Cervical cytology

Question 1

Describe the ectocervix

Answer 1

 Ectocervix, Portio, Anterior & Posterior lips, vaginal surface of cervix
 Extends from external os to vaginal fornix
 Protects underlying tissue
 Estrogen repsonsive

Question 2

Describe the endocervix

Answer 2

Glandular columnar cells are in the endo cervix
 Single layer mucin-producing columnar cells
 Extend from internal os (proximal) to the external os
(distal) ~ liens endocervical canal going into the uterine
cavity

Question 3

What is the squamocolumnar junction

Answer 3

is the site of active metaplasia, or conversion of one cell type (columnar) to another (squamous)

Question 4

What affects the SCJ?

Answer 4

o Estrogen dependent  estrogen exposure pushes the glandular cells out

Question 5

What is often the site of cellular abnormalities in the cervix?

Answer 5

Zone of transformation

Question 6

What is ectopy?

Answer 6

pronounced eversion of the columnar epithelium

Question 7

Who presents with ectopy?

Answer 7

• Women that are pregnant or using hormonal contraception

Question 8

What is considered a persistent HPV infection? What is the most persistent subtype?

Answer 8

-Over 2 years with the same HPV type
-16 is the most persistent subtype

Question 9

HPV primary prevention? Who qualifies?

Answer 9

9-valent vaccine
M/F ages 9-45
suggested to do it age 11-12

Question 10

Secondary prevention HPV

Answer 10

Pap

Question 11

How many strands of HPV are oncogenic?

Answer 11

approximately 20

Question 12

Which strands cause genital warts?
Which strands are high risk?

Answer 12

• warts: 6 & 11
  -high risk: 16 & 18

Question 13

What percentage of HPV clears in 1 year? 2 years?

Answer 13

• 1 year = 70%
• 2 years = 90%

Question 14

S/s cervical cancer

Answer 14

-abnormal vaginal bleeding
-postcoital bleeding
-vaginal discharge –> watery, mucoid, purulent, malodorous

Question 15

Define: colposcopy

Answer 15

magnification and illumination to aid visual inspection of the cervix, vagina, and anogenital area

Question 16

What occurs during a colposcopy?

Answer 16

o Dilute acetic acid applied to cervix or vagina to highlight dysplastic areas
o Targeted biopsies are performed based on clinician’s assessment

Question 17

What is a histology?

Answer 17

study of tissue

Question 18

How is histology tissue obtained?

Answer 18

during colposcopy

Question 19

What is squamous metaplasia?

Answer 19

 Normal process
 Triggered by exposure to acid environment of vaginal
from increased estrogen levels
 Columnar epithelium is replaced by squamous
 Common to see gland opening and Nabothian cysts
 Vulnerable to oncogenic HPV
 This area will turn white with acetic acid application
because this correlates with cells changing

Question 20

What is dysplasia?

Answer 20

abnormal tissue typically affected by HPV; cervical intraepithelial neoplasia (CIN) – looking at tissue that turned white with acetic acid because we know that abnormal cells are targeted and turn white

Question 21

What are the different classifications of dysplasia

Answer 21

 Normal
 Mild Dysplasia (CIN 1): 1/3 squamous epithelium is abnormal  < 1% progress; 10% progress to 2/3
 Moderate Dysplasia (CIN 2): 1/3- 3/4 epithelium is abnormal  ~ 5% progress to ICC
 Severe Dysplasia (CIN 3): >3/4 epithelium is abnormal
* Older term Carcinoma in situ (CIS): Full thickness lesion
* 12-40% progress to ICC  considered a direct precursor to cervical cancer
 Invasive Cervical Cancer: Abnormal cells break through the basement membrane lead to invasion of surrounding tissues

Question 22

What are atypical glandular cells

Answer 22

endocervical cells, endometrial cells or glandular cells

Question 23

What is the most common type of cervical cancer?

Answer 23

Squamous cell carcinoma

Question 24

Where does squamous cell carcinoma develop?

Answer 24

Squamous cells of ectocervix

Question 25

What develops from glandular cells?

Answer 25

adenocarcinoma

Question 26

What to avoid (patient) before pap?

Answer 26

- Patient should avoid intercourse, douching, tampon use or vaginal meds 2 days prior

Question 27

Tools and techniques of performing a pap

Answer 27

o Spatula should be rotated at least 360 degrees around ectocervix o Endocervical brush should NOT be turned MORE than 180 degrees o Broom should be rotated 5x around ectocervix o Brush does not remain in the collection device

Question 28

Can you do surveillance with cytology?

