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MBBS IV - Junior Clerkship WCS > JC103 (O&G) - Cervical cancer screening > Flashcards

JC103 (O&G) - Cervical cancer screening Flashcards

1
Q

Cervical cancer

  • Reasons to why it is suitable for screening
A
  1. High prevalence
  2. Suitable disease:
    • Early treatment is effective
    • Long progression from precancer lesions to invasive cancer
  3. Suitable tests
    • Minimally invasive sample collection
    • Cervix is accessible to cytologic screening or HPV testing
  4. Suitable screening programs (territory-wide Cervical Screening Programme)
  5. Cost-effective screening test
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2
Q

Personnel/ organisations involved in population-wide cervical cancer screening

A

 Training and education of medical personnel, smear takers
 Cytology pathology laboratory accreditation – QA
 Colposcopy accreditation – QA
 Audit (based on CSIS)

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3
Q

Target population for cervical cancer screening in HK

A

Start screening at age 25 or commencement of sexual life
Stop at age of 65

Screen women >65 years who:
 Have never had a cervical smear, or
 Request a cervical smear

Avoid cervical screening during pregnancy (induce anxiety)

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4
Q

Frequency of cervical cancer screening in HK

A

After 2 consecutive normal annual smears, screen at 3-yearly intervals

Annual screening for persons at high risk of developing cervical carcinoma more rapidly, eg. Immunosuppression, HIV

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5
Q

System for cervical smear screening in HK

Methods for increasing reach of screening program

A

Organized screening with central registry - Cervical cancer screening information system (CSIS) HK:

  • Send reminders for screening
  • Trace abnormal results and defaulters
Methods to increase reach 
 Public education
 Health workers education
 Publicity (mass media)
 School education (young people)
 Clinics/ centres – Department of Health: Women’s health centre, Well Women Clinics, Family Planning Association
 Mobile units
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6
Q

Pap smear

  • Sampling devices
  • Site of sampling
  • Sampling technique
  • Storage and labeling method
A

Tools:
Wooden/ plastic Ayre’s spatula
Endocervical brush
Choose rize based on vagina: e.g. larger for multiparous

Site: cells from cervical os at transformation zone (squamocolumnar junction)

Technique:

  • Push sampler gently and rotate around cervical os
  • Rinse brush into vial for liquid- based cytology (LBC)/ fix immediately
  • Discard spatula or brush

Storage:

  • Label, check identity
  • Fill request form with matched identity
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7
Q

Patient information contained on a request form for pap smear

A

Fill in request form properly with matched identity:
 Clinical data (helps cytopathologist make the correct diagnosis)
 Age
 Last menstrual period/ duration of menopause
 Parity
 Contraceptive history
 Drug/ medical history

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8
Q

Contraindications to pap smear

A

Blood in vagina or cervix (normal menstruation or other pathologies)

Obvious or gross growth on cervix (covered by necrotic cells, causing false negative cytology) - Biopsy indicated

Cervix cannot be seen

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9
Q

Causes of unsatisfactory pap smear

A
  1. Artifacts – air-dried (should fix immediately)/ too thick/ too scanty cells/ heavily blood- stained
  2. Marked inflammation/ infection (PMN+++ masks host cells)&raquo_space;> treat infection and repeat
  3. Menopausal (atrophic epithelium  cells look abnormal)&raquo_space;> apply local estrogen and repeat
  4. Post-treatment (radiotherapy, chemotherapy)
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10
Q

Uterine cervix tumor types

A

Epithelial:

  • Squamous cell tumors and precursors
  • Glandular tumors and precursors
  • Other epithelial tumors

Mesenchymal tumors and tumor-like conditions

Mixed epithelial and mesenchymal tumors

Melanocytic tumors

Lymphoid and haematopoetic tumors

Secondary tumors

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11
Q

Name the system that standardizes terminology & reporting of cervical cytology

A

The Bethesda system (TBS):
Merged Dysplasia and Carcinoma-in-situ into Squamous intraepithelial lesion (SIL):
behaviour, molecular virologic findings and morphologic features

