Chapter 22: Cervical Screening And Cervical/Vulval Cancer Flashcards
You are a trainee intern in general practice with Saskia, an asymptomatic 26 year old nulliparous NZ European woman. Saskia had a routine cervical screening test taken last week and has been told that the result is “not absolutely normal”. The smear is reported as “ASCUS” and she asks you what this means. From the following options, which is the MOST APPROPRIATE response to explain ASC-US?
Some cells in the basal third of the epithelium of the cervix are atypical. There is a moderate risk of her developing cervical cancer in the next few years.
Some cells in the cervix are showing enlarged nuclei and increased division. There is a moderate risk of her developing cervical cancer in the next few years.
ASCUS stands for abnormal squamous cells of undetermined significance. These are unlikely to be precancerous. A follow up smear in 12 months is recommended.
Some of the cells covering the cervix show increased mitotic activity. There is a moderate risk of her developing cervical cancer in the next few years.
There are atypical cells in the squamous epithelium of the cervix that have a moderate risk of malignant progression
ASCUS stands for abnormal squamous cells of undetermined significance. These are unlikely to be precancerous. A follow up smear in 12 months is recommended.
You are a trainee intern in general practice with Maeve, a 26 year old nulliparous Pākehā woman. Maeve has been advised that a routine cervical screening test taken the previous week was reported as showing a low-grade squamous intraepithelial lesion LSIL (CIN 1). Maeve asks you what would have happened if she hadn’t had her smear taken. From the following options, what is the MOST APPROPRIATE response to her about the natural history of CIN1?
The abnormal cells become more active in about 30% of women, with progression to a more advanced precancer - but rarely cancer. You will probably need a LLETZ treatment.
This smear result is due to infection with a HPV virus, and always resolves as your immune system gets rid of the virus within around 6-12 months.
The abnormality nearly always progresses to a high-grade squamous intraepithelial Neoplasia (HSIL, or CIN2/3), meaning that you are likely to need treatment.
The smear result likely indicates infection with the HPV virus without significant precancerous changes, and these appearances will most likely resolve as your immune system gets rid of the virus
The smear has shown low-grade abnormal cells which often become more severe, with about 25% progressing to invasive cervical cancer. You should be referred to colposcopy.
The smear result likely indicates infection with the HPV virus without significant precancerous changes, and these appearances will most likely resolve as your immune system gets rid of the virus
You are a trainee intern in general practice with Awhina, a 42 year old para 3 Māori woman whose recent smear has shown HSIL (CIN2/3). Her husband had a vasectomy seven years ago. Her children are aged 14, 12 and 7. All of her previous smears have been normal. Of the following, which is the MOST IMPORTANT predisposing factor to Awhina developing HSIL?
She had chlamydia aged 25
She has used the oral contraceptive pill
She has HPV-16
She smokes 10-20 cigarettes per day
She first had sex when aged 21
She has had two sexual partners
She has HPV-16
You are a trainee intern in general practice with Jess, a 43 year old para 3 Pākehā woman whose recent smear showed LSIL (CIN 1). Because of her age, high-risk HPV testing was also done. This was positive, so Jess was referred for a colposcopy. Jess’ husband had a vasectomy seven years ago. Her three daughters are aged 14, 12 and 7. All her previous cervical screening tests have been normal and her last smear was five years ago. She has had warts on her hands during her last pregnancy but these went away by themselves. Jess asks whether there is anything she has done that has contributed to her developing a cervical abnormality. Of the following options, which would be the MOST IMPORTANT risk factor for Jess?
Jess has used the oral contraceptive pill
Jess smokes cigarettes
Her husband has penile warts
Jess has had previous termination of pregnancy
Jess has had chlamydia which was treated
Jess smokes cigarettes
Penile warts - 6 and 11 - very low risk for HPV
You are a trainee intern in general practice with Jess, a 43 year old para 3 Pākehā woman whose recent smear showed LSIL (CIN 1). Because of her age, high-risk HPV testing was also done. This was positive, so Jess was referred for a colposcopy. Jess’ husband had a vasectomy seven years ago. Her three daughters are aged 14, 12 and 7. All her previous cervical screening tests have been normal and her last smear was five years ago. She has had warts on her hands during her last pregnancy but these went away by themselves. Jess asks whether there is anything she has done that has contributed to her developing a cervical abnormality. Of the following options, which would be the MOST IMPORTANT risk factor for Jess?
