Cervical Disorders Flashcards
What are the Non-Sexual Risk Factors for Cervical Cancer?
- Multiparity, 2-4x risk.
- Use of Tobacco, 2-4x risk.
- Inadequate or NO screening, 2-6x risk**
What is the 3rd most common malignancy in women worldwide?
Cervical Cancer.
What are the Sexual Risk Factors (4) for Cervical Cancer?
- Early age @ first intercourse, 2-4x risk.
- Multiple Sexual partners, 2-5x risk.
- PREVIOUS Hx of STI’s, 2-10x risk.
- INFECTION w/HPV, >20x risk**
What is the main risk factor for cervical cancer?
Oncogenic HPV infection.
Which specific HPV increases the rate of severe dysplasia (CIN3) and cervical cancer?
Positive infection of HPV 16 or 18.
What age is cervical cancer most frequently diagnosed? Average age?
Between the ages of 35-44 w/the average age at 50.
*Rarely diagnosed younger than 20.
What race/ethnicity is most prevalent for cervical cancer?
Hispanic > AA > White > American Indian > Asian/Pacific Islander.
What are some benign lesions of the cervix?
Ectropion, Cervical Polyps, Nabothian Cyst.
Columnar epithelium replacing squamous epithelium on the outer surface of the cervix that develop in response to hormonal changes, chronic inflammation and is a normal among women of child-bearing age?
Ectropion.
The proliferation of benign stroma covered by epithelium and most commonly visible on the cervical os on speculum examination?
Cervical polyp.
Can be pedunculated or sessile and may be due to an inflammatory proliferation?
Cervical Polyp.
What are the principal symptoms of a cervical polyp?
Discharge and abnormal bleeding, which should be further evaluated and not completely attributed to a cervical polyp.
Dilated, obstructed mucosa glands that are covered by squamous epithelim?
Nabothian cyst.
Do nabothian cysts need to be treated?
No treatment; they are benign lesions.
What is the difference between Cytology and Histology?
Histology is evaluation of tissues done with a biopsy of tissues; where a Cytology is the study of a collection of cells.
What is the transformation zone?
An area of metaplasia or the transformation of one differentiated cell type to another differentiated cell type. The change may be benign or malignant.
What part of the female anatomy is the most common area for cell differentiation?
The cervix is an area of active squamous cell proliferation.
What does LSIL and HSIL stand for?
LSIL – Low-grade Squamous intraepithelial lesion.
HSIL – High-grade Squamous intraepithelial lesion.
What does CIN stand for?
Cervical Intraepithelial Neoplasia.
CIN2 that is p16 positive is classified as?
HSIL.
CIN2 that is p16 negative is classified as?
LSIL.
What is the Bethesda Classification System?
It is a standardized system to classify cervical and vaginal cytology (pap) and histology.
What is the previous term for classification of LSIL and CIN1?
Mild Dysplasia.
*CIN1 is low-grade and pre-cancerous.
What is the previous term for classification of HSIL and CIN2?
Moderate Dysplasia.
*CIN2 is high-grade and pre-cancerous.
What is the previous term for classification of HSIL and CIN3?
Either Severe Dysplasia or Carcinoma in-situ.
*CIN3 is high-grade and a cancerous lesion.
Non-enveloped double-stranded DNA virus?
HPV – Human Papillomavirus.
**>100 different types.
What are HPV 6 and 11 most often associated with?
90% External Genital Warts – Condyloma Acuminata.
Of the 15-20 oncogenic types of HPV, which account for the majority of worldwide cervical cancers?
HPV 16 (54%) and HPV 18 (13%).
What will most males and females be infected with and never know?
HPV infection – at least one type of mucosal HPV at some point in their lives.
What age group is HPV infections most common in?
Teens and early 20s.
What are the mechanisms of HPV transmission and Acquisition?
- Sexual contact (MC means of transmission):
- -intercourse, genital or oral contact; may result from a non-penetrative sexual contact. - Non-sexual routes:
- -mother to newborn.
- -Fomites (undergarments, surgical gloves, etc; hypothesized but not well documented).
What is the approximate time of HPV infection from time of first sexual intercourse?
Approx. 40% of HPV infections occurred within 2 yrs of first sexual intercourse.
What percentage of HPV infections are transient in women b/t ages of 15-25 and what is the median length of infection?
80%, medial length of 8 months for infection to clear with as long as 24 months.
Which HPV type is seen more often as a persistent infection?
HPV 16.
What age groups have the highest prevalence of HPV infection?
Ages 20-24 yrs.
