Cervical screening and colposcopy

Question 1

Describe the National Cervical Screening Programme in NZ and routine screening:

Answer 1

All SEXUALLY ACTIVE women age 25 to 69 years old.

After first ever smear OR if first smear in more than 5 years, second smear should be performed 12 months later and if both normal smear interval increased to every 3 years.

Question 2

What are the recommendations from the NCSP on screening women aged 70 years and older who were unscreened or under-screened prior to age 70?

Answer 2

Should have TWO consecutive normal cytology samples taken 12 months apart before ceasing cytology screening.

Question 3

What are the recommendations from the NCSP for follow-up after successful treatment of high grade squamous disease?

Answer 3

Discharge from colposcopy to primary care for test of cure:

• Co-testing (cytology + hrHPV test) should be performed at 6 months and 12 months
• If any concerns or abnormalities, should return to colposcopy at 6 months post-treatment for co-testing.

Question 4

What is the negative predictive value for hrHPV testing in detecting high grade abnormalities?

Answer 4

NPV 99% and is more sensitive than cytology.

Question 5

Describe the 4 groups of women in which reflexive hrHPV testing is performed currently:

Answer 5

• Women >30 years old with AS-CUS or LSIL (without an abnormal smear in last 5 years).
• All women receiving treatment for high-grade lesions to assess whether lesion has completely resolved.
• Women with HSIL or ASC-H more than 3 years ago with subsequent repeated negative cytology
• Discordant cytology and colposcopy results for post-colposcopy management.

Question 6

Why might a smear cytology be considered unsatisfactory?

Answer 6

Sample taking:

• Inadequate number of cells sampled
• Contact bleeding
• Contaminants e.g. lubricant

Clinical factors:

• Bleeding
• Inflammation
• Cytolysis

Lab technical processing issues.

Question 7

How should an unsatisfactory smear cytology be managed?

Answer 7

• Repeat smear within 3 months.
• Refer to colposcopy to exclude high grade lesion after 3 consecutive unsatisfactory smear reports
• Prescribe course of vaginal oestrogen cream nightly for 2-3 weeks prior to repeating smear in postmenopausal, postnatal and breastfeeding women.

Question 8

If a woman aged 25-69 with NO abnormal smear history within last 5 years has a smear report showing ASC-US or LSIL, how should she be managed?

Answer 8

Repeat smear in 12 months time:

• if persistent abnormality: refer for colposcopy
• if negative, repeat smear again in 12 months and if negative return to 3 yearly screening. If abnormal refer to colposcopy

Question 9

If a woman aged 25-69 WITH an abnormal smear history within last 5 years has a smear report showing ASC-US or LSIL, how should she be managed?

Answer 9

Refer to colposcopy

Question 10

If a woman aged 25-69 with with a PRIOR HIGH GRADE ABNORMALITY more than 5 years ago has a smear report showing ASC-US or LSIL, how should she be managed?

Answer 10

Refer to colposcopy

Question 11

If a woman aged more than 30 with NO abnormal smear history within last 5 years has a smear report showing ASC-US or LSIL, how should she be managed?

Answer 11

She will receive reflexive hrHPV testing:

• If positive, she should be referred to colposcopy.
• If negative, she should have a repeat smear in 12 months and if negative she should return to 3 yearly screening.

Question 12

What are the indications for colposcopy?

Answer 12

· Persistent abnormalities on repeat smear.
· HSIL, ASC-H at any smear.
· Abnormal smear in 30+ with no abnormal smears in last 5 years that tests positive for HrHPV.
· 3 consecutive unsatisfactory smear results.
· Other indications: sexual abuse investigation; cervical polyp; associated suspicious lesions of genital tract.

Question 13

Describe the steps you would do to perform colposcopy:

Answer 13

• Examine in lithotomy position with speculum using colposcope.

General assessment:

• Adequate OR inadequate (and if inadequate, for what reason)
• Visibility of SCJ: fully, partially or not visible
• Transformation zone type 1, 2, or 3. Whole TZ should be visualised.

Note other typical appearances of CIN:
- Abnormal capillary patterns such as punctation and mosaicism

Apply acetic acid 5% and assess for acetowhite changes.

Apply Lugol’s iodine (Schiller’s test) and assess for areas of poor iodine uptake and delineate lesion.

Biopsy dysplastic areas.
Perform endocervical curettage in non-pregnant women with smears showing atypical glandular cells or adenocarcinoma in situ.

Question 14

List colposcopic changes (grade 2/major changes) that make you suspicious of a high-grade lesion or invasive cancer:

Answer 14

• Dense acetowhite epithelium and rapid appearance of acetowhitening.
• Sharp regular border.
• Cuffed crypt (gland) openings
• Blood vessels: coarse mosaic and punctation.
• Inner border sign: inner more proximal lesion more severe/higher grade.
• Ridge sign
• Rag sign
• Iodine negative areas in association with acteowhitening.
• Erosions
• Leukoplakia

Question 15

Regarding colposcopic assessment of ASC-US or LSIL:

How should an unsatisfactory colposcopy be managed?

Answer 15

Repeat cytology

- If low-grade, repeat colposcopy, cytology and hrHPV testing in 12 months.

Question 16

How should LSIL / CIN1 confirmed on histology be managed?

Answer 16

· Treatment is not recommended because such lesions are considered to be an expression of a productive HPV infection
· Refer back to sample taker for repeat cytology at 12 and 24 months; if both negative can return to 3 yearly screening.
· Refer back to colposcopy if either repeat test shows ASC-US/LSIL or higher degree of abnormality.

