The Pap Smear, Cervical Dysplasia and Cancer

Question 1

What types of epithelium make up the cervix?

What is the junction called? What is its significance?

Answer 1

Columnar epithelium (endocervix) and stratified non-keratinized squamous epithelium (ectocervix)

Squamocolumnar junction - site where >90% of cervical neoplasms arise

Question 2

Which 4 types of HPV cause the majority of cancers?

Which 2 are responsible for 70% of cervical cancer?

Answer 2

Types 16, 18, 31 and 35

Type 16 and 18

Question 3

Which 2 types of HPV are associated with genital warts and low grade lesions?

Answer 3

Type 6 and 11

Question 4

What are 10 risk factors for cervical neoplasia?

Answer 4

Multiple sex partners (or partner with multiple partners)
Young age of first sexual encounter/pregnancy
Smoking (3.5x increased risk) - greatest risk
HIV
Organ transplant
STIs
DES exposure
Infrequent/absent pap smears
High parity
Lower SE status

Question 5

What are the consensus screening guidelines for the following:

<21 y/o
21-29 y/o
30-65 y/o
>65 y/o
After hysterectomy

Answer 5

<21 y/o: no screening

21-29 y/o: cytology alone every 3 years

30-65 y/o: HPV and cytology “co-testing” every 5 years

> 65 y/o: no screening following adequate negative prior screening

After hysterectomy: no screening

Question 6

What changes occur to the SCJ with age?

Answer 6

Begins more outside of the cervical canal pre-menopasual and then recedes back into the canal post-menopause.

Question 7

What are the types of specimens used in the 2001 Bethesda system? (2)

What are the 2 categories of specimen accuracy?

Answer 7

Liquid (MC) or conventional based.

1. Satisfactory for evaluation (including presence or absence of endocervical cells)
2. Unsatisfactory for evaluation (reason listed)

Question 8

What are the general categorization using the 2001 Bethesda system? (3)

Answer 8

1. Negative for intra-epithelial lesion or malignancy.
2. Epithelial cell abnormality (see interpetation/result)
3. Other (see interpretation/result)

Question 9

If the Bethesda system reporting does not show anthing suggestive of cervical cancer, but an infection instead, what bugs can be found (minus HPV)? (5)

What reactive cellular changes can be seen? (5)

Answer 9

Trichomonas
Candida (fungal infections)
Floral shift suggesting bacterial vaginosis
Actinomyces - rare
HSV

Inflammation
Radiation
IUD
Glandular cell SP hysterectomy
Atrophy

Question 10

What epithelial cell abnormalities can be seen on pap smear? (4)

Answer 10

Atypical squamous cells: ASC-US (undetermined significance), ASC-H (high-grade)

LSIL

HSIL

SCC

Question 11

Which atypical glandular cells on pap suggest neoplasm? (2)

Answer 11

Endometrial cells

Glandular cells

Question 12

What options are there for a woman with ASC-US on cytology? (2)

Answer 12

1. Repeat cytology after 1 year
   - if negative, continue routine screening
   - if worse/same, do a colposcopy
2. HPV testing
   - if positive, do a colposcopy
   - if negative, repeat cotesting in 3 years

Question 13

What should be done in women with LSIL with no HPV test or positive HPV?

Answer 13

Colposcopy

Question 14

What should be done in a woman with HSIL? (2)

Answer 14

Immediate LEEP or Colposcopy (most common)

Question 15

Gold standard with directed biopsy for diagnosis/screening of cervical cancer?

Answer 15

Colposcopy

Question 16

What occurs with a colposcopy?

Answer 16

Cervix is washed with acetic acid, which dehydrtaes the cell and large nuclei of abnormal cells, which become “acetowhite”.

Question 17

What changes can be seen on colposcopy in abnormal exam? (5 most severe to least severe)

What must be seen on colposcopy?

What is done if an abnormality is seen?

Answer 17

Masses, abnormal vessels, mosaicism, punctations, acetowhite changes.

SCJ

Biopsy and ECC

Question 18

What are the ablative vs, excisional options for treating cervical cancer/atypia?

Answer 18

Ablative: cryotherapy, laser ablation (both less common now)

Excisional: cold knife cone (CKC), loop electrone excisional procedure (LEEP) (more common now)*

Question 19

Excisional techniques are required when… (3)

Answer 19

Endocervical curettage is positive (CKC)

Unsatisfactory colposcopy (no SCJ)

Major discrepancy between pap and biopsy (ex: high grade on pap and negative colposcopy, etc.)

Question 20

Risks of excisional procedures include… (4)

Answer 20

Increased risk of cervical incompetence and resultant 2nd trimester pregnancy loss

Increased risk of PPROM

Cervical stenosis

Typical operative risks - bleeding, infection, etc.

Question 21

Clinical symptoms of cervical cancer (3)

Answer 21

Watery vaginal bleedng

Post-coital bleeding

Intermittent spotting

Question 22

4 ways to decrease risk of cervical cancer

Answer 22

Sexual abstinence/limiting partners

Use of barrier protection (not fully protective)

Regular exams/pap smears

HPV vaccination

Question 23

Current recommendation for HPV vaccination

Can they have it if pap is abnormal?
Is it OK in pregnancy?

Answer 23

All boys and girls 9-45 y/o (used to only be up to 26 y/o)

Yes, they can get it if pap is normal.
Should not be used in pregnancy because there have been no studies.

Question 24

Side effects of Gardasil (5)

Answer 24

*Syncope and dizziness (MC)

Nausea, headache, fever, injection site reactions