Clin: Pap Smear - Wooton Flashcards
what is the site where more than 90% of cervical neoplasia arise?
squamocolumnar junction (SCJ)
what happens to the SCJ as women age?
it moves up into the cervical canal, becoming protected
how many strains of HPV are associated with cancer?
15
which 4 strains cause the majority of cancer?
- *16, 18**, 31, 45
- 16 and 18 responsible for 70% of cervical cancer
which HPV strains are associated with genital warts and low grade lesions?
6, 11
what are the risk factors for cervical neoplasia?
- multiple sexual partners
- young age at first intercourse
- smoking (3.5x greater risk)
- organ transplant
- DES exposure
- high parity (esp with multiple partners)
what are the screening guidelines for females under 21?
NO screening
what are the screening guidelines for females age 21-29?
pap cytology every 3 years
what are the screening guidelines for females age 30-65?
HPV and cytology every 5 years
what are the screening guidelines for females age 65 and over?
no screening following adequate negative prior screening
what are the screening guidelines for females after hysterectomy?
NO screening
a satisfactory specimen on the 2001 Bethesda system has both what?
endo and ectocervix spacimen
what organisms can be identified using the 2001 Bethesda system?
- trichomonas
- fungal organisms consistent with Candida
- shift in flora suggestive of bacterial vaginosis
- bacteria morphologically consistent with actinomyces
- cellular changes consistent with HSV
what epithelial cell abnormalities can be identified using the 2001 Bethesda system?
atypical squamous cells
- of undermined significance (ASC-US)
- cannot exclude high grade (ASC-H)
low grade squamous intraepithelial lesion (LSIL)
high grade squamous intraepithelial lesion (HSIL)
squamous cell carcinoma
what is the order of cervical changes leading to cervical cancer?
normal -> LSIL -> HSIL -> cervical cancer
what if a woman tests positive for ASC-US, but negative for HPV?
repeat co-testing in 3 years
what if a woman tests positive for ASC-US, and is HPV positive?
needs colpo
what if a woman tests positive for LSIL, but negative for HPV?
repeat co-testing in 1 year
what if a woman tests positive for LSIL with positive HPV test?
needs colpo
what if a woman tests positive for LSIL with no HPV test?
still needs colpo to be safe
what if a woman tests positive for HSIL?
requires automatic colpo workup
what is the gold standard for diagnosis and treatment of cervical cancer?
colpo with directed biopsy
what happens to abnormal cells when they are washed with 3% acetic acid?
acetowhite changes: the acid dehydrates the cells and large nuclei of abnormal cells turn white
NOTE: must visualize the entire SCJ
LSIL is considered what on the CIN grading system?
CIN I
HSIL is considered what on the CIN grading system?
CIN II or III
when mosaicism is visualized on a cervix, what CIN stage is it almost always?
CIN III (high grade lesion)
cryotherapy and laser ablation are examples of what type of treatment?
ablative
cold knife cone (CKC) and loop electrode excision procedure (LEEP) are examples of what type of treatment?
excisional
when would you perform excisional techniques?
- endocervical curettage positive (needs cold knife cone)
- unsatisfacotry colposcopy (no SCJ)
- substantial discrepancy between pap and biopsy (high grade pap vs negative colpo)
what are the risks of excisional procedures?
- increased risk cervical incompetence and resultant second trimester pregnancy loss
- increased risk PPROM
- cervical stenosis
- operative risks (bleeding, infection)
97% of cervical cancer is caused by what?
HPV
- SQQ = 80%
- adenocarcinoma = 15%
watery vaginal bleeding, postcoital bleeding, intermittent spotting
- spread by direct invasion and lymphatic spread
cervical carcinoma
how would you manage microinvasive cervical cancer?
cold knife cone or hysterectomy
how would you manage invasive cervical cancer?
radical hysterectomy with lymph node dissection
how would you manage bulky disease cervical cancer?
radical hysterectomy with lymph node dissection or radiation therapy and cisplatin-based chemo
how would you manage stage IIb and greater cervical cancer?
external beam radiation and concurrent cisplatin-based chemo
how can you prevent cervical cancer?
- sexual abstinence/limiting number of partners
- use of barrier protection
- regular exams and pap smears (est to reduce morbidity/mortality by 40%)
- HPV vaccination
what is the injection series for HPV vaccine?
1st dose, 2nd dose 2 months later, 3rd dose 6 months from first
recommended routine vaccination for all girls and boys 9-26
FDA approved use in men/women ages 27-45
what vaccination routine does the ACIP recommend for adolescents less than 15 years of age?
2 routine doses separated by 6-12 month intervals
can you receive the HPV vaccine if you’ve had an abnormal pap?
yes
can you receive the HPV vaccine during pregnancy or breastfeeding?
pregnancy - NO
breastfeeding - yes
what does the 4 strain Guardasil protect against?
6, 11, 16, 18
- 70% of cervical, vaginal and 50% of vulvar cancers
what does the 9 strain vaccine protect against?
6, 11, 16, 18, 31, 33, 45, 52, 58
what are the side effects for Cervarix (older vaccine that protected against 16 and 18, but no longer available in US)?
- syncope
- dizziness
- nausea
- headache
- fever