Jess has used the oral contraceptive pill
Jess smokes cigarettes
Her husband has penile warts
Jess has had previous termination of pregnancy
Jess has had chlamydia which was treated
Jess smokes cigarettes
Penile warts - 6 and 11 - very low risk for HPV
You are a trainee intern in general practice with Hannah, a 25 year old nulliparous Pākehā woman who presents to discuss contraception. She is currently using condoms. Hannah has not previously had a cervical screening test, so you advise her to have one and to join the National Cervical Screening Programme (NCSP) register. You provide some additional information. Of the following options, which statement about cervical screening in the NCSP is TRUE?
To register with the NCSP, Hannah needs to complete in writing an enrolment form
There is only a small initial cost to join the register
Only doctors who are specially trained can take the cervical screening samples
If Hannah enrols, the NCSP will inform Hannah when her next cervical screen is overdue
The NCSP informs enrolled women only if their result is abnormal
If Hannah enrols, the NCSP will inform Hannah when her next cervical screen is overdue
You are a trainee intern in a gynaecology clinic with Fergie, a 34 year old para 3 NZ European woman who has been referred for colposcopy because her smear showed HSIL (probable CIN 2/3). Fergie was asymptomatic and had not previously had an abnormal smear. Of the following options, where are you MOST LIKELY to see the cervical abnormality in a woman with HSIL?
On the anterior lip of the cervix
On the posterior lip of the cervix
In the vaginal fornices
In the transformation zone of the cervix
In the endocervical canal
In the transformation zone of the cervix
You are a trainee intern in general practice with Dawn, a 34 year old para 3 Samoan woman who has presented with an episode of postcoital bleeding. Dawn has never had an abnormal smear. Her last smear was two years ago. Dawn is on the oral contraceptive pill. General and abdominal examination is unremarkable. From the following options, what is MOST IMPORTANT aspect of the speculum examination?
Take swabs for an STI
Take a swab for bacterial vaginosis
Carefully examine the cervix and vaginal sidewalls
Show the speculum to the woman before insertion
Take an HPV test
Carefully examine the cervix and vaginal sidewalls
You are a trainee intern in general practice reviewing the result of a routine cervical screening test you recently took on Rena, a 34-year-old British woman. Rena had previously had a normal cervical screening history. The test is reported as showing “Atypical squamous cells of uncertain significance (ASC-US). Routine high-risk HPV (HrHPV) testing will be reported separately.” From the following options, what is the most important impact the result of the HrHPV test will have on Rena’s management?
If the HPV test is positive, Rena should be referred to colposcopy
If the HPV test is positive, Rena will need STI testing
If the HPV test is positive, Rena will need a cone biopsy
If the HPV test is negative, the interval to the next smear test is the routine three years
If the HPV test is positive, Rena must have genital warts
If the HPV test is positive, Rena should be referred to colposcopy
You are a trainee intern in general practice reviewing Bernie, a 33 year old nulliparous Pākehā woman who recently had a routine cervical smear. The report reads: “Low grade squamous intraepithelial lesion (LSIL). High-risk HPV detected.” Bernie’s previous history was of regular and normal smears. She uses a 30 ug ethinyl oestradiol combined oral contraceptive pill. She has genital warts. From the following options, what is the MOST APPROPRIATE management?
Refer Bernie for colposcopy now based on the LSIL, HrHPV positive result
Advise Bernie to stop the oral contraceptive, and repeat the cytology test in 12 months.
Refer Bernie for cryotherapy treatment of genital warts and repeat the cytology in 6 months
Recommend HPV immunisation with the nonavalent vaccine, “Gardasil-9”
Repeat the cytology test in 6 months, and refer to colposcopy if the result is still LSIL.
Refer Bernie for colposcopy now based on the LSIL, HrHPV positive result
You are a trainee intern at a colposcopy clinic reviewing Joy, a 38-year-old para 3 New Zealander of Chinese ethnicity. Joy had a colposcopy a week ago colposcopy following a LSIL, HrHPV positive screening test. The colposcopy identified an area of acetowhite change and a biopsy of this area was taken. The histology of this cervical biopsy has been reported as showing high-grade change involving the full thickness of the cervical epithelium, but not breaching the basement membrane. Which of the following is the most likely DIAGNOSIS on the histopathology report?
