Lecture 2: Pap Smear, Cervical Dysplasia, Cancer

Question 1

1. Which 2 HPV strains cause HIGH-GRADE cervical cancers?
2. Which 2 HPV strains cause genital warts (LOW GRADE lesion)

Answer 1

1. HPV 16, 18** –> HIGH GRADE
2. HPV 6,11 –> LOW GRADE

Question 2

What is the only modifiable risk factor to reduce risk of cervical cancer?

Answer 2

- SMOKING *******

Other risk factors:

1. Multiple sexual partners
2. Young age at first intercourse
3. HIV + Organ transplant
4. STI’s
5. DES exposure
6. High parity

Question 3

What are the pap smear screening guidelines based on age for …

1. Under 21?
2. 21-29?
3. 30-65?
4. 65+?

Answer 3

1. no screening
2. cytology alone every 3 years
3. HPV and Cytology “cotesting” every 5 years (preferred)
4. No screening following adequate negative prior screening

Question 4

What are the pap smear screening guidelines following hysterectomy?

Answer 4

No screening

Question 5

If 40 y/o patient had an unknown HPV status on her last pap result.

When is next pap?

Answer 5

3 years

(when unknown)

Question 6

What 6 things can the 2001 Bethesda System tell us about a pap smear?

Answer 6

1. • Specimen type
2. • Specimen adequacy = satisfactory or unsatisfactory (not enough cells)
3. • General categorization
4. - Organisms
5. • Other non neoplastic findings: inflammation, radiation, IUD
6. • Epithelial cell abnormalities

Question 7

What are the guidelines for managment of a women w/ atypical squamous cells of undetermined significance

(ASC-US) on cytology?

Answer 7

Repeat cytology at 1 year and do HPV testing

Question 8

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 8

then back to routine screening (if Negative)

or do colposcopy ( ≥ASC)

Question 9

What are the guidelines for managment of a women w/…

Atypical squamous cells of undetermined significance

(ASC-US) if…

HPV testing is positive

HPV testing is negative?

Answer 9

- Positive = managed same as LSIL —> colposcopy

• Negative = repeat cotesting at 3 years

Question 10

What are the guidelines for managment of a women w/…

LSIL and negative HPV test?

Answer 10

• 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 11

What are the guidelines for managment of a women…

1) w/ LSIL and no HPV test

or

2) LSIL with a positive HPV test?

Answer 11

Colposcopy

Question 12

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

Answer 12

1. I_mmediate loop electrosurgical excision_

or

2. Colposcopy (w/ endocervical assessment)

Question 13

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

Answer 13

- Colposcopy w/ directed biopsy

Question 14

What are 2 CONCERNING findings on Colposcopy?

(that may indicated cervical cancer)

Answer 14

1. • Mosaicism***
2. - Abnormal blood vessels****

Other colposcopy findings

1. • Acetowhite changes
2. • Punctuations (tiny blood vessels)
3. • Masses

Question 15

Which 3 instances require excisional techniques for cervical neoplasia?

Cold Knife Cone (CKC)

Loop Electrode Excision Procedure (LEEP)

Answer 15

1. • + Endocervical curettage (needs cold knife cone)
2. - Unsatisfactory colposcopy (No SCJ)
3. - Substantial discrepancy btw pap and biopsy (i.e., high grade pap, but negative colposcopy)

Question 16

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

Answer 16

1. • PPROM ↑ risk ******
2. • Operative risks –> bleeding, infection******
3. • Cervical incompetence ↑ risk (and resultant 2nd trimester pregnancy loss)
4. • Cervical stenosis

Question 17

What is the most obvious symptom of cervical carcinoma?

What is the CAUSE of cervical cancer (91%)?

Answer 17

1. • VAGINAL BLEEDING AFTER SEX/INTERCOURSE****
     * - Intermittent spotting, also watery, vaginal bleeding*
2. _HPV (squamous cell carcinoma)***_

Question 18

How is cervical carcinoma staged?

Answer 18

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

Question 19

1. Which age demographic is recommended the HPV vaccine?
2. Cautionary Side Effect of HPV Vaccine (Gardasil)?
3. What additional prevention should be taken w/ HPV vacine, to prevent cervical cancer?

Answer 19

1. • 9-45 y/o men AND women (LARGE RANGE)
     * *can receive even if have abnormal pap!**

2. SYNCOPE (dizziness, fainting)***, headache

3. Barrier Protection***

Question 20

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

Answer 20

• 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 21

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

Answer 21

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

Question 22

List 6 AE’s associated with HPV vaccination?

Answer 22

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