What is the importance of HPV infection?
HPV persistence is KEY!!!
–If the infection is persistent with high-risk oncogenic HPV subtypes, the risk is higher for development of pre-invasive and invasive disease.
What is another important aspect of the HPV infection?
- Most HPV infections are asymptomatic.
2. 90% of cases are cleared by the body’s immune system in 2 yrs.
What area of the female anatomy is the most vulnerable to HPV-related disease?
The transformation zone.
Who are considered the Rarely and Never Screened for cervical cancers?
Minorities, Low SES, Foreign born (living in the US <10 yrs), No usual source of health care.
When does cervical cancer screening begin?
At age 21.
*Women <21 should NOT be screened regardless of age of sexual contact.
These tests lead to an increase in detection of high-grade precancerous lesions?
PAP and HPV testing for women of age 30-65 yrs completed every 5 yrs.
What age do we stop screening for cervical cancer?
Age 65 for women with adequate negative prior screening within the last 20 yrs.
What is the rationale for stopping cervical cancer screening at age 65?
CIN2+ is rare after age 65 and the incident HPV infection is unlikely to lead to cancer within the remaining lifetime.
Is screening for vaginal cancer necessary after a hysterectomy?
No. Primary vaginal cancer is rare.
Should screening for cervical cancer be continued after treatment of a high-grade precancerous lesion?
Yes, continued for 20 yrs after treatment with a cytology alone every 3 yrs.
What does ASCUS stand for?
ASCUS – Atypical Squamous cells of undetermined significance.
**It is the MC abnormal pap finding.
What is the mgmt of a 21-24 y/o w/LSIL, ASCUS or ASCUS positive HR HPV?
**Repeat PAP in 1 yr.
*Observation for 2 yrs w/low-grade cytological abnormalities.
What is the mgmt of a 21-24 y/o w/ASC-H, HSIL, AGC?
Colposcopy.
**ASC-H: Atypical/Abnormal Squamous Cells, cannot r/o HSIL.
**AGC: Atypical glandular cells.
What is the mgmt of a 25 and older with ASCUS positive HR HPV or greater (ASC-H, HSIL, AGC)?
Colposcopy.
What is the mgmt of a 30 yr and older with LSIL negative for HR HPV?
Repeat co-test (PAP test w/HR HPV) testing in 1 yr.
What is the mgmt of a 30 and older with LSIL HPV unknown or HR HPV positive?
Colposcopy.
What is a Colposcopy?
A type of procedure that closely examines the cervix, vagina and vulva for disease; the instrument used is a colposcope.
What is the mgmt of a woman age >30 y/o with a HPV negative ASCUS?
Re-screening w/cotesing in 3 yrs.
What is the mgmt of a woman age >30 y/o with a HPV positive and negative cytology?
- Option 1 – 12 mo f/u w/co-testing.
- Option 2 – test for HPV 16 or HPV16/18 genotyping.
- -If either positive, refer for a colposcopy.
- -If either negative, 12 mo f/u w/co-testing.
A well-demarcated, dense, opaque, acetowhite area in the transformation zone of the cervix?
CIN diagnosis via colposcopic.
Neoplastic epithelial cells that have invaded the stroma underlying the epithelium?
Invasive cervical cancer; CIN3.
Painful and embarrassing to treat and many pt’s experience recurrence after treatment?
Anogenital or External genital warts.
All prophylactic HPV vaccines are made from?
Virus-like particles; it does not contain any virus DNA, therefore, it is non-infectious and cannot cause actual disease or cancer.
Which HPV vaccine is most commonly used in the US?
9-Valent/9vHPV (Gardasil 9).
What is the efficacy of the 9-valent HPV vaccine?
Approx. 97% protection against HPV 31, 33, 45, 52, 58 with similar protection against HPV 6, 11, 16, 18-related disease.
Dosage guidelines for the HPV vaccine?
- Series started before age 15: 2 doses (0, 6-12 mo).
2. Series started on or after age 15: 3 doses (0, 1-2, 6 mo).
What age do we give the HPV vaccine?
- Routine vax at age 11 or 12 yrs; can start as early as 9.
- Up to age 26 for females.
- Up to age 21 for males w/exception of MSM or immunocompromised (HIV +).
What is the cascade of events from non-cancer to invasive cancer?
- Infection w/HR HPV type (16/18).
- Establishment of a persistent HPV infection.
- Transformation of epithelial cells to pre-invasive neoplastic cells.
- Malignant transformation of intraepithelial neoplasia into invasive cancer.
