Cervical cancer/dysplasia

Question 1

What are screening recs for CIN2, CIN3 and AIS?

Answer 1

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.

Question 2

What are testing recs for healthy pts?

Answer 2

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.

Question 3

What is Bethesda nomenclature?

Answer 3

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.

Question 4

When is an ECC recommended?
When can you defer ECC?

Answer 4

• 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.

Question 5

What are the new ASCCP guidelines?

Answer 5

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.

Question 6

What is management for AGC/AIS cytology in non-pregnant?

Answer 6

• 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

Question 7

What is management of endometrial cells on cervical cytology?

Answer 7

Benign endometrial cells:
- premenopausal: no eval
- post menopausal : endometrial sampling

Atypical endometrial cells: ECC + endometrial sampling. If negative, add colpo.

Question 8

What is post pap management for women under age 25?

Answer 8

• 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.

Question 9

What is management of pregnancy w/ pap?

Answer 9

• 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.

Question 10

What is management of HIV pos/immunosuppression?

Answer 10

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.

Question 11

Discuss a LEEP vs cone?

Answer 11

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.

Question 12

How do you manage positive margins on excision specimen for CIN2/3?

Answer 12

post-treatment HPV status is MOST accurate predictor of treatment outcome (not positive margins).

PREFERRED: f/u HPV testing in 6 months
– if HPV neg: HPV annually x3 and if neg, q3yr for 25yr
–if HPV pos, colpo/biopsy.

ACCEPTABLE: colpo w/ ECC at 6 mo

Question 13

What are situations where CKC is preferable to LEEP?

Answer 13

• completed childbearing
• postmenopausal (transformation zone higher in endocervical canal)
• AIS
• r/o mciroinvasion
• inadequate colpo
• positive ECC
• positive margins on LEEP

Question 14

What is management after excision procedure?

Answer 14

If excision for CIN2/3: HPV testing in 6 mo.
- If neg -> annual HPV x3yr -> q3yr for 25yrs.
- If pos: colpo + biopsy.

Question 15

What is management of positive margins on cone biopsy for pap w/ AGC? Had colpo & ECC w/ AIS.

Answer 15

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.

Question 16

How do you perform a LEEP?

Answer 16

local anesthesia and vasoconstrictor solution (lidocaine + epi, eg, 5 to 10 mL of 1 percent lidocaine with 1:100,000 epinephrine).
- place injection into cervix and 3,6,9 and 12 o’clock.

Set electrosurgical generator is set at 30 to 40 watts on cut and blend

The loop is carefully passed simultaneously around and under the transformation zone, thus excising it. The loop should be allowed to glide through the cervix from one side to the other, allowing the cutting current to divide the tissue. If the surgeon attempts to pull quickly through the cervix, the loop will drag, bend, or adhere to the tissue, resulting in a shallower excision than was intended. If the loop moves too slowly, however, excess thermal damage to the specimen will occur. Occasionally, it is necessary to make additional passes in order to ensure complete removal of endocervical disease.

An ECC is performed following completion of excision, and hemostasis is obtained with a Ball electrode or regular tip cautery.

Question 17

What is lidocaine dosing?

Answer 17

max dose of lidocaine + epi: 7 mg/kg
- max one 50ml vial.
- cannot exceed total dose 500mg lidocaine

Question 18

What are side effects of lidocaine?

Answer 18

• Metallic taste
• Peri-oral numbness
• Tinnitus
• Slurred speech and blurry vision
• Altered consciousness
• Convulsions
• Cardiac arrhythmias
• Cardiac arrest.

If suspect toxicity:
- stop injections nd terminate procedure
- give O2/IVF. Do EKG and pulse ox. Transfer to PACU/ICU. If in office, call EMS.
- perform procedure under IV sedation in the future.

Question 19

What is VIN?

Answer 19

VIN usual type: HSIL VIN due to HPV
VIN differentiated: vulvar dermatosis (lichen sclerosis).
Tx to prevent vulvar squamous cancer. Options=excision, ablation, topical tx.

Excision if incr risk invasive dz, solitary lesion.
Ablation: multifocal lesions but no worrisome features for invasion
Topical (Imiquimod): prefer to avoid excision/ablation.
Recurrent lesions w/o evidence of invasion: ablative or topical therapy to avoid multiple excision procedures.

Question 20

What is management of VIN?

