old patient presents for evaluation of abnormal cervical cytology performed 2 weeks ago by her primary clinician. She hands you the results that are consistent with atypical squamous cells of undetermined significance (ASC-US),
Her high risk human papillomavirus (HPV) result is positive.
She states, “I know it means I have cancer. How could this have happened to me?”
The patient undergoes colposcopy, cervical biopsy at 11:00, and endocervical curettage. She tolerates the procedure well.
Biopsy results reveal:
ECC: benign endocervical cells
Cervical biopsy at 11:00: CIN 1
You tell your patient this is not cancer, and the likelihood is that the lesion will be resolved by her own immune system
She expresses her enormous relief and thanks you for your help.
cervical carcinoma
-Cervical carcinoma is the most common cause of cancer deaths in patients in most developing nations
-HPV is the causative agent of cervical carcinoma in virtually all cases
HPV
-all people who have been sexually active have been infected with human papillomavirus
-In about 90% of patients, HPV infections resolve spontaneously
-If HPV infection does not resolve and if the patient is infected with a high oncogenic HPV type, cervical neoplasia may result
-In most cases, neoplasia does not indicate carcinoma
nonavalent HPV vaccine
-Gardasil-9
-Protects against infection from:
-HPV types 16, 18, 31, 33, 45, 52, and 58 that may cause cervical, vulvovaginal, anal, oropharyngeal and other head and neck malignancies
-HPV types 6 and 11 that may cause genital warts
-Can prevent >93% of all cervical cancers and a large number of other HPV anogenital cancers
-CDC reported >80% decline in HPV vaccine-type infections in U.S. girls and women between the ages of 14-19 years (88%) and 20-24 years (81%) within 12 years after the introduction of HPV vaccination protocols in 2006
USPSTF recommendations for cervical cancer screening for average risk pts
rationale for using primary HPV screening alone in pts
HPV DNA testing is more sensitive for testing for cervical carcinoma in situ (detects >90%) than cytology is alone (detects 50-70%)
recommendations for screening for pts who are NOT average risk
-Consider annual screening in patients with:
-Abnormal immune systems
-Organ transplant
-HIV+/AIDS
-On immunosuppressant medication for various conditions
-History of diethylstilbestrol exposure in utero
-Recent h/o abnormal Paps and/or cervical neoplasia
-CIN grade 1 -> CIN 2 -> CIN 3
-bottom pic- normal
-squamous metaplasia is NORMAL
-top pic:
-SIL- results from the pap - cytologic
-low grade (CIN1) vs high grade (CIN2/3)
-CIN1 is like a wart on the cervix VERY low chance of becoming cancer
-CIN- bx- histology
-CIN3 = carcinoma in situ
-2+3 can potentially become cancer
abridged bethesa system
-Addresses adequacy of specimen
-Satisfactory
-Presence or absence of blood, inflammation, or transformation zone
-Unsatisfactory
-Squamous intraepithelial lesion
Abbreviated as SIL
Used to describe cytologic! abnormality
-Cervical intraepithelial neoplasia
Abbreviated as CIN
Used to describe histologic abnormality
-Interpretation
-Negative for intraepithelial lesion or malignancy (NILM)
-Infections
-Cervical cytology can detect:
-T. vaginalis
-Candida spp.
-Shift in flora consistent with bacterial vaginosis
-Reactive changes
-!!However, one should not rely on cervical cytology to screen adequately for these infections
-If you suspect infection, or if cytology suggests an infection, test for it directly
epithelial cell abnormalities: squamous cells
-Atypical squamous cells of undetermined significance (ASC-US)
-!!MC type of abnormal cervical cytology result
-Atypical squamous cells of undetermined significance, cannot exclude high grade squamous intraepithelial lesion (ASC-H)
-A more worrisome, rare result
-Low grade squamous intraepithelial lesion (LSIL)
-Encompasses:
-HPV infection
-mild dysplasia, cervical intraepithelial neoplasia (CIN) grade 1
-High grade squamous intraepithelial lesion (HSIL)
-encompasses:
-moderate dysplasia, CIN 2
-severe dysplasia (carcinoma in situ, CIN III)
-squamous cell carcinoma
epithelial cell abnormalities: glandular cells
-Atypical glandular cells (cervical, endometrial, or not otherwise specified [NOS])
-Atypical glandular cells, favor neoplastic
-Endocervical adenocarcinoma in situ (AIS)
-Adenocarcinoma
-These are rare findings, and have a high interobserver variability
-!!When in doubt, ask your cytologist and pathologist to review slides!
