Cervical Dysplasia Flashcards
1
Q
cervical cancer
A
- 3rd most common GYN cancer
- Lifetime risk <1%
- Mean age at diagnosis 48 yrs
- HPV central to development of cervical neoplasia
- 99.7% of cervical ca due to HPV infection
- 70% are squamous cell carcinoma, 10-25% are adenocarcinoma
- Risk Factors: increased risks for HPV infection
- Early sexual activity
- High lifetime number of sexual partners
- Infection with HIV
- Smoking
- Long-term use of oral contraceptives (>5 years)
- Low socio-economic status
- Protective Factors
- Use of barrier contraception and spermicides
- High levels of vitamin C
- Screening Tools
- Pap smear
- HPV testing
- Colposcopy
- Effectiveness of Early Detection
- May prevent or delay progression to invasive cancer
- Lowers incidence of invasive cervical cancer by 91%
- Lowers mortality from cervical cancer 20% - 60%
2
Q
cervical cancer screening USPSTF recommendations
A
- The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
Grade: A Recommendation. - The USPSTF recommends against screening for cervical cancer in women younger than age 21 years.
Grade: D Recommendation. - The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
Grade: D Recommendation. - The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.
Grade: D Recommendation. - The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.
Grade: D Recommendation. - These recommendations apply to women who have a cervix, regardless of sexual history. These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
3
Q
Papanicolaou smear
A
- Screening test for the early detection of cervical dysplasia and cancer
- Effectively screens for squamous cell carcinoma of the cervix
- Spatula samples the ectocervix
- Endocervical brush collects endocervical cells and cells from the transformation zone
- Cytobrush is all-in-one sampling tool
4
Q
pap smear - exam
A
- Not a sterile exam
- Gown & drape patient
- Gloves
- Speculum
- Cytobrush & collection kit
- Warm water or lubricant*
- Over age 30 is the only column that differs à
5
Q
pap smear - results
A
- Risk of invasive cervical cancer increases with persistent high-grade lesions
- Most abnormal Pap results are low-grade lesions in young women (<30 yrs), due to HPV infection
- Majority of lesions regress spontaneously within 8-24 months
- If abnormal Pap results (cytology) you want to know HPV status
- Order reflex testing at time of exam
- Reflex means that if the pap is normal, no HPV will be tested, but if its abnormal, they will also look for HPV
- Order HPV testing at next exam
- Order reflex testing at time of exam
- Pap smear can be affected by having sex in the last 72 hrs
6
Q
Bethesda classification of pap smear results
A
- Low-Risk Group
- ASC-US
- Atypical Squamous Cells of Undetermined Significance – the cells look a little different but not THAT different
- LSIL
- Low-grade Squamous Intraepithelial Lesion – there’s definitely something abnormal about these cells
- ASC-US
- Low-risk group may require colposcopy or repeat Pap testing
- Management of LSIL is usually colposcopy
- High-Risk Group – ANY HIGH RISK PERSON REQUIRES COLPOSCOPY AND BIOPSY
- ASC-H (Atypical Squamous Cell cannot exclude HSIL)
- HSIL (High-grade Squamous Intraepithelial Lesion)
- Squamous Cell Carcinoma
- AGC (Atypical Glandular Cells)
- specify cervical, endometrial, other
- AGC favor Neoplastic
- AIS (Endocervical Adenocarcinoma in situ)
- Adenocarcinoma
- Other Malignant Neoplasms (Ovary, Vaginal, etc.)
- High-risk group requires colposcopy, biopsy, tx
7
Q
ASC-US follow-up
A
- Women ages 21-24: repeat Pap smear in 12 months
- Women ≥25 yrs: reflex testing for HPV
- If HPV testing not available, repeat Pap smear 12 months
- HPV negative, repeat Pap smear 3 yrs
- HPV positive, send for colposcopy
8
Q
LSIL and AC-US in post-menopausal women
A
- Often due to effect of estrogen loss on epithelium
- Low rate of HPV infection in this population – abnormal results usually not due to HPV in postmenopausal women – usual issue is estrogen loss
- Premarin 1gm vaginally qhs x 3 wks, then repeat cytology 1 week after estrogen treatment completed
- Alternatively, treat with typical dose vaginal estrogen and repeat Pap in 6 months
- If cytology does not normalize, colposcopy is needed
- Patients with a concerning Pap history should be sent for colposcopy as the first step
9
Q
human papillomavirus (HPV)
A
- Types 16 and 18 are high-risk, strongly associated with cervical cancer
- Types 6 and 11 are low-risk, most commonly associated with genital warts
- Most commonly occurs in young women (age <30 yr)
- Usually transient infection that resolves spontaneously
- Now available: HPV vaccine
10
Q
HPV testing
A
- HPV DNA testing may be added to cervical cytology for screening in women aged ≥30 years
- HPV testing should be discontinued at the same age and under same circumstances as cytology screening
- HPV testing should not be added to cervical cancer screening:
- In women age <30 years
- In women who are immunosuppressed
11
Q
HPV and Cytology results
A
- Cytology negative, HPV negative → Routine screening at 3-5 years
- Cytology negative, HPV positive → Repeat both tests in 12 months* (see next set of bullet points for what to do at the 12 month mark)
- Cytology ASC-US, HPV negative → Repeat cytology 3 years for most patients
- Cytology ASC-US, HPV positive → Colposcopy
- Cytology >ASC-US, any HPV result → Colposcopy
12
Q
HPV and Cytology results FU
A
- Cytology negative, HPV positive → Repeat Pap + HPV test in 12 months:
- Both negative → Routine screening at 3-5 years
- Cytology ASC-US, HPV negative → Repeat Pap with HPV test in 12 months
- Cytology >ASC-US, HPV negative → Colposcopy
- Any cytology result, HPV positive → Colposcopy
- Evaluation strategies — For nonadolescent women, there are three acceptable management schemes for evaluation of ASC-US.
