Cervical Neoplasia / Cancer Flashcards
Pap smears -when to start
Start at age 21 regardless of sexual hx (ACOG 2009)
If ascus and under 20 (who knows why they got a pap)….
Repeat in 12 mo
Women from ages 21 to 30 be screened….
every three years using either the standard Pap or liquid-based cytology.
Women age 30 and older who have had three consecutive negative cervical cytology test results may be screened…
Once every three years with either the Pap or liquid-based cytology
Once every five years with co-testing
Women with certain risk factors may need more frequent screening, including those who have….
HIV, areimmunosuppressed, were exposed to diethylstilbestrol (DES) in utero, and have been treated for cervicalintraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.
If total hysterectomy for benign condition, does the patient still need PAPs?
NO
If supracervical hysterectomy & still have cervix, does the patient still need PAPs?
Yes, regular screening
Should a pap be deferred if bleeding is present?
Yes, defer Pap smear if bleeding present (messes up results)
Pap result: Atypical squamous cells (ASC)
Many have severe dysplasia
If ASC-US… what are the next steps in w/u?
Reflex HPV testing.
If positive, then colpo.
If not then repeat Pap in 1 year
If ASC-H or LSIL / HSIL or atypical glandular cells… what are the next steps in w/u?
Get colpo! Don’t bother with HPV.
Worrisome colpo results
Acetowhite changes, mosaicism, punctations, atypical vessels → biopsy these!
Path results: CIN I
Repeat cytology q6mo x 2 or repeat HPV testing in 1 year
Path results: CIN II / III
Treat with surgical excision (LEEP > cold knife cone)
After colpo, need to do a cone / Leep excision if….
AdenoCa in situ, positive endocervical curretage (LSIL,HSIL, etc), unsatisfactory colpo (can’t visualize entire transition zone, etc), or big discrepancy between Pap & bx results (e.g. HSIL on Pap, then normal colpo → need excision!)
LEEP complications
Cervical stenosis, insufficiency, infection, bleeding.
CIN
Disordered growth & development, starting at basal layer
Most commonly during menarche and after pregnancy (more metaplasia) → metaplasia of transition zone
Which types of HPV are high risk?
HPV 16/18/31/45 are high risk
Other risk factors for CIN
Cig smoking, immunodeficiency (HIV)
Vaccination against HPV
Guardasil
Cervical cancer:
80% SCC, most of rest is adenoCa (think clear cell adenoCa with DES exposure in utero)
Risk factors for cervical cancer
High risk serotypes (16, 18, 31, 45), immunosuppression, HIV (cervical cancer = HIV-defining illness)
Diagnosis of cervical cancer
Usually asx (need to screen with Paps!).
Can have postcoital bleeding, see mass on spec exam, etc
Cancer can only be diagnosed with tissue bx, not with Pap!
How to stage cervical cancer
Staging is clinical (only GYN cancer with clinical staging) - look for invasion to adjacent structures /metastasis (EUA, CXR, cystoscopy, proctoscopy, IVP, barium enema).
MRI / CT can’t be used for staging; also, staging doesn’t change based on operative findings
Definition of stages I-IV of cervical cancer
Stage I: confined to cervix
Stage II: beyond cervix but not to lower ⅓ vagina or pelvic sidewalls
Stage III: to pelvic sidewalls or lower ⅓ of vagina
Stage IV: beyond pelvis, or into bladder/rectum, or distant mets
Treatment of preinvasive / microinvasive (stage I-Ia) cervical cancer
Simple hysterectomy
Consider cold knife cone if fertility highly desired
Treatment of early (stage Ia-2 to IIa) cervical cancer
Radiation or radical hysterectomy + bilat LN dxn
Includes parametria, upper vaginal cuff, uterosacral / cardinal ligaments, vascular supply
Decision based on age, ability to tolerate surgery, ?nearby rad facilities
If young, may lean towards surgery (keep ovaries!
Treatment of advanced (IIb-IV) cervical cancer
Treat with chemoradiation (cisplatin-based + internal & external rad)
Treatment of recurrent cervical cancer
Can treat with pelvic exenteration & get 50% survival
Palliation of cervical cancer
Cisplatin chemo and/or palliative radiation
