Lecture 2: Pap Smear, Cervical Dysplasia, Cancer

Question 1

List 6 AE’s associated with HPV vaccination?

Answer 1

• Syncope** (most common)
• Dizziness + Nausea + HA + Fever
• Injection site rxns (pain, swelling, and redness)

Question 2

How many injections are in a series of HPV vaccine and what is the recommendation for scheduling?

Answer 2

• 3 injection series:
• 1st dose
• 2nd dose 2 months later
• 3rd dose 6 months from the first (can still be given if interval varies)
• In children <15 y/o give 2 doses separated by 6-12 month

Question 3

What are the recommendations for the HPV vaccine?

Answer 3

• All girls and boys ages 9-26 y/o
• Approved for use in men and women 27-45 y/o

Question 4

What are the risk factors for cervical neoplasia?

Answer 4

• Multiple sexual partners
• Young age at first intercourse
• Smoking
• HIV + Organ transplant
• STI’s
• DES exposure
• High parity

Question 5

What are the pap smear screening guidelines following hysterectomy?

Answer 5

No screening

Question 6

How is invasive (early stages) cervical carcinoma managed clinically?

Answer 6

Radical hysterectomy w/ LN dissection

Question 7

What is the gold standard for diagnosis and treatment planning of abnormal pap smear?

Answer 7

Colposcopy w/ directed biopsy

Question 8

What are the 2 ablative techniques for cervical neoplasia?

Answer 8

• Cryotherapy
• Laser ablation

Question 9

What are the abnormalities you are looking for on Colposcopy?

Answer 9

• Acetowhite changes
• Punctuations (tiny blood vessels)
• Mosaicism
• Abnormal blood vessels
• Masses

Question 10

What are 3 instances when excisional techniques are done for cervical neoplasia?

Answer 10

• Endocervical curettage positive (needs cold knife cone)
• Unsatisfactory colposcopy (No SCJ)
• Substantial discrepancy btw pap and biopsy (i.e., high grade pap and negative colposcopy)

Question 11

What are the guidelines for managment of a women w/ LSIL and negative HPV test?

Answer 11

• Repeat co-testing at 1 year (preferred), but colposcopy is acceptable
• If cytology and HPV negative —> repeat at 3 years
• If ≥ASC or HPV positive –> then colposcopy

Question 12

Which strains of HPV cause the majority of cancers?

Answer 12

HPV 16, 18, 31, and 45

Question 13

What can the 2001 Bethesda System tell us about a pap smear?

Answer 13

• Specimen type
• Specimen adequacy = satisfactory or unsatisfactory (not enough cells)
• General categorization

- Organisms

• Other non neoplastic findings: inflammation, radiation, IUD
• Epithelial cell abnormalities

Question 14

What are 3 signs/sx’s related to cervical carcinoma?

Answer 14

• Watery vaginal bleeding
• Postcoital bleeding
• Intermittent spotting

Question 15

What are the pap smear screening guidelines based on age?

Answer 15

• Under 21 = no screening
• 21-29 y/o = cytology alone every 3 years
• 30-65 y/o = HPV and Cytology “cotesting” every 5 years (preferred)
• 65+ y/o = no screening following adequate negative prior screening

Question 16

What are the guidelines for managment of a women w/ atypical squamous cells of undetermined significance (ASC-US) if HPV testing is positive vs. negative?

Answer 16

• Positive = managed same as LSIL —> colposcopy
• Negative = repeat cotesting at 3 years

Question 17

What are the guidelines for managment of a women w/ HSIL?

Answer 17

• Immediate loop electrosurgical excision

or

• Colposcopy (w/ endocervical assessment)

Question 18

What are the guidelines for managment of a women w/ atypical squamous cells of undetermined significance (ASC-US) on cytology?

Answer 18

Repeat cytology at 1 year and do HPV testing

Question 19

How is stage IIb and greater cervical carcinoma managed clinically?

Answer 19

External beam radiation and concurrent cisplatin based chemotherapy

Question 20

If a patient already has an abnormal pap can they receive an HPV vaccine; what about during pregnancy and breast feeding?

Answer 20

• Can receive if already have abnormal pap
• NOT for use in pregnancy, but safe in breastfeeding

Question 21

What are the guidelines for managment of a women w/ LSIL and no HPV test or LSIL with a positive HPV test?

Answer 21

Colposcopy

Question 22

How is microinvasive cervical carcinoma managed clinically?

Answer 22

Cold knife cone or hysterectomy

Question 23

What are 4 risks associated with excisional procedures for cervical neoplasia?

Answer 23

• ↑ risk of cervical incompetence and resultant 2nd trimester pregnancy loss
• ↑ risk of preterm premature rupture of membranes (PPROM)
• Cervical stenosis
• Operative risks –> bleeding, infection…

Question 24

How is bulky disease cervical carcinoma managed clinically?

Answer 24

Radical hysterectomy w/ LN direction or radiation therapy and cisplatin-based chemo

Question 25

What are the guidelines for managment of a women w/ atypical squamous cells of undetermined significance (ASC-US) after repeat cytology at 1-year if result is negative or ≥ASC is found?

Answer 25

• Negative: then back to routine screening
• ≥ASC: then do colposcopy

Question 26

How is cervical carcinoma staged?

Answer 26

• Clinically by:
• PE
• Radiologic exams –> CXR and skeletal XR’s + intravenous pyelogram
• Cystoscopy
• Sigmoidoscopy
• Liver function studies

Question 27

If 40 y/o patient had an HPV status that was unknown on her last pap result when would she need another pap?

Answer 27

3 years when unknown