Cervical cancer/dysplasia Flashcards
What are screening recs for CIN2, CIN3 and AIS?
continue age-based screening for at least 25yrs post-treatment (even if it goes past age 65)
Combined cytology + HPV= 99% neg predictive value for CIN2 and 3.
What are testing recs for healthy pts?
age 21 pap q3yr
age 30 pap +HPV q5 or pap alone q3 OR high-risk hPV testing q5
stop age 65 if no pap testing (and no CIN2/3/AIS). Need adequate negative past screening tests.
If total hyst for benign: stop paps. If for hx CIN2/3: q3yr until 25yrs post tx surveillance. If for treatment of CIN2-3, annual pap x3 then q3
- HPV is transient and cervical dysplasia can regress. tx impacts future fertility.
- How do you manage pap w/ insufficient endocervical transformation zone? Can repeat pap in 1 yr.
Management of unsatisfactory pap? If <30, repeat in 2-4 months. If >30, repeat pap or colpo. If 2 unsatisfactory, colpo.
What is Bethesda nomenclature?
Squamous cells
- ASCUS: HPV and if high risk -> colpo
- ASC-H: cannot r/o SIL -> colpo
- LSIL: HPV and CIN1
- HSIL: CIN2/3/CIS
- SCC: invasive carcinoma
Glandular cells
- atypical endometrial: NOS in menstruating woman w/o risk factors for endometrial cancer
- atypical endocervical or glandular: favor dysplasia.
**CIN3 and AIS are precursors to cancer, CIN2 is considered threshold for tx if > 24.
When is an ECC recommended?
When can you defer ECC?
- high grade cytology (HSIL, ASCUS-H, AGUS, carcinoma)
- HPV 16/18
- previously treated for CIN 2+
- squamoucolumnar junction not fully visualized at colpo
- Age 40
ECC preferred for all pts >40. AVOID in pregnancy.
Can defer ECC when:
- excision procedure planned.
- endocervical canal doesn’t admit sampling device
- nullips <30 w/ ASCUS or LSIL.
What are the new ASCCP guidelines?
HPV result dominates over cytology result
- management for age 25+ based on present risk of CIN3 or higher. If immediate risk of CIN 3 is > 4%, do colpo or tx. If < 4%, consider 5 year CIN risk.
- if age 27-45 undergoing tx for CIN2, need HPV vaccine if unvaccinated.
If age 30+ with neg pap, positive HPV? Repeat in 1 yr. If same in 1 yr, colpo.
If pregnant: ASCUS/LSIL/HPV pos, need colpo or colpo PP.
If HSIL, CIN2: colpo + biopsy q3mo
What is management for AGC/AIS cytology in non-pregnant?
- Colpo and ECC REGARDLESS OF HPV result. and EMB if 35+
- Endometrial sampling: age 35+ or high risk for endometrial cancer (obesity, AUB, chronic anovulation)
- If colpo result is AIS/AGC: cone/ECC (cone better bc improved eval of deep margins and possibility of endocervical skip lesions). can do hyst if AIS.
- if colpo result is CIN2/3: general management
- if colpo is < CIN2: annual co-testing x3yr
What is management of endometrial cells on cervical cytology?
Benign endometrial cells:
- premenopausal: no eval
- post menopausal : endometrial sampling
Atypical endometrial cells: ECC + endometrial sampling. If negative, add colpo.
What is post pap management for women under age 25?
- Pap cytology LSIL, ASCUS + HPV or ASCUS no HPV: rpt cytology alone at 1 & 2 yrs. If HPV was done and negative, cytology in 3 yrs.
- Colpo if high grade cytology (HSIL, ASC-H, AIS) OR low-grade persists at 2 year follow-up (from above).
COLPO results:
- If CIN3: excisional tx recommended.
- if squamocolumnar junction or upper limits of lesion not visualized: excisional tx.
-If CIN 2: observation preferred. tx acceptable. need cytology + colpo q6mo. If CIN2 persists for 2 years, treatment recommended.
What is management of pregnancy w/ pap?
- no ECC or endometrial salpling
- for CIN2/3: colpo q4-6 mo or defer colpo until PP (4 weeks postpartum)
- AIS: refer to gyn onc.
What is management of HIV pos/immunosuppression?
Screening within 1 yr of insertional sex and continue throughout lifetime.
- annually for 3 years then q3yr (cytology alone) until age 30.
- age 30+, cytology alone or co-testing q3y
- if HPV testing unavailable, repeat pap 6-12 mo and colpo if ASCUS or higher.
Discuss a LEEP vs cone?
LEEP:
- less invasive, less costly, performed in office, fewer complications
- smaller specimen, incr risk of positive margins, thermal damage obstructing interpretation of sample, thermal injury to vagina, lidocaine toxicity/vasovagal reaction, discomfort
CONE
- less likely to have positive margins
- technically more difficult
- done in OR, takes longer and expensive.
- high incidence of bleeding, infertility, cervical incompetence, SAB, PTL.
How do you manage positive margins on excision specimen for CIN2/3?
post-treatment HPV status is MOST accurate predictor of treatment outcome (not positive margins). risk persistent recurrent disease with positive margins is 50%.
PREFERRED: f/u HPV testing in 6 months regardless of margins
– if HPV neg: HPV annually x3 and if neg, q3yr for 25yr
–if HPV pos, colpo/biopsy.
ACCEPTABLE: colpo w/ ECC at 6 mo
What are situations where CKC is preferable to LEEP?
- completed childbearing
- postmenopausal (transformation zone higher in endocervical canal)
- AIS
- r/o mciroinvasion
- inadequate colpo
- positive ECC
- positive margins on LEEP
What is management after excision procedure?
If excision for CIN2/3: HPV testing in 6 mo.
- If neg -> annual HPV x3yr -> q3yr for 25yrs.
- If pos: colpo + biopsy.
What is management of positive margins on cone biopsy for pap w/ AGC? Had colpo & ECC w/ AIS.
Need repeat cone excision due to risk of persistent AIS and possibility of invasive adenocarcinoma.
- STILL need repeat cone EVEN if hyst planned.
- gyn onc consultation.