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12
Q

Outline the classification systems for Epithelial** cervical cancer

3 main histological groups after classification

A

Atypical squamous cells
 Of undetermined significance (ASC-US)
 Cannot exclude HSIL (ASC-H)

Neoplasm:
1. Bethesda system (TBS): classify cytology by pathohistological features as
 Low-grade squamous intraepithelial lesion (LSIL)
 High-grade squamous intraepithelial lesion (HSIL)
2. WHO Classification of uterine cervix tumors: Specify CIN = cervical intraepithelial neoplasia as CIN-I to CIN-III, VAIN I- VAIN III and VIN I- VIN III**
3. WHO classification of female genital tumors: Specific as HPV-associated or HPV-independent

SCC:
 SCC, HPV- associated
 SCC, HPV- independent
 SCC, NOS (not otherwise specified)

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13
Q

2 lab tests for HPV status of female genital tumors

A

HPV molecular testing

p16 IHC

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14
Q

7 types of uterine cervix glandular tumors (WHO)

A

Adenocarcinoma in-situ

  • HPV associated type
  • HPV independent type

Adenocarcinoma, HPV associated

Adenocarcinoma, HPV Independent

  • Gastric type
  • Clear cell type
  • Mesonephric type

Adenocarcinoma, others

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15
Q

3 main groups of epithelial cervical cancer after classification

A
  1. Atypical squamous cells
     Of undetermined significance (ASC-US) - most common smear result
     Cannot exclude HSIL (ASC-H)
  2. Squamous intraepithelial lesions (SIL)
     Low-grade squamous intraepithelial lesion (LSIL)
     High-grade squamous intraepithelial lesion (HSIL) - features of invasion
  3. SCC:
     SCC, HPV- associated
     SCC, HPV- independent
     SCC, NOS (not otherwise specified)
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16
Q

Atypical squamous cells of undetermined significance (ASC-US)

  • Incident rate in population-wide pap smears
  • Risk
  • Management of ASCUS smear result
A

ASC-US
- Most common abnormality in screening population (60-80%), majority turns out as normal/ LSIL

Risk:
- progression into HSIL, Invasive epithelial cervical cancer (rare)

ASCUS: Repeat cytology at 6 months and 12 months

  • Both normal = repeat cytology at 3 years
  • ASCUS or above within 12 months = Colposcopy

HPV test as triage or co-testing

  • High risk, HPV positive = Colposcopy
  • High risk, HPV negative = Repeat co-testing or cytology at 3 years
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17
Q

Atypical squamous cells - Cannot exclude HSIL (ASC-H)

Risks
Proportion that turn out to be HSIL?

A

Risks:
 Higher risk of oncogenic HPV DNA detection
 Higher risk of underlying CIN 2 or worse (30- 40%) in biopsy compared to ASC-US

High proportion (24-94% in diff. studies) turned out to have HSIL (CIN II-III)

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18
Q

Types of atypical glandular cells/ precursors of adenocarcinoma

A

Atypical endocervical cells

  • NOS or specify in comments
  • favor neoplastic type

Atypical endometrial cells
- NOS or specify in comments

Atypical glandular cells:

  • NOS or specify in comments
  • favor neoplastic type

Endocervical adenocarcinoma in situ

  • HPV associated
  • HPV independent
19
Q

Compare the histological difference between atypical glandular cells and adenocarcinoma-in-situ at cervix

A

Atypical glandular cells:
- Eccentric hyperchromatic nuclei with mucin vacuole
- microglandular hyperplasia
= benign lesion related to hormonal effect

Adenocarcinoma-in-situ
- Marked increased N/C ratio, nuclear overlapping, glandular configuration
= favor neoplastic lesion

20
Q

Most common glandular cervical tumors in HK

A

Most common = precursor glandular lesions:
Atypical Glandular Cell-FN (favor neoplasia): 27-96% turned out to have HSIL (CIN2-3), AIS, Ca

AGC-NOS (not otherwise specified): 9-41% turned out to have HSIL (CIN2-3), AIS, Ca