Question 17

A woman is referred to colposcopy with an ASC-H/HSIL smear but her colposcopy was satisfactory and normal or biopsy negative.

How should she be managed?

Answer 17

Perform review cytology (repeat smear):
- If review confirms high-grade lesion, repeat colposcopy and cytology in 3 months time.

If repeat cytology and colposcopy at 3 months:

• Normal: repeat cytology in 12 months
• LSIL: individualise management with MDM
• HSIL, CIN2/3: treatment

Question 18

A woman is referred to colposcopy with an ASC-H/HSIL smear but her colposcopy was UNsatisfactory:

How should she be managed?

Answer 18

Perform review cytology (repeat smear):

• If review confirms ASC-H or HSIL, cone biopsy/type 3 excisional treatment recommended.
• If review confirms ASC-US or LSIL, individualise management at MDM.

Question 19

Excisional treatments of the cervix are associated with what obstetric risks?

Answer 19

• Preterm delivery
• Low birth weight
• Premature rupture of membranes.

Question 20

What is the most important risk factor for treatment failure with excisional treatment?

Answer 20

Involved excision margins.

Question 21

List the indications for colposcopy during pregnancy:

Answer 21

• HSIL/ASC-H smear
• Glandular lesion on smear
• Concerning cervical appearance or persistent postcoital bleeding

Question 22

List the issues with colposcopy during pregnancy:

Answer 22

• Cervix is hypetrophied and hyperaemic
• Increased vaginal wall laxity making visualisation difficult
• Deciduosis: similar appearance to malignancy with exaggerated squamous metaplasia and vascular changes
• Increased risk of bleeding
• Increased amount of cervical mucus produced

Goal: to rule out invasive cancer. Biopsy ONLY if invasive cancer is suspected. Otherwise, reassess 6-12/52 postpartum

Question 23

During pregnancy:
When should treatment for invasive cancer be performed?

What are the issues associated with excisional treatment during pregnancy?

Answer 23

• Excisional treatment should be performed between 12 and 20 weeks ideally.

Issues include:

• Risk of pregnancy loss
• Risk of haemorrhage; may need haemostatic sutures
• May need cerclage
• High risk of recurrence or persistence.

Question 24

Describe squamous metaplasia

Answer 24

• Through exposure to oestrogen, the glycogen in the cells of the vagina is converted into lactic acid.
• This acidity, along with other factors, stimulates the replacement of the columnar epithelium with squamous epithelium.
• This process is known as metaplasia
• Metaplasia results in the formation of a new SCJ
• The area between the original SCJ and the new SCJ is known as the transformation zone

Question 25

What are the 3 types of Transformation zones?

Answer 25

1. SCJ is fully visible and located fully on the ectocervix
2. SCJ is fully visible (with or without endocervical speculum) and is located either fully or partially within the endocervical canal
3. The SCJ is within the endocervical canal and is only partially visible or not at all visible, even using an endocervical speculum

Question 26

How does acetic acid identify abnormal cervical cells?

Answer 26

• Acetic acid causes reversible coagulation and precipitation of proteins in the epithelial cells
• if draws water out of the cells, causing the cell membrane to collapse around the large abnormal nucleus (if present)
• Because of these changes, the epithelium, which is normally a transparent filter, becomes opaque and does not allow passage of light through it
• in normal squamous epithelium, the cells have low protein levels. Because the cytoplasm is replaced by glycogen and the nuclei are very small or absent, acetic acid has NO effect, because there is no protein to coagulate
• in neoplastic epithelium, there are many cells with high protein content because of large nuclei, extra chromatin and intact cytoplasm. The excess protein gets coagulated and this gives it a WHITE appearance
• The higher the grade of neoplasia, the greater the protein content and the greater the density of ACETOWHITENING

Question 27

How does Lugol’s Iodine identify abnormal cervical cells?

Answer 27

Brown staining of the Intracellular glycogen, which normal cells have.

High grade CIN lesions have low amounts of glycogen because the epithelium is poorly differentiated, and hence they do not turn brown

Also called Schillers test

Question 28

What are the treatment options for HSIL (CIN2/3)

Answer 28

Cryotherapy
Thermal ablation
LLETZ
Cone biopsy / cold knife conisation

Question 29

What are the criteria for cryotherapy for HSIL (CIN2/3)

Answer 29

• Lesion on ectocervix only
• T1 TZ
• Lesion does not occupy more than 75% cervix
• Site of lesion can be covered by the tip of the cryotherapy proble
• NO suspicion of invasive cancer
• NO glandular abnormality

Question 30

What are the cytological findings in HSIL?

Answer 30

Moderate to severe dyskaryosis
Nuclear enlargement
Variation in size and shape of nuclei
Increased nuclear: cytoplasmic ratio
Hyperchromatism

Question 31

What are the cytological findings in LSIL?

Answer 31

Mild dyskaryosis

Question 32

4 Indications high grade and to biopsy during colposcopy

Answer 32

1. Colour tone and intensity of acetowhite
2. Margins and surface contour of acetowhite
3. Vascular pattern - punctuation, mosaic, atypical vessels or irregular size, shape, course
4. Iodine staining/Schillers tear - poorly differentiated cells do not have glycogen to uptake the iodine and stain brown

Question 33

3 ways HPV evades humoral immune system

Answer 33

Downregulates inflammatory micro environment

Inhibits recruitment of langerhan cells and dendritic stromal cells

Inhibits entry of effector T cells into epithelium