HPV
CIN 3 / HGSIL
Cervicitis
Microinvasion
CIN 1 / LGSIL
CIN 3 / HGSIL
You are a trainee intern in a colposcopy clinic seeing Nora, a 35 year old asymptomatic para 3 Māori woman for treatment of biopsy proven CIN3. Nora has completed her family. When the colposcopy was done the area of the lesion was small and the lesion was able to be completely visualised. There was no evidence of a glandular lesion in the cervical canal. Of the following options, what is the MOST APPROPRIATE treatment?
LLETZ (Large loop excision of the transformation zone)
Cone biopsy
Further biopsy
Cryotherapy
Hysterectomy
LLETZ
Cone biopsy is more extreme
You are a trainee intern in general practice reviewing the notes of Larni, a 36 year old para 3 Pasifika woman who had a routine cervical screening test with you last week The smear results has returned as HSIL (probable CIN 2/3). Of the following factors in her history, which would MOST LIKELY have predisposed her to having this abnormality?
Diethylstilboestrol exposure in utero
First pregnancy at age 16
Past history of two premature births
Smoking
A cervical infection with HPV-16
A cervical infection with HPV-16
You are a trainee intern attending a gynae oncology multidisciplinary team meeting (MDT). Naomi, a 51 year old Niuean woman, is being discussed. She had been seen urgently last week in the colposcopy clinic after her GP noted a 2 cm fungating mass on the posterior cervical lip, which bled profusely when a smear was taken. The cervical screening test had been reported as abnormal with a high grade cervical squamous intraepithelial lesion (HSIL). A biopsy taken last week has confirmed squamous cell carcinoma. Radiological investigations have shown that the lesion is restricted to the cervix and there is no evidence of metastasis. From the following options, what is the MOST LIKELY treatment for Naomi?
Total hysterectomy and bilateral salpingo-oophorectomy
Radiation therapy (brachytherapy)
Chemotherapy
LLETZ biopsy under general anaesthesia
Radical hysterectomy and pelvic lymph node dissection
Cone biopsy under general anaesthesia
Radical hysterectomy and pelvic lymph node dissection
You are a trainee intern in a gynaecology clinic seeing Jane, a 30 year old asymptomatic nulliparous Fijian Indian woman who required a cone biopsy for AIS – adenocarcinoma in situ. Histology confirmed the excised lesion as AIS, and this was completely excised. Jane is now planning a pregnancy. From the following options, what is the most important pregnancy complication of Jane’s cervical abnormality and treatment?
Premature delivery or preterm prelabour rupture of membranes
Cervical tear causing primary postpartum haemorrhage after vaginal delivery
Recurrence of the AIS lesion during her pregnancy
An antepartum haemorrhage related to residual or recurrent AIS
Failure of the cervix to dilate in labour, requiring delivery by caesarean section (cervical stenosis)
Premature delivery or preterm prelabour rupture of membranes
You are a trainee intern in a general practice. Penny, a 16-year-old Tongan school girl who attends with her mother. Penny’s mother required a radical hysterectomy for cervical cancer when aged 33. Penny and her mother have heard that there is a vaccine to prevent cervical cancer. From the following options, what is the MOST APPROPRIATE information to tell them about the current Gardasil-9 vaccine?
Penny will have to pay for the vaccine, as she is over 12
Penny is too old for the vaccine, but should have a smear test
Penny will not need smear tests if she gets the vaccine
The vaccine is most effective if given prior to exposure to the HPV virus
The vaccine prevents all genital warts
The vaccine is most effective if given prior to exposure to the HPV virus
You are a trainee intern at a family planning clinic reviewing Lucy, a 39-year-old para 2 NZ European woman. Lucy has a 9-week history of post coital bleeding and a brown discharge. She had been using the oral contraceptive pill for a year without problems until the development of the PCB and discharge. On speculum examination, there is a 7mm smooth, cherry-red, polypoid mass protruding from the cervical os. A cervical smear was taken, and this caused slight bleeding. The mass was grasped with forceps, and avulsed by torsion. The microscopy report stated “An inflamed polypoid mass covered by endocervical epithelium undergoing squamous metaplasia.” From the following options, what is the MOST LIKELY diagnostic summary on the histology report?
Cervical ectropion
Endocervical polyp
Cervical endometriosis
Cervical adenocarcinoma
Endometrial polyp
Endocervical polyp
Benign, no endometrium.
