CERVICAL CYTOLOGY MANAGEMENT GUIDELINES CAMTASIA

Question 1

Pap smear

Answer 1

Pap is screening tool

Tissue sample is diagnose

Question 2

TERMINOLOGY REVIEW: Specimen Adequacy

Answer 2

1. Satisfactory for evaluation OR unsatisfactory for evaluation ** need lots of squamous cells to be satisfactory specimen ***
2. If adequate squamous cells, will comment on presence/absence of an endocervical/transformation zone component of endocervical or squamous metaplastic cells

Question 3

The transformation zone

Answer 3

The transformation zone is where ectocervix meet endocervix , endocervix meet ectocervix
**now that you two have been introduced, we can have squamous metaplasia but hopefully not cervical cancer !!!!
Post-menstural & pregnant women don’t have the endocervical component !!!

Question 4

TERMINOLOGY REVIEW: interpretation/result

NORMAL FINDINGS

Answer 4

• negative for intraepithelial lesion or malignancy = GOOD NEWS !!!
• report may include comment about organisms present (trichomonas, candida, ect.)
• report may include comment about other non-neoplastic findings (atrophy, inflammatory cellular changes, IUD-associated change, ect)
• you may or may not decide to evaluate further or tx these additional criteria depending on the patient situation

Question 5

TERMINOLOGY REVIEW: abnormal cells

Answer 5

one type of epithelial cell abnormality is :
→Atypical squamous cells (ASC) divided further into :
(1) Atypical cells of undetermined significance (ASC-US) – cellular abnormalities that were more marked than those attributable to reactive changes but that quantitatively or qualitatively fell short of a definitive dx of squamous intraepithelial lesion (SIL) —- may be normal but need to keep eye on thing…
(2) Atypical squamous cells, cannot exclude high grade lesion (ASC-H) : positive predictive value for CIN 2 or 3 (moderate or severe dysplasia)
ASC-US not same as ASC-H

Question 6

potential serious ladder past ASC are

Answer 6

• low-grade squamous intraepithelial lesion (LSIL)- includes mild dysplasia, cervical intraepithelial neoplasia (CIN) 1
• high-grade squamous intraepithelial lesion (HSIL)- includes moderate and severe dysplasia, carcinoma in situ, CIN 2 and CIN 3

Question 7

HPV (HUMAN PAPILLOMAVIRUS)

Answer 7

• necessary for development of cervical cancer
• almost exclusively acquired through sexual exposure
• there are many many strains ~40 strains
• infect the genital tract:
• high risk (HR) HPV: ~12 Strains known to be cancer-causing
• low risk HPV: not thought to be cancer causing (but can cause genital warts, for example)
• anyone can have >1 strain
• HPV infection comes & goes- can be cleared by immune system

Question 8

In 2009, ASCCP published another management option for women age 30 & older who have negative PAP and positive HPV:

Answer 8

For women age 30 and older can be helpful to know which HR type of HPV it is ….
→women with negative PAP but positive HPV types 16 & 18 = COLPO NOW
→Women with negative PaP but positive HPV other than types 16 & 18 : repeat both tests in 12 months.

For women age 30 & older …it matters which type of high risk HPV they have !!!
**in other words, HPV types 16 & 18 are not only HIGH RISK, they are HIGH HIGH RISK !!!!

Question 9

WHEN DO WE TEST FOR HPV?

Answer 9

• we only ever test for HIGH risk HPV types
• We DO test for HPV in these situation:
- routine co-testing (with a Pap) in women 30 and over
- triage women age 21 & over with ASC-US Paps
- triage of women age 25 & over with LSIL Paps

Question 10

• We DO NOT test for HPV in these situations:

Answer 10

screening before HPV vaccination

• routine co-testing in women less than age 30
• investigation of genital warts or other STIs

Question 11

HOW OFTEN SHOULD WOMEN HAVE A PAP?

Adolescents (20 y.o and younger)

Answer 11

DO NOT SCREEN = NO PAP
Regardless of age @ first sexual intercourse
Regardless of risk factors.

Question 12

HOW OFTEN SHOULD WOMEN HAVE A PAP?

Women 21-29 y.o

Answer 12

Pap ever 3 years

DO NOT routinely test for HPV

Question 13

how often should women have a pap?

Women age 30-65

Answer 13

Pap (w/o HPV) every 3 years
(preferred by USPSTF) 
OR
Pap (w/ HPV) every 5 years 
(preferred by ACS/ASCCP/ASCP)

Question 14

HOW OFTEN SHOULD WOMEN HAVE A PAP?

women more than age 65

Answer 14

No more Paps for women with adequate prior screening and not otherwise at high risk for cervical cancer ( USPSTF)
No more Paps for women with adequate prior screening, no hx of CIN 2 or 3. Do not resume screening even if new partner (ACS/ASCCP/ASCP)

Question 15

Exclusions (women who need more frequent Paps)

Answer 15

• immunocompromised HIV
• Diethylstilbestrol (DES) daughters
• Hx of cervical cancer or CIN 2 or 3

Question 16

26 y.o whose Pap result from liquid based Pap specimen is :

Atypical squamous cells of undetermined significance (ASC-US) HPV positive

Answer 16

→ refer for COLPO

Question 17

T is a 23 y.o. who pap result is

Low grade Squamous Intraepithelia lesion (LSIL)

Answer 17

→ Repeat cervical cytology in 12 months.

Question 18

M. is a 39 y.o. who Pap result is : Atypical Glandular cells (AGC) with atypical endometrial cells

Answer 18

→ Endometrial & colposcopy/endocervical sampling

Question 19

C. is a 42 y.o who Pap result is : Atypical Squamous Cells : cannot exclude high-grade SIL (ASC-H)

Answer 19

→ COLPOSCOPY

Question 20

J. is a 30 y.o. who Pap result is : negative for intraepithelial lesion or maglignancy HR HPV positive—HPV type 16/18 negative. This is the first year that she has had an HPV test.

Answer 20

→ Repeat both cytology and HR HPV test in 12 months.