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Repro Exam II > Dunn CIS : gest trophoblastic disease and pap smear > Flashcards

Dunn CIS : gest trophoblastic disease and pap smear Flashcards

1
Q

Gestational Trophoblastic Disease (GTD)

A

Abnormal proliferation of trophoblast of the placenta
Broad category

Result of an aberrant fertilization event that leads to a proliferative process
Incidence higher in Asian and Latin American American countries (1:12-5800 ns 1:1000-1500 in North America and Europe)
SX: Consistent with early pregnancy
Vaginal bleeding is common – usually thought to be threatened abortion; due to separation of tumor from underlying decidua
Risk Factors
Age >35
HX of previous GTD

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2
Q

Benign nonneoplastic trophoblastic lesions

A

Exaggerated placental site

Placental site nodule

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3
Q

Hydatidiform mole types

A

(80% of cases)
Complete mole
Partial mole
Invasive mole (chorioadenoma destruens)

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4
Q

Gestational Trophoblastic Neoplasia (GTN)

A 
True neoplasia – potential for local invasion or metastases
- Choriocarcinoma
- Placental site trophoblastic tumor
- Epithelioid trophoblastic tumor
Curable in 85-100% cases
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5
Q

Complete mole

A

46, XX
Can have 46, XY if fertilized by two sperm
All paternal chromosomes
Haploid sperm fertilizes an “empty” ovum
- (w/o or inactivated maternal chromosomes)
No fetal tissue

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6
Q

Incomplete mole

A

69, XXY
Fertilization of ovum with haploid maternal chromosomes by two sperm
Fetal tissue present

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7
Q

Causes of hydatidiform moles

A

Genomic imprinting
Paternal genes = Placental growth
Maternal genes = Fetal growth
Excess paternal genes  excessive placental or trophoblastic growth

Mechanism
Many suggested causes:
- Unstable mitochondrial DNA
- Overexpression of oncogenes
- Downregulation of tumor suppressor genes
- Telomerase activity
- Cell-cell adhesion molecules
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8
Q

Complete Molar Pregnancy

A

Fertilization of an empty ovum either by two sperm or one sperm that duplicates (46XX or46XY)
Excessive uterine size for gestational age d/t tumor or hemorrhage and retained clot
Can become choriocarcinoma

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9
Q

Partial Molar Pregnancy

A

Fertilization of a haploid ovum by either two sperm or one sperm that duplicates causing 69XXX, 69XXY, or 69Xyy
Presence of a fetus; some fetal cardiac tones may be detected
Less likely to become malignant

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10
Q

Complications: Most due to highly elevated HCG levels

A

Ovarian enlargement due to theca lutein cysts
Hyperemesis gravidarum
Early development of preeclampsia (before 20 weeks)
Hyperthyroidism
Hemorrhage (<500mL common)

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11
Q

Risk Factors for moles

A

Extremes of maternal ages (<20 or >40 yo)

Diet deficient in folate or β-carotene

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12
Q

typical History/PE of mole

A 
1st Trimester painless bleeding
Hyperemesis gravidarum
Preeclampsia/eclampsia <24 weeks
Uterine size > EGA
Hyperthyroidism
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13
Q

Diagnosis of moles

A 
No fetal heartbeat
Increased β-hCG (>100,000 mIU/mL)
Pelvic exam
- Enlarged ovaries (bilateral theca-lutein cysts)
- Grapelike cluster expelled into vagina

U/S

  • “snowstorm” appearance, cluster of grapes
  • No gestational sac/fetus
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14
Q

Treatment of moles

A

D&C

  • Serial β-hCG
  • Until 3 consecutive values are obtained

If persistently high

  • Postmolar GTN
  • Chemotherapy and/or excisional surgery
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15
Q

Persistent disease (after moles)

A

15-20% after a complete mole; 3-5% after a partial mole
Characteristics that increase the likelihood of neoplasia after molar evacuation include large theca lutein cyst (>6cm),excessively enlarged uterus for dates, age over 40, previous GTD, initial hCG >100,0000 mlU/mL, the presence of hyperplasia or atypia on histology, and heterozygosity (dispermic moles)
Follow HCG levels
- T1/2 = about 48 hours
- Steady HCG levels indicates persistent disease
— Usually invasive mole; <10% choriocarcinoma
Once HCG levels are stable at <5 for 3 weeks, ok to resume attempts at pregnancy

