Cervical Screening Symposium

Question 1

What cancers are largely caused by HPV?

Answer 1

Cervix
Penis
Vulva/vagina
Anus

Question 2

How does HPV infect?

Answer 2

Passes into micro-abrasions in the epithelium - invade basal cells

Question 3

How does HPV infection become pre-cancerous?

Answer 3

Virus DNA with cell DNA invades other cells
Leads to more damage and disorganisation
Grows to full thickness

Question 4

How are people immunised against HPV?

Answer 4

2 dose regimen

Question 5

What is the SCCRS?

Answer 5

Scottish Cervical Call Recall System
Smear taker enters request details
Vials sent to lab (added to SCCRS)
Patient details received, vials stained
Cytology lab puts results on SCCRS
Woman + GP receive results

Question 6

How does the cervix change in puberty?

Answer 6

Increased vascularity and interstitial fluid

Glandular epithelium metaplasia to squamous epithelium

Question 7

Why does vaginal glandular epithelium undergo metaplasia in women going through puberty?

Answer 7

Response to increased acidity in the vagina

Question 8

Which part of the cervix is susceptible to HPV? Why?

Answer 8

Transitional zone

Large amount of cell turnover here

Question 9

How are women screened for cervical cancer?

Answer 9

Smear every 5 years

Question 10

How are cervix samples tested?

Answer 10

Liquid based cytology
HrHPV test
(If +ve) - Reflex Cytology

Question 11

How does the HPV test work?

Answer 11

Identifies HPV type using viral DNA and RNA

High risk type > specific genotyping

Question 12

How are cervical cytology samples tested?

Answer 12

Cells scraped from transformational zone
Look for dyskaryosis
Look for underlying CIN

Question 13

What is CIN?

Answer 13

Cervical intraepithelial neoplasia

Question 14

What is dyskaryosis?

Answer 14

Abnormal cells

Question 15

What are the different epithelium of the cervix?

Answer 15

Endocervix - columnar epithelium

Ectocervix - squamous epithelium

Question 16

How are cervical samples processed?

Answer 16

Thin layer of cells with PAP smearing

Question 17

What features suggest dyskaryosis?

Answer 17

Nucleus:

• Increased size
• Increased Nuclear:cytoplasmic ratio
• Variation in size/shape
• Coarse irregular chromatin
• Nucleoli

Question 18

What do different grades of dyskaryosis reflect?

Answer 18

Degree of underlying CIN

Question 19

What do Koilocytes suggest?

Answer 19

HPV infection

Question 20

How do HPV tests and Cytology differ?

Answer 20

HIV test: 
 - Cervical cells
 - Identifies infection
 - Sensitive
Cytology: 
 - Cervical cells 
 - Cellular changes (grading)
 - Specific

Question 21

What happens next if a patient has a negative HrHPV?

Answer 21

Routine recall in 5 years

Question 22

What happens next if a patient has a positive HrHPV?

Answer 22

Cytology normal - repeat in 1 year

Dyskaryosis: refer to colposcopy

Question 23

What is the process for colposcopy?

Answer 23

Education and Advice
Magnification + light on cervix
Acetiv acid + iodine

Question 24

What is the benefit of colposcopy?

Answer 24

Identify limits of lesion
Biopsy site
Showing CIN/metaplasia

Question 25

How is CIN managed?

Answer 25

Low grade - return | High grade - treat

Question 26

What is the function of HPV E7 protein?

Answer 26

Prevent cell cycle arrest

Question 27

What is the function of HPV E6 protein?

Answer 27

Inhibit cell death

Question 28

Which cells does HPV infect?

Answer 28

Basal cells

Question 29

What is Koilocytosis?

Answer 29

Cells with wrinkled nucleus and perinuclear halo | Multinucleation

Question 30

What are the main low risk types of HPV?

Answer 30

6, 11, 42, 44

Question 31

What are the main high risk types of HPV?

Answer 31

16, 18, 31, 45

Question 32

What do low risk HPV types cause?

Answer 32

Genital warts Low grade CIN Transient infection

Question 33

What do high risk HPV types cause?

Answer 33

High grade CIN/Cancer | Persistent infection

Question 34

How does high grade HPV cause CIN?

Answer 34

Persistent infection Viral DNA integrates into host cell genome Overexpression of viral E6 and E7 proteins Deregulation of host cell cycle

Question 35

How does high grade CIN present histologically?

Answer 35

Neoplastic/undifferentiated cells fill full thickness of epithelium

Question 36

What is CIN?

Answer 36

Disorganised proliferation of abnormal cells in squamous epithelium Precursor to cancer

Question 37

How is CIN treated?

Answer 37

LLETZ Thermal coagulation Laser ablation

Question 38

How is CIN treatment followed up?

Answer 38

``` Confirm treatment was effective Prevent invasive cancer Reassure the woman Increased risk of cervical cancer Follow up LBC at 6 months (cytology - high risk HPV) ```

Question 39

How is the patient managed if her follow-ups are both negative?

Answer 39

Return to recall (every 5 years)

Question 40

How is the patient managed if either of her follow-ups are positive?

Answer 40

Return to colposcopy