AGC after confirmation tests:
 9.2%: CIN II-III
 4.3%: CIN I
 5.7%: carcinoma of corpus (endometrial cancer)
 2.8%: carcinoma of ovary (ovarian cancer)
 2.1%: extragenital malignancies
 1.4%: adenocarcinoma of cervix

20
Q

Most common glandular cervical tumors in HK

A

**AGC-FN (favor neoplasia): 27-96% turned out to have HSIL (CIN2-3), AIS, Ca

*AGC-NOS (not otherwise specified): 9-41% turned out to have HSIL (CIN2-3), AIS, Ca

AGC after confirmation tests:
 9.2%: CIN II-III
 4.3%: CIN I
 5.7%: carcinoma of corpus (endometrial cancer)
 2.8%: carcinoma of ovary (ovarian cancer)
 2.1%: extragenital malignancies
 1.4%: adenocarcinoma of cervix

21
Q

Glandular cervical cancer

Management of Atypical Glandular Cell smear result

A

AGC - endometrial cells: Endometrial sampling

  • Positive = refer for treatment
  • Negative: Colposcopy + biopsy + Endocervical sampling

All subcategories of AGC + negative endometrial sample for AGC- endometrial cells:
- Colposcopy + biopsy + Endocervical sampling
» lesion identified = treatment
» No lesion:
i. AGC favours neoplasia or Endocervical AIS = Diagnostic excisional conization and follow-up ultrasound pelvis to exclude adnexal pathology
ii. AGC-NOS: repeat cytology 6 monthly until 4 consecutive normal results OR Diagnostic excisional conization if abnormal cytology

22
Q

List 4 advanced techniques for gynaecological cytopathology testing

A

Automation in cytology preparation

Liquid-based cytology (LBC)

Automated screening with imaging system, computer-assisted

Applications of molecular tests: IHC, ISH, DNA, HR-HPV tests**

23
Q

Benefits of liquid based cytology LBC for cervical smears

A

 Less unsatisfactory smear: more clarity, uniformity, reproducibility
 Less reactive atypia
 Increased definitive diagnosis of SIL

24
Q

List oncogenic, high risk HPV subtypes

A

15-20 oncogenic (high risk - HSIL, CA): HPV 16, 18, 31, 33, 45, 51, 52, 58, 59 etc

HPV 16, 18 cause 70% of cervical cancer

25
Q

Indications for direct colposcopy and biopsy

A

HPV 16 or 18 positive

Abnormal (HSIL), Regardless of HPV status

Abnormal (LSIL) HPV +ve

ASC-H

Inconclusive (ASC-US), High-risk HPV+

26
Q

Outline 3 follow-up options for abnormal cervical smear

A
  1. Repeat smear and cytology or HPV test
  2. colposcopy and punch biopsy for histological diagnosis
  3. Take biopsy for obvious lesion e.g. endometiral/ endocervical
27
Q

Management of ASC-US smear result

A

Repeat smear in 6 months, 12 months
Refer for colposcopy and biopsy if abnormality persists

OR

Triage with test for high-risk HPV
Positive = colposcopy
Negative = repeat cytology screening (co-testing or cytology) in 3 years

28
Q

Management of ASC-H smear result

A

Refer colposcopy and biopsy
- 2 consecutive normal = back to normal routine

Obtain endocervical sampling if unsatisfactory colposcopy

  • No lesion = repeat cytology every 6 months
  • Persistent abnormal cytology = repeat colposcopy
29
Q

Management of LSIL smear result

A

Refer colposcopy and biopsy

Co-testing for High risk HPV (hrHPV)
- HPV positive = colposcopy
- HPV negative = repeat co-testing in 12 months

Cytology
» Abnormal = colposcopy
» Both normal, = repeat co-testing or cytology in 3 years, then routine screening

30
Q

Management of HSIL smear result

A

Refer colposcopy

If gross lesion seen = Punch biopsy

Immediate biopsy regardless of HPV status

31
Q

Management of atypical glandular cells on cervical smear

A

Refer to colposcopy, endometrial biopsy and endocervical sampling (endometrial sampling first for AGC-Endometrial cells)

