Pap Smear, Cervical Dysplasia, Cervical Cancer Flashcards
Site where >90% of cervical neoplasia arises
Squamocolumnar junction
Which HPV strains cause the majority of cancers?
16 and 18 are responsible for 70% of cervical cancers
Other high risk types are 31 and 45
Risk factors for cervical neoplasia
Multiple sexual partners or sexual partner with multiple sexual partners
Young age at first intercourse or pregnancy
Smoking
HIV
Organ transplant
STI
DES exposure
Infrequent or absent pap screening tests
High parity
Low SES
Pap smear screening guidelines by age
Under 21 = no screening
21-29 = Cytology alone every 3 years
30-65 = HPV and Cytology “co-testing” every 5 years
65+ = no screening following adequate negative prior screening
After hysterectomy = no screening
Management of women with pap cytology result: atypical squamous cells of undetermined significance (ASC-US)
Preferred next step is HPV testing
If HPV test is positive, the next step is colposcopy. If HPV test is negative, repeat cotesting in 3 years.
[an acceptable initial next step would be repeat cytology in 1 year, and if that is positive to proceed with colposocopy]
Management of women with pap cytology result: LSIL with negative HPV test
Preferred next step is repeat cotesting in 1 year
If that repeat cotesting is both cytology negative and HPV negative, repeat cotesting again in 3 years.
However, if that repeat cotesting is positive for either atypical squamous cells or HPV, proceed with colposcopy
[an acceptable initial next step would be to do a colposcopy right away, but the above is the recommended plan]
Management of women with pap cytology result: LSIL with either no HPV test, or a positive HPV test
Colposcopy!
Management of women with pap cytology result: HSIL
Immediate loop electrosurgical excision OR colposcopy with endocervical assessment
Colposcopy with directed biopsy is the gold standard for dx and treatment planning. What are the goals of colposcopy?
Must visualize the ENTIRE squamocolumnar junction, looking for acetowhite changes, punctations, mosaicism, abnormal vessels, and/or masses
May perform directed biopsy and endocervical curettage (ECC)
A 34 y/o asian female presents for f/u after an abnormal pap smear. The pt’s pap smear was LSIL with positive high risk HPV. This is her first abnormal pap. She denies any abnormal bleeding or vaginal discharge. What is the next step in this pt’s management?
Colposcopy
Treatment options for precancerous cervical lesions
Ablative (destroy cervical tissue) — via cryotherapy or laser ablation
Excisional — via cold knife cone (CKC) or loop electrode excisional procedure (LEEP)
When are excisional techniques performed?
Positive endocervical curettage (needs cold knife cone)
Unsatisfactory colposcopy (No SCJ)
Substantial discrepancy between pap and biopsy (i.e., high grade pap and negative colposcopy)
Risks of excisional procedures
Increased risk of cervical incompetence and resultant second trimester pregnancy loss
Increased risk of preterm premature rupture of membranes (PPROM)
Cervical stenosis
Operative risks — bleeding, infection
Symptoms of cervical cancer
Watery vaginal bleeding, postcoital bleeding, intermittent spotting