- Reflex HPV testing — Reflex HPV testing (also referred to as secondary HPV testing) is the collection a specimen for HPV testing when the cytology sample is collected, but performing the HPV test only if the cytological results are ASC-US. Positive or negative HPV testing results are defined as positive or negative for high-risk subtypes. HPV testing usually tests for these subtypes, and not for low-risk HPV subtypes or for a single subtype.
- Based upon guidelines from the American Society for Colposcopy and Cervical Pathology and the American Cancer Society:
- Positive HPV test — Women age 21 years or older with a positive HPV test are evaluated with colposcopy.
- Negative HPV test
- Ages 21 to 29 years – Repeat cervical cytology in three years
- Ages 30 to 65 years – Screen with cervical cytology and HPV testing in five years
- HPV-negative ASC-US is usually due to disturbances in maturation or cellular changes related to inflammation or atrophy.
- HPV testing instead of cytology at 12 months has been proposed since the specificity of HPV testing is high in this setting; however, the sensitivities of the two tests have not been compared in controlled trials. If HPV testing remains negative at 12 months, these authors have also proposed that the patient return to routine screening intervals, based upon her age and prior screening history.
- Persistent HPV-negative ASC-US — Some women have persistent HPV-negative ASC-US. This is most likely due to inflammation or atrophy. Such women can be followed with annual cervical cytology if there are no symptoms of postcoital or abnormal uterine bleeding and if a pelvic examination is normal.
- Repeat cytology — Cytological evaluation can be repeated in 6 and 12 months and, if normal, routine screening may be resumed. A second abnormal smear (ASC-US or greater) is evaluated with colposcopy. About 65 percent of women will be referred for colposcopy using this strategy.
- The rationale for repeated cytological evaluations is the potential that a significant abnormality will be missed on a single repeat smear (15 to 33 percent), as well as inter- and intraobserver variability in diagnosis of ASC. The disadvantages of this approach are the need for multiple follow-up visits, potential delay in histological diagnosis, and a lack of data regarding optimum frequency and duration of testing.
- Immediate referral to colposcopy — Colposcopy with directed biopsies, as indicated, yields timely information about the presence or absence of significant disease. However, colposcopy is expensive, can be uncomfortable, and potentially leads to overdiagnosis and overtreatment.
- (from UpToDate 6/2012)
13
Q
Colposcopy
A
- Dissecting microscope with various magnification lenses, used to provide an illuminated, magnified view of the cervix
- Improved visualization of epithelial surfaces enhances ability to distinguish normal from abnormal areas and obtain directed biopsies from suspicious tissue
- Primary goal is to identify precancerous and cancerous lesions and treat them early
- Acetic acid solution is used to improve visualization of abnormal areas. Three to 5 percent acetic acid is applied to the cervix using cotton swabs to enhance definition of the squamocolumnar junction. After 30 to 60 seconds, the acidic solution dehydrates cells so that squamous cells with relatively large or dense nuclei (eg, metaplastic cells, dysplastic cells, cells infected with human papilloma virus) reflect light and thus appear white. If no lesions are seen, a dilute Lugol’s or Schiller’s solution may be applied to the cervix and vagina. The colposcopist should be able to differentiate between minimally abnormal and significantly abnormal findings. Traditionally, only a single biopsy was obtained from the most abnormal appearing area using long biopsy instruments. However, detection of CIN is enhanced by obtaining multiple biopsies, such as from another part of the most abnormal appearing area or from more than one abnormal appearing area to aid in detection.
14
Q
squamocolumnar junction
A
- Normal SCJ
- ASC-US
- SCJ: The current junction where the squamous and columnar cells meet on the surface of the cervix at the time the patient is being evaluated; it demarcates the junction of the endocervical glandular epithelium and the squamous epithelium after squamous metaplasia is completed.
15
Q
Cervical lesions
A
- Low grade cervical lesion
- High grade cervical lesion
- Low grade: This lesion represents a geographic map-like, low-grade dysplasia. The lesion itself is irregular, and it extends to the posterior cervical portio.
- High grade: with coarse punctation on the anterior lip of the cervix.