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16
Q

Bacterial vaginosis

A

No inflammation, thus other symptoms such as pain/itching/inflammation suggest concomitant infection with other organisms
Most common cause of vaginal discharge in reproductive age women
Overgrowth of anaerobic bacteria: Gardenerella is key
Loss of lactobacilli
Risk factors: sexual activity, douching
50-70% asymptomatic

The characteristic milky or creamy vaginal discharge of BV associated with high vag pH and Fishy odor

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17
Q

Diagnosis of bacterial vaginosis

A 
Diagnosis based on 3 or more Amsel criteria
- Homogenous white to gray discharge
- pH > 4.5
- (+) whiff test with KOH
Clue cells on wet mount
Gram stain is gold standard, rarely done
PCR-based assay
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18
Q

what we will see in bacterial vaginosis on microscope

A

absence of WBC’s and stippling of epithelial cells

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19
Q

BV: Associated complications

A

PID, post-abortal PID, post-hysterectomy infections

pre-term delivery, PROM, amniotic fluid infection, chorioamnionitis, post-partum endometritis

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20
Q

BV Treatment

A

Metronidazole (avoid alcohol)

  • 500mg PO BID x 7 days
  • 0.75% gel 5g vaginally daily x 5 days

Clindamycin

  • 2% cream 5g vaginally QHS x 7 days
  • 300mg PO BID x 7 days
  • 100mg vaginal suppository QHS x 3 days
  • 2% Clindesse cream 5g as single vaginal dose

Tindazole
- 1g PO daily x 5 days

Treatment of asymptomatic women no recommended unless prior to procedures
Treatment of partners not recommended

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21
Q

Trichomonas vaginalis- discharge

A

Bubbly discharge of vaginal fluid

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22
Q

Pap smears- Normal vs. Abnormal

A

Cellular Level:

  • Increased nuclear to cytoplasmic ratio
  • Abnormal cell structure
  • Koilocyte indication of HPV infection
23
Q

Human papilloma virus stats

A

20 million infected persons
6 million new HPV infections per year in the U.S.
75% of sexually active adults will be infected sometime in their life
More than 100 types of virus
40 types sexually transmitted

24
Q

HPV 3 types of infection:

A 
Latent: 
Accounts for most HPV
No visible lesion
Only diagnosed by DNA hybrid testing
DNA testing performed in the evaluation of an abnormal pap smear

Subclinical Infection:
Lesions visible only during colposcopy
Frequently have an abnormal pap

Clinical Infection:
Visible “warty” growths called Condylomata Accuminata
On vulva, vagina, cervix, urethra, perianal

25
Q

HPV is associated with

A

Genital neoplasias
Cervical, vaginal, vulvar cancers
11,000 new cervical cancers yearly
8,000 vaginal/vulvar cancers

Genital Warts (Condyloma)

26
Q

HPV: External genital warts

A

Condylomata Accuminata
1 million new cases in U.S. yearly
HPV infection usually clears spontaneously within 2 years

27
Q

HPV risk types

A

High Risk: 16 – 18 30

Low Risk: 6 – 11 (causes warts)

28
Q

TREATING WARTS

A

Relieve symptoms
- Pain and bleeding
Cosmetic concerns
Psychological concerns

29
Q

Cytology of pap smear

A

Normal
ASCUS – Atypical Squamous Cells of Undetermined
Significance
ASC – H - Atypical Squamous Cells favor high grade lesion
AGUS – Atypical Glanular Cells of Undetermined Significance
LSIL – Low Grade Squamous Intraepithelial Lesion
HSIL – High Grade Squamous Intraepithelial Lesion
Invasive Cancer

30
Q

Work-up abnormal pap

A

Age dependent
Degree of abnormality
Risk factors

31
Q

Risk Factors (cervical cancer)

A 
No recent pap
 Smoking
 Age of 1st intercourse
 Number of partners
 Immunocompromised (HIV)
32
Q

Colposcopy

A

Looking at Cervix through Microscope
Normal Cervix
Abnormal Cervix – patterns
Transformation Zone

33
Q

Histology of cervical cancer

A 
Cervical Intraepithelial Neoplasia 
CIN I - Mild Dysplasia
 CIN II – Moderate Dysplasia
 CIN III -  Severe Dysplasia, Carcinoma in Situ
 Invasive Cancer
34
Q

Activity of disease (CIN)

A

CIN I – 70% - regress, 20% stay the same,
10% progress
CIN II – 30% regress, 30% stay the same,
30 – 40% progress
CIN III – all need treatment
Invasive Cancer – all need treatment

35
Q

Treatment of cervical cancer

A 
Follow up Pap
Destruction (cauterization, cryotherapy)
Excision (loop, cone)
Hysterectomy
Radical Hysterectomy (includes top third vagina parametrium  and lymph nodes)
36
Q