Answer 20

• Initial: WLE. +margins common and risk for recurrent disease. If microscopically positive, observe + colpo w/ biopsy. IF grossly visible, re-excise.
• Recurrence: simple vulvectomy (removal of entire vulvar and perineal tissues).
• can occur early or late >10yrs. monitor vulva q6mo x 5yr then annually.
• risk factors for recurrence: immunosuppression, multifocal dz, lesion >3cm, age >50, + margins on excision specimen, smoking.

Question 21

What is differential diagnosis of 60 y/o with 2cm beefy lesion on vulva?

Answer 21

Pigmented nevi
Dysplastic nevi
Melanoma
Vulvar VIN or SCC
Paget’s disease

-need WLE! Do biopsy FIRST at margin of lesion (include normal appearing tissue bc biopsy at center of lesion may be nondiagnostic due to necrosis).

Question 22

What is Paget’s disease?

Answer 22

<1% of all vulvar malignancies. white pts in 60-70s.
- sx=PRURITIS. demarcated, raised edges, multifocal.
- ddx: vulvar biopsy of all suspicious lesions
-tx: WLE or vulvectomy depending on extent of disease. refer to gyn onc.
- high rate of recurrence.

Question 23

What are indications for a LEEP?

Answer 23

• Treat CIN 2/3/CIS
• inadequate colpo or inability to fully evaluate transformation zone
• positive ECC
• treat cervical stenosis
• persistent LSIL on pap

Question 24

What is management of 26 P0 w/ CIN3 on colpo and ECC?

Answer 24

Could do cone (bc positive CIN3 on ECC).
How deep do you go with a LEEP? Go 7-8mm into tissue.
What is a top hat? Take additional 0.5cm. Indications: pos ECC or inadequate colpo.

Question 25

How is cervical cancer staged?

Answer 25

staged clinically initially, now surgical and radiological eval included.
- determined at time of primary diagnosis
- spreads by direct extension or lymphatic and hematogenous spread.
- outcomes depend on tumor size, node involvement.

Question 26

What is cervical cancer staging?

Answer 26

Stage 1: confined to cervix
- 1A: microscopic lesion (<5 mm depth of invasion)
- 1B1: visible lesion <4cm

stage 2: limited to upper 2/3 vagina w/o side wall involvement
- 2A: beyond uterus, upper 2/3 vagina, no parametrium
-2B: extension to parametrium, no side wall

Stage 3: lower 1/3 vaginal, extends to pelvic wall
3A: lower 1/3 vagina
3B: pelvic sidewall, +- hydronephrosis or non-functioning kidney
3C: lymph nodes

Stage 4: beyond pelvis
4B: distant organs

LVSI: lymph-vascular space invasion

Question 27

What is cervical cancer treatment?

Answer 27

Stage 1A1: cone or simple hyst

1A1 + LVSI or IA2: rad hyst + nodes
IB and 2A: rad hyst + nodes or radiation + cisplatin
2B and above: radiation + cisplatin

*modified rad hyst: removal of uterus/cervix/upper 1/3 or vagina/parametria.

• in pregnancy: 1st trimester no change. 2nd trimester: terminate and treat. 3rd tri: consider risks/benefits of prematurity vs. delayed treatment.

Question 28

What percent of cervical cancers are due to HPV?

Answer 28

90%

Question 29

How would you manage post colpo biopsy in pregnant patient with microonvasion?

Answer 29

Micro-invasion: invasion of stoma <3mm??
If < 20w, need cone. If clear margins, repeat colpo in 3rd tri
- re evaluate PP

Question 30

How would you manage post colpo biopsy in pregnant patient with microonvasion?

Answer 30

Micro-invasion: invasion of stoma <3mm??
If < 20w, need cone. If clear margins, repeat colpo in 3rd tri
- re evaluate PP

Question 31

What is AIS?

Answer 31

Malignant endocervical glands present, disease doesn’t invade into underlying tissue.
- favorable prognosis with treatment
- tx is cervical conization followed by TAH
- do cone first to assess extent of disease and avoid under-treating invasive disease.

Question 32

What are indications for cone?

Answer 32

Inadequate colposcopic examination
High grade dysplasia on ECC
AIS on colpo biopsy
Significant discrepancy between Pap smear and biopsy findings
The need to eliminate thermal artifact associated with LEEP or laser
Surgeon’s preference
Colposcopic examination concerning for invasive cancer (even if biopsies show only carcinoma in situ)
Persistent/recurrent dysplasia
Large/extensive lesion