Answer 28

o Surveillance with cytology alone is acceptable only if testing with HPV or co-testing is not feasible.  Cytology is less sensitive than HPV testing for detection of precancer and is therefore recommended more often. - do this in 6 month intervals if HPV calls for annual testing -recommended annually when HPV suggested Q 3 years

Question 29

Frequency of Pap testing

Answer 29

i. Ages 21-29: Pap every 3 years **ACOG/ASCCP allow for primary hrHPV testing q 5 years in persons age 25-29 ii. Ages 30-65: Cytology (pap) every 3 years OR Primary hrHPV testing every 5 years OR Cytology (pap) + hrHPV (co-testing) every 5 years

Question 30

When can you stop doing a pap?

Answer 30

a. Age 65 with: i. 2 consecutive negative HPV tests ii. 2 consecutive negative co-tests iii. 3 consecutive negative cytology tests within the past 10 y, with the most recent test occurring within the recommended interval for the test used b. Note: ASCUS cytology with HPV negative are NOT sufficient to exit screening c. Patients with prior CIN 2-3 require screening with HPV testing or co-testing q 3 years for 25 years s/p tx even if this extends beyond 65

Question 31

Who must continue with pap beyond 65 and cannot stop?

Answer 31

a. Exposed to DES (diethylstilbestrol) in utero b. Immunocompromised i. HIV ii. Organ transplant c. Previous hx cervical CA or high grade cervical lesion d. Person undergoing surveillance for abnormal results

Question 32

Pap screening guidelines for total hysterectomy

Answer 32

a. Total hysterectomy – never had CIN 2+  routine cytology screening and HPV testing should be discontinued b. Hx of CIN 2/3 prior to hysterectomy  at risk for recurrent CIN of the vaginal cuff i. HPV based testing Q3 years for 25 years post treatment

Question 33

What age do you start HPV testing?

Answer 33

25

Question 34

ASCUS with + HPV - what to do?

Answer 34

 Refer to colposcopy vs repeat in 1 year based on patient hx

Question 35

o ASCUS with (-) HPV

Answer 35

 Repeat co-testing in 3 years if prior benign hx

Question 36

ASC-H next steps

Answer 36

o Colposcopy regardless of age or HPV status

Question 37

LSIL-H next steps

Answer 37

o Colposcopy regardless of age or HPV status

Question 38

HSIL next steps

Answer 38

o Colposcopy regardless of age or HPV status

Question 39

What if there are endometrial cells? -Premenopausal -Post menopausal -Post-hysterectomy

Answer 39

pre-menopausal: Benign appearing endometrial cells, endometrial stomal cells, histiocytes consistent with LMP  no further workup Post-menopausal: Benign endometrial cells on pap  Endometrial sampling IS INDICATED Post-hysterectomy: Benign glandular cells  no further workup

Question 40

atypical glandular cells (other than atypical endometrial cells) next steps?

Answer 40

 Colposcopy w/ endocervical sampling (if not pregnant) * If >= 35 or <35 and risk of endometrial neoplasia  include endometrial biopsy

Question 41

CIN-1 next steps

Answer 41

- HPV test in 1 year - persistent CIN-1 for 2 years --start to think excision if over 25

Question 42

CIN-2 next steps

Answer 42

o Tx is indicated except when young or pregnant or want to become pregnant  can have them come back in 6 month intervals for pap and colposcopy

Question 43

CIN-3 - can you treat in pregnancy?

Answer 43

Do not treat during pregnancy

Question 44

Excisional treatment for CIN2/3

Answer 44

o LEEP  Might leave cauterization areas that make it hard to ensure clean margins o Cold knife conization  Performed in the OR under anesthesia  Do this if you need to ensure clean margins

Question 45

POST CIN treatment -over 25 -under 25

Answer 45

o >= 25 HPV based testing at 6 mos  HPV +: colpo and biopsy  HPV (-): HPV based testing annually Q3 years o < 25  cytology at 6 mos  Abnormal  colpo and biopsy  Normal  continue cytology q 6 mos. for 3 years * Reaches 25  transition to HPV testing

Question 46

Follow up for CIN with positive margins

Answer 46

o HPV testing at 6 mos  + -- colpo and biopsy  (-) -- HPV annually for 3 years