Approach To Abnormal Pap Smears And Neoplasia Flashcards
Performing a Pap test
1) patient lies supine on the exam table in the normal position
- also ask the patient to do an exam
2) place speculum in to support walls and visualize the cervix and upper vagina
3) insert collection device and rotate 180 degrees in the same direct for 7 rotations
4) place exfoliated cells in liquid preservative
ACOG screening guidelines for pap smears
Less than 21 = DONT SCREEN
- **exception = HIV patients
Age 21-29 = cytology alone every 3 years
Age 30-65 = cytology + HPV co-testing every 5 years or cytology alone every 3 years
Age 65 and older:
- if normal in prior screens = DONT DO
- if abnormal in prior screens (CIN2/3, AIS, HSIL) = continue routine screening for at least 20 yrs after treatment or regression of the dysplasia
Women with total hysterectomy
- if normal prior screens = DONT DO
- if diagnosed with CIN2/3 before or cervical cancer before = continue routine screening for the next 20 years after treatment (do cytology alone on the proximal fornix of the vagina)
HIV patients
- <21 and sexually active = screen within 1 year of sexual activity and being routine afterwards
- if 21 -30 = cytology at baseline diagnosis and every year for 3 consecutive years. If negative all 3 times = F/U every 3 years. If abnormal = continue yearly
- 30 and up = same cytology alone as 21-30 but can also do contesting
- if co testing = baseline test for cytology and HPV. If negative = F/U every 3 years, if positive for for one or the other = contest in 1 yr and if this is positive = colposcopy is required*
Co-testing screening guidelines with > 30 yrs old HIV+ patients for pap smears
Obtain a baseline co-testing forHPV and cytology
- if both are negative = continue every 3 years
- if cytology is negative but HPV is positive = continue co-test yearly
- if 1 year F/U cytology is abnormal or HPV + = colposcopy required
Histology terminology
LSIL = CIN1
HSIL = CIN2/3
- *CIN2 can technically be HSIL or LSIL based on p16 staining:
- negative staining = LSIL
- positive staining = HSIL**
HPV
Main cause of abnormal Pap smears (99.7% of carcinomas have this)
- 16 and up serotypes are the most dysplastic cancer types
Most common serotypes for cervical dysplasia
- HPV 16 = most common (6-10%)
- HPV 18 = (3-4%)
- HPV 33-39 (3-4%)
Median duration of infection
- 8 months
- 70% cleared in 1 year; 90% cleared in 2 years
Risk factors HPV dysplastic types
African American and Hispanic races
- 4x and 2x respectively
Alcohol consumption
- 2x increased
> 2-3 sexual partners in 1 year
- 3x increased
> 6 sexual partner history of your main regular partner (significant other has had sex with > 6 people)
- 10x increased
HPV oncogenesis
Viral DNA E6
- inhibits p53 (crucial for programmed apoptosis)
Viral DNA E7
- inhibits Rb protein which releases E2F transcription factor which causes cellular proliferation
What is the target of HPV vaccinations
The L1 protein
- this protein will assemble itself it not VLPs which the body can then attack
- protects against 6/11/16/18/31/33/45/52/58
Are recommended for anyone between age 9-45
- NOT pregnant patients but OKAY in lactation
- target age = 11-12 yr old girls and boys
Give 2 doses of the vaccine = <15 yrs old (start dose and 6-12 months after)
Give 3 doses if > 15 years old (start dose, 1-2 months after and 6 months after)
Reported test results for Pap smears
NIL = negative result for intraepithelial lesions
- proceed with routine cervical cancer screening
ASC-US = atypical squamous cells of unknown significance
- 5% of Pap smears show this
- risk of dysplasia = CIN1 or 2 = 20-30%; CIN 3 = 0.1
- need to do a rHPV cytology if this is the result. If positive = colposcopy. If negative = repeat rHPV every 3 years
- if the colposcopy shows negative = do rHPV every 1 year