For AGC-FN or AGC- endocervical cells: if no significant pathology for source of abnormal cells&raquo_space; Diagnostic cold knife cone biopsy/ conization

For AGC-NOS: Repeat 6-monthly until 4 consecutive normal results, then resume normal screening schedule

32
Q

Management of adenocarcinoma in situ cervical smear result

A

Refer for colposcopy and biopsy +/- endocervical sampling and endometrial sampling

Cone biopsy if no lesions found

33
Q

Colposcopy for cervical lesions

  • Method
  • Functions
  • Sample area
A

Instrument:

  • Magnify cervix 8-25X using binocular optic instrument
  • 3-5% acetic acid: dense aceto-white lesions, abnormal vascular pattern, punctations and mosaic
  • Adjunctive test (Schiller’s test): Lugol’s iodine negative (normal = dark; abnormal cannot be stained)

Functions:

  • Punch biopsy of gross lesion if seen
  • Visualize lesion
  • Find vascular patterns

Sample area:
whole lesion and squamocolumnar junction

34
Q

Management of unsatisfactory colposcopy sampling

A

Good sample needs squamocolumnar junction and whole lesion:

Squamocolumnar junction not seen: Obtain endocervical sampling:

  • If no lesion identified, review material, repeat colposcopy with estrogen in menopausal women
  • If lesion persists, diagnostic cone biopsy
  • If abnormal cytology persists, repeat colposcopy
  • If cytology is normal twice, back to routine screening

Whole lesion not seen = diagnostic cone biopsy

35
Q

Management of low-grade CIN cervical smear result

A

Follow up every 6 months:

  • Majority of low grade cervical intraepithelial neoplasia regressed spontaneously (over 2 years) - follow up till normal
  • If persisted for 2 years - consider treatment

If patients not reliable for follow-up, can offer treatment at diagnosis

36
Q

Treatment options of high grade cervical CIN

A 
A. Ablative therapy (no histology):
 Cryotherapy (-50oC) to freeze the tissue
 Cold coagulation
 Diathermy
 Laser evaporisation

B. Excision therapy – cone biopsy for histology:
 Knife
 Laser
 Large loop excision (electric) of the transformation zone of the cervix (LLETZ) – most commonly used:

C. Hysterectomy (rarely indicated)

37
Q

Most common treatment options for high grade cervical CIN

Complication

A

Large loop excision (electric) of the transformation zone of the cervix (LLETZ)

Complications:
 Intraoperative and postoperative bleeding (1-8%)
 Infection
 Cervical stenosis (1%)
 Cervical deformity
 Cervical incompetence
 Premature rupture of membrane, premature labour, low birthweight

38
Q

Monitoring method after treatment of high-grade cervical CIN

A

Repeat cervical smear at 6 month intervals till normal for 3 consecutive smears then annually

39
Q

Treatment of early invasive cervical cancer

A

Radical hysterectomy with bilateral pelvic lymphadenectomy; or radiotherapy

40
Q

Primary prevention of cervical cancer

A

Healthy lifestyle (do not smoke for better immunity)

Safer sex

HPV vaccines

41
Q

Types of HPV vaccines

A

Vaccine types and HPV subtypes:

Bivalent - 16, 18
Quadrivalent - 16, 18, 6, 11
Nonavalent - 6/ 11/ 16/ 18/ 31/ 33/ 45/ 52/ 58 (5 additional oncogenic)

42
Q

Benefits of higher HPV vaccination rate

A 
Reduction in: 
 Abnormal cervical cytology
 High-grade CIN
 Colposcopy examination
 Operative procedure for treatment of high-grade CIN
43
Q

Target populations recommended for HPV vaccine in Hong Kong

Dosing regimens

A

Prophylactic HPV vaccines for women with no prior exposure to the virus (i.e. in never-sexually active women)

Women aged >15 = 3-dose regimen
Girls aged <15 = 2-dose regimen within 6-12 months

Should not be given to pregnant women

MBBS IV - Junior Clerkship WCS (131 decks)

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