Indications for Conization

A 
Treatment for CIN II or III
Endocervical disease on colposcopy
Discrepancy between PAP and colposcopy
Inadequate colposcopy
Depth of invasion
37
Q

WHO ARE THE RARELY AND ENVER SCREENED

A 
Minorities
Low SES*
Foreign born
Living in the US < 10 years
No usual source of health care
38
Q

Natural History of Cervical Cancer

A

HPV infection –>
(6-12 months) disappearance or
(6-24 months) CIN 1 or

CIN 2,3 (10-13 years to invasive CA)

39
Q

major contributing factor to most cervical cancer deaths today.

A

Being rarely or never screened

40
Q

Why isn’t “finding lesions” the objective of screening?

A

Don’t know which lesions will progress.

Need to place emphasis on:

  • Persistent HPV infections
  • CIN 3 (no margin for error)

CIN 2 in older women (no risk to pregnancies)

Persistent CIN 2 and CIN 2/3 in non- adolescent women

41
Q

Cervical cancer screening should begin at age

A

21, regardless of age or sexual onset

42
Q

Adolescent Needs

A

Care for contraception and STI screening/treatment.

No Pap test

No speculum exam for asymptomatic women

STI testing can be done using urine

43
Q

Screening for ages 21-29

A

Cytology alone every 3 years

HPV testing “should not be used to screen”

  • Not as a component of cotesting
  • Not as a primary stand-alone screen
44
Q

Rationale for Avoiding HPV Tests Among Women Ages 21-29

A

Prevalence of carcinogenic HPV approaches 20% in teens and early 20s

Most carcinogenic HPV infections resolve without intervention

Identifying carcinogenic HPV that will resolve leads to repeated call-back, anxiety, and interventions without benefit

45
Q

Screening For Women Ages 30-64

A

Cytology + HPV testing (Cotesting) every 5 years is preferred

Cytology alone every 3 years is acceptable

46
Q

Rationale for Cotesting, Ages 30-64

A

Increased detection of prevalent CIN3

Decreased CIN3 in subsequent screening rounds

Achieves risk of CIN3 equal to cytology alone
@ 1-3year intervals

Enhances detection of adenocarcinoma/AIS

Minimizes the increased number of colposcopies, thus it reduces harms.

47
Q

Managing ASC-US/HPV negative tests

A

Women with ASC-US cytology and negative HPV test results should continue screening per age-specific guidelines.”

CIN3 risk of ASC-US/ HPV neg <2%, below threshold for colposcopy.

48
Q

Immediate HPV genotyping

A

If HPV 16 or HPV16/18 positive, refer directly to colposcopy.

If HPV 16 or HPV 16/18 negative, repeat cotest in 12 months and then…

  • If either repeat test is positive, refer to colposcopy
  • If both tests are negative, return to routine screening.
49
Q

When to Stop Screening

A

Stop at age 65 for women with adequate negative prior screening, no CIN2+ within the last 20y.

*** Definition of adequate negative screening:
- 3 consecutive negative Paps or
- 2 consecutive negative HPV tests
(Tests within 10 years of stopping; most recent within 5 years.)

Stop after hysterectomy with removal of cervix and no history of CIN2+
- “Evidence of adequate negative prior screening is not required”

50
Q

Rationale for stopping (cervical cancer screening) after Hysterectomy

A

Vag cancer rate is 7/million/year

663 vag cuff Paps needed to find one VAIN

2,066 women followed after hyst. for average 89 months

– 3% had VAIN, 0 had cancer

Risk of Pap abnormality after hyst = 1%.

Compare risk of breast cancer in men for which screening is not recommended.

51
Q

When NOT to stop at age 65 years

A

If history of CIN2, CIN3, or AIS

– Continue “routine screening” for at least 20 years, “even if this extends screening past age 65.”

52
Q

Screening a Vaccinated Cohort

A 
“ Recommended screening practices should not change on the basis of HPV vaccination.”
Vaccination against HPV 16/18
- Reduces CIN3+ by 17-33%
- Reduces colposcopy by 10%
- Reduces treatment by 25%

But who is vaccinated?
- Recall? Completed series? HPV naïve?

53
Q

“The biggest gain in reducing cervical cancer incidence and mortality would be achieved by

A

increasing screening rates among women rarely or never screened. . .

Clinicians, hospitals, health plans, and public health officials should seek to identify and screen these women.”

Repro Exam II (18 decks)

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