LGSIL = low grade squamous intraepithelial lesion
- need to colposcopy and no rHPV
- chance of CIN2/3 = 12-16%
ASC-H = Pap tests lack conclusive cytology to be labeled as HSIL
- diagnosis of CIN 2-3 on colposcopy biopsies = 40% chance
- MUST do colposcopy but DONT do rHPV follow up
HGSIL = most aggressive type and essentially about to be invasive
- 0.7% of Pap smears
- MUST get colposcopy with LEEP (excision)
AGC = atypical glandular cells
- 0.1% of Pap smears
- must get colposcopy with or without LEEP
- need to do ECC also
- endometrial biopsy is needed in = (menorrhagia symptoms, women >35 with no risk factors of cancer, women <35 with risk factors for cancer)
- pregnancy = no endometrial curttage/biopsy! (Will cause abortion
Exceptions to ASC-US and LSIL work ups
If age 21-24
- colposcopy = DONT DO and instead repeat cytology in 1 year: if HSIL/ASC-H = colposcopy
If >ASC-US after 2 years = colposcopy
if it doesnt progress from ASC-US = routine screen every year
Postmenopausal women (do one of the following)
- rHPV
- Pap tests 6 and 12 months after
- colposcopy
Exception to ASC-H or HSIL
Age 21-24
- colposcopy: if no CIN 2-3 = cytology and colposcopy every 6 months for 2 years. If it continues to be HSIL = LEEP time (excision)
Pregnant
- colposcopy but NO LEEP unless confirmed concer
- follow up cytology and colposcopy 6 wks post partum also and then from here can consider LEEP
Pap smear organism reports
are incidental and Non-diagnostic if found
Trichomoniasis
- asymptomatic = undergo standard diagnostic testing and still treat with metronidazole or tinidazole
- symptomatic = treat with metronidazole or tinidazole and then undergo standard diagnostic testing
Bacterial vaginosis and vulvovaginal candidiasis
- asymptomatic = nothing
- symptomatic = undergo standard diagnostic testing and consider treatment (oral metrondiazole)
If you diagnose an abnormal Pap test what should you always do
Refer to gynecology
Colposcopy
Diagnostic test to visualize abnormal changes and biopsy for histologic diagnosis
3% acetic acid is placed on cervix and acts as a “desiccant”
- abnormal cells will appear enlarged due to HPV replication
- nuclear enlargement will also be seen as acetowhite changes
Findings to list on colposcopy
- acetowhite changes/plaques
- punctuations
- mosaicism
- abnormal blood vessels
- if any of these findings = biopsy the area (is painful and uncomfortable)
Biopsy results
- LSIL preceded by lesser Pap smear results = rHPV every 1 year
- LSIL preceded by HSIL or ASC-H = both rHPV at 1 and 2 years and LEEP (if 24 years or younger = do every 6 months for 2 years)
- HSIL regardless of Pap smear results = LEEP
Treatment options for HSIL/cancers/ precancerous lesions
1) cryosurgery
- cells are destroyed with cold thermal energy
- quick and easy
- downside = malodorous discharge for 2-3 wks following. Can hinder colposcopy as SCJ is obscured
2) laser therapy
- CO2 laser works by vaporizing cervical cells
- precise and heals well and spears excisions/disruption
- downside is only cost (expensive)
3) LEEP (Loop electro surgical Excision Procedure)
- most common**
- apply anesthesia and stain cervix with logo solution/3% acetic acid
- electro surgical generator is set to 40 watts then use loop to pass under and around the transformation zone excising it
- downside = 1.5x increase in preterm deliveries**
4) cold knife conization
- ONLY used for persistent severe dysplasia, CIS and AIS and early invade cancers
- downside = 2.5x increase in preterm deliveries (often need to cesarean section in future pregnancies)**
5) hysterectomy
- remove entire cervix and uterus
- increases morbidity and mortality in general
- **10-20% of patients will still show abnormal vaginal papsmears (need to continue vaginal Pap smears for 20yrs after treatment)