You are a trainee intern in a gynaecology clinic. Sneha is a 51-year-old G3P2 Indian woman who had a cervical biopsy a week ago. She had initially presented to her GP with a three month history of offensive vaginal discharge, postcoital bleeding and dyspareunia. Sneha had not previously had a cervical screening test, and has lived in New Zealand for the past 12 years. Sneha’s GP noted a 2 cm fungating mass on the posterior cervical lip which bled profusely when a smear was taken. The smear had been reported as abnormal ASC-H (abnormal squamous cells of uncertain significance, ?high grade). The biopsy taken last week has confirmed squamous cell carcinoma. Of the following options, what is Sneha’s main risk factor for cervical cancer?
Dyspareunia
Multiparity
Being unscreened/under screened
Caesarean section delivery
Indian ethnicity
Being unscreened/under screened
You are a trainee intern in general practice. You are about to undertake a routine cervical screening test on Huhuna, a 30 year old para 2 wahine Māori. Which of the following options will be the most important when you perform the cervical screening?
Inspecting the cervix
Rinsing the sampler in the transport fluid
Using a cervi-broom
Rotating the sampler around the TZ once
Swabbing any mucus from the cervix
Tightening the fluid container lid
Ensuring an adequate sample of cells is taken from the cervical transformation zone
Ensuring an adequate sample of cells is taken from the cervical transformation zone
Kerry is a 29 year old Pākehā trans man who you are seeing in General Practice. He asks you whether he needs a cervical smear. He has been on masculinising gender affirming hormone therapy for 2 years. He plans on having a bilateral mastectomy (top surgery) next year. He is amenorrhoeic on Depo provera. Kerry is an otherwise healthy non-smoker. He had the Gardasil vaccine 6 years ago. Of the following options, which statement is correct regarding Kerry’s need for a cervical smear?
Kerry does not need a cervical smear as he has had his Gardasil vaccinations and these protect against HPV.
Kerry will need to have a colposcopy with a gynaecologist as smears are not able to be interpreted in people on testosterone therapy.
Any person who has a cervix who has ever been sexually active should have a smear. A small speculum should be used to reduce Kerry’s discomfort.
It will not be possible to take a cervical smear because the hormones Kerry is taking make the cervix smaller
Any person who has a cervix who has ever been sexually active should have a smear. A large speculum will need to be used to find Kerry’s cervix.
Any person who has a cervix who has ever been sexually active should have a smear. A small speculum should be used to reduce Kerry’s discomfort.
You are a trainee intern in Family Planning seeing Huia Brown, a 38-year-old Māori wahine. Huia has presented for a cervical smear after receiving a letter from the National Cervical Screening Programme (NSCP) reminding her that she is due for a cervical smear. Huia asks you some questions about the NSCP, including how effective it has been in reducing rates of cervical cancer in wāhine Māori. Of the following options, which statement BEST DESCRIBES cervical screening rates in wāhine Māori compared with Pākehā women in Aotearoa?
Wāhine Māori are more likely to be diagnosed with cervical cancer than Pākehā women
Wāhine Māori are more likely to be screened for cervical cancer than Pākehā women
Wāhine Māori are more likely to be diagnosed with earlier stage cervical cancer than Pākehā women
Wāhine Māori are more likely to present earlier for a cervical smear than Pākehā women
Wāhine Māori are more likely to be over-screened for cervical cancer than Pākehā women
Wāhine Māori are more likely to be diagnosed with cervical cancer than Pākehā women
You are a trainee intern in colposcopy clinic sitting in on a consult with Ana. Ana is a 44-year-old wahine Māori who has been referred with a high-grade cervical smear. The smear was taken at a marae-based clinic and Ana attends with her sister. The colposcopic examination findings are consistent with a high-grade lesion and there is no evidence of malignancy. Of the following options, which statement will best describe the examination findings and tests taken when Ana has her colposcopy?
The colposcopic findings are of a reddened cervix with a dense uptake of Lugol’s iodine. Two representative biopsies are taken.
The colposcopic findings are of a dense uptake of Lugol’s iodine. There were no acetowhite areas. Two representative biopsies are taken.
The colposcopic findings are of a dense acetowhite lesion with coarse mosaicism. There is a wide iodine negative area. Two representative biopsies are taken.
The colposcopic findings are of a 2cm exophytic lesion at 12:00. A biopsy is not required as the diagnosis is obvious and a biopsy would be uncomfortable for Ana.
The colposcopic findings are of a 2cm exophytic lesion at 12:00. There is a large acetowhite area. Two representative biopsies are taken.
The colposcopic findings are of a dense acetowhite lesion with coarse mosaicism. There is a wide iodine negative area. Two representative biopsies are taken.
No iodine = no glycogen. Acetowhite = high nuclear:cytoplasma ratio.