cytology and histology
-In general:
-Histology=cytology:
-LSIL=CIN I
-HSIL=CIN II/III
-Squamous cell CA=squamous cell CA
abnormal cervical cytology
-In these photographs, please note:
-Large nuclei
-Multiple nucleoli
-Mitotic figures
-With LSIL, note perinuclear halos associated with koilocytosis (due to HPV effect) - dont need to know
-Cytology:
-ASC-US
-ASC-H
-LSIL
-HSIL
-adenocarcinoma
management of the abnormal pap smear: colposcopy
-should NOT be menstruating during colposcopy
-Apply 5% acetic acid (household vinegar) to cervix liberally to evaluate for acetowhite lesions that suggest high nucleic activity
-Collect ECC -> except in pregnant pts
-May use Kervorkian curette or histobrush
-Perform punch bx of any visible lesions, ideally at border of lesion and normal tissue (tischler)
-Ensure that you always bx the most suspicious lesion
-In order to be an adequate exam, one must visualize:
-The entire transformation zone
-The upper extent of the lesion
colposcopic appearance of CIN1
-Features of CIN 1:
-Sharply demarcated lesion
-Almost translucent gray to white lesion
-Appears flat
-No vascular changes noted
colposcopic appearance of CIN2
-Features of CIN II (seen at 11-2:00 and at 5-8:00 at R):
-Lesion is not as sharply demarcated as in CIN I
-Appears dull, oyster gray to yellow
-Appears “heaped up”, not flat
-Friability
-May have vascular changes- Mosaicism is noted here
colposcopic appearance of CIN3/carcinoma in situ
-Features of CIN III/CIS:
-Thickened, white to yellow lesion
-Punctation noted (seeing vessels end on)
-Mosaicism noted
-Friability
invasive squamous cell CA
-Features of invasive SCC:
-Fungating lesion that may replace cervix
-Friability
-Vascular changes
principles regarding current management of abnormal cervical cancer screening results (dont need to know)
-Recommendations are based on risk! of existing carcinoma in situ (CIS, CIN 3, adenocarcinoma in situ) at the time of evaluation !rather than the specific result itself!
-The risk has been calculated by algorithms developed for every potential abnormality by the American Society for Colposcopy and Cervical Pathology (ASCCP)
-The following slides reflect what one finds when one consults a source
-Free download available at https://app.asccp.org/
-Or else download the ASCCP app for smartphones at https://app.asccp.org/
example of management of pt with ASC-US cervical cytology and +HR HPV co-testing results (dont memorize)
techniques used in management of cervical ds
-cryotherapy
-loop electrosurgical excision procedures (LEEP)
-cold knife conization of the cervix (cone bx)
cryotherapy of cervix
-Uses liquid nitrogen or carbon dioxide to freeze cervix and then thaw it
-May employ single or double freeze technique
-Either will destroy neoplastic tissue
-May result in profuse, watery vaginal discharge x 4-6 weeks
-Not generally used for CIN 2 or CIN 3
loop electrosurgical excision procedure (LEEP)
-Uses electrical current to cut and coagulate simultaneously
-Allows operator to remove cervical neoplasia
-May cause heavy vaginal bleeding
-May also rarely result in infection
-Possible increased risk of cervical insufficiency
-An appropriate, commonly used treatment for CIN 2 or CIN 3
conization of cervix
management of CIN1
-no tx needed intially
-risk of progression to cancer is <0.5%
-f/u for 2 years:
-If persistent for at least 2 years, consider f/u or tx
-Could include
-Cryotherapy
-LEEP
-Conization
management of CIN2 and 3
-excisional procedures:
-LEEP
-cold knife conization
management of adenocarcinoma in situ or adenocarcinoma
-no invasive ds - conization of cervix
-invasive ds- hysterectomy
which of the following is best tx option for cervical intraepithelial neoplasia grade 3
-cryotherapy
-vaginal hysterectomy
-loop electrosurgical excision procedure
-application of 85% tricholroacetic acid
