11/3- Lab 1: HPV and Pap Smears Flashcards
(41 cards)
1
Q
Cervical cancer is the #__ cause of cancer deaths
A
Cervical cancer is the #20 cause of cancer deaths
2
Q
What is the epidemiology of cervical cancer?
- Highest rate of diagnosis in what ages
- Median age at diagnosis
- Highest in what population
A
- Highest rate of diagnosis in 35-44 yo
- Median age at diagnosis = 49 yo
- Highest incidence in Hispanics
3
Q
What are the 2 different ways to obtain a cervical vaginal smear?
A
1. Conventional
- Instrument samples both ecto and endocervix; spread on a slide
2. Liquid based cytology
- Same method, but spatula is placed in liquid fixative and sent to pathology where a monolayer circle slide is produced
- Benefits:
- Machines are used to initially screened slides and this produces uniform, thin sheet
- Allows quick molecular testing for HPV genotypes
4
Q
What tissue is sampled in pap smear?
- Describe the different types
A
The transformation zone
- Where the normal columnar mucous-secreting endocervical cells transform into squamous epithelial cells lining ectocervix
- Most cancers arise here
5
Q
Why is the transformation zone screened so heavily?
A
It has metaplastic squamous cells predisposed to HPV infection
6
Q
How does the transformation zone change with age/other health conditions?
A
The transformation zone is higher in the endocervical canal for young women and those who have not been pregnant
7
Q
What is seen here?
A
Normal squamous cells (ectocervix)
- May be “intermediate” or “superficial”
- As the squamous epithelium matures, the nucleus becomes smaller and darker; cytoplasm becomes translucent
- Nucleus of intermediate cell = size gaze for dysplasias
8
Q
What is seen here?
A
Normal columnar epithelial (endocervical) cells
9
Q
What is seen here?
A
Atrophic smear from post-menopausal (estrogen deficient) woman (could also be seen if breast-feeding or if tumor present)
- Not many mature squamous epithelial cells
- More parabasal cells
10
Q
Case 1)
- 25 yo woman, G1P0, 12 wks pregnant
- Chief complaint: vaginal itching and thick white “cottage cheese” discharge
- What is the diagnosis?
A
Candida infection
11
Q
Describe Candida infection
- Speculum/colposcopic view
- Discharge
- Symptomic infections
A
- Thick, curd-like discharge
- Symptomatic patients complain of severe pruritus and thick white vaginal discharge
Symptomic infections:
- Diabetes mellitus
- Antibiotics
- Pregnancy
- Immunocompromised states
12
Q
How does Candida infection appear cytologically?
A
- Smears may show numerous neutrophils
- Epithelial cell clusters arranged around pseudohyphae in a “Shish kebab” look
- Pseudohyphae of Candida love glycogen that is found abundantly in squamous epithelial cells (why they are so closely associated)
13
Q
What is seen here?
A
Candida infection
14
Q
Case 2)
- 32 yo woman
- Chief complaint: copious yellow discharge
- Exam findings include “strawberry cervix” and abundant yellow discharge
- What is the diagnosis?
A
Trichomonas infection
15
Q
Describe a Trichomonas infection
- How common
- Discharge
- Exam findings
A
- 15% of STD clinics
- Frothy, copious discharge
- Discharge is often malodorous, with a greenish-yellow color
- “Strawberry cervix”: vascular congestion
16
Q
What causes Trichomonas vaginalis?
- How does it appear on cytology?
A
- Flagellate protozoan
- T vaginalis are oval or pear shaped and have a small green nucleus and green cytoplasm with red granules
- Flagella is difficult to visualize in PAP smear
17
Q
How does Trichomonas vaginalis appear cytologically?
A
- T vaginalis are oval or pear shaped and have a small green nucleus and green cytoplasm with red granules
- Flagella is difficult to visualize in PAP smears
- Smears often show mixed inflammation (lymphocytes and neutrophils)
18
Q
What is seen here?
A
Trichomonas vaginalis infection
19
Q
What is seen here?
A
Trichomonas vaginalis infection
20
Q
Case 3)
- 20 yo woman in for routine Pap smear
- Social/GYN history includes menses at 12 years, first intercourse at 16 years; 5 lifetime partners and no tobacco use
- What are some red flags for cervical dysplasia in this history?
A
- Early age of intercourse (16 yo)
- 5 lifetime partners
21
Q
How do we make the diagnosis of low grade squamous intraepithelial lesion (LSIL) on a pap smear?
A
- Compared to nuclei of intermediate cells; LSIL cell nuclei is >3x’s larger
- Moderate variation in nuclear size and shape with occasional binucleation or multinucleation.
- Nuclear hyperchromasia
- The abnormal nucleus is conserved throughout the entire thickness of the squamous epithelium! (CIN I/mild dysplasia)
- Can be picked up just by sampling surface epithelial cells
22
Q
What else is seen cytologically in low grade dysplasia (apart from nuclear changes)?
A
Koilocytes (HPV effect): squamous epithelial cells filled with HPV virus particles
- Perinuclear halo
- Nuclear enlargement
- Hyperchromasia and wrinkling
As the virus particles are formed, they destroy the cytoskeleton of the cell, resulting in that wrinkling
- Recall, these are another sign of low grade dysplasia (LSIL)
23
Q
What is seen here?
A
LSIL (low grade dysplasia)
24
Q
What is seen here?
A
LSIL on colposcopy
- Fine mosaicism (due to irregular vascularity; high grade will have coarser mosaicism)
- Punctuation
25
What two features can be used to make the diagnosis of low grade dysplasias?
- Mature squamous epithelium with enlarged nucleus (2.5-3x)
- Koilocytes
26
What are other names/classification systems of mild squamous dysplasia?
LSIL or CIN 1
27
What are the histological features of mild squamous dysplasia (LSIL) or CIN 1?
- Dysplastic changes involving the lower third of the epithelium.
- The most superficial cells show extensive HPV changes or Koilocytes:
* Perinuclear halo
* Nuclear enlargement, hyperchromasia and wrinkling
28
Key note on features in dysplasia/the spectrum for mild vs. high grade dysplasia
- Mild dysplasia has abnormal nucleus but mature cytoplasm
- As you progress to higher grade dysplasias, nucleus is still abnormal but now cytoplasm is less mature (less cytoplasm)
29
Case 4)
- 35 yo woman for follow up Pap smear
- Social/GYN history: menses at 13 yrs, first intercourse at 15 yrs; 7 lifetime partners
- Previous abnormal Pap smears
- Positive for tobacco history
- What's significant in this history?
Many risk factors for cervical dysplasia
30
High grade squamous intraepithelial lesions are also called what? What classes are included?
**HSIL**
- Includes moderate and severe squamous dysplasia/CIS
- CIN 2 and CIN 3 (carcinoma in situ)
(Cytologically, they are just separated mild or high grade dysplasia; this determines management)
31
What is seen cytologically in high grade squamous intraepithelial lesions?
- Markedly increased nuclear to cytoplasmic ratio (large nucleus and scant cytoplasm), less number of koilocytes
- Sheds in syncytial groups and occasional single cells
- Large hyperchromatic nuclei
32
What is seen here?
**HSIL,** high grade dysplasia
- Very abnormal nucleus
- Very little cytoplasm (immature); very high N:C ratios
- Syncytial groups
33
What is seen here?
**HSIL** on colposcopy
- Mosaicism (coarser; much more abnormal vasculature than mild)
34
What is seen histologically in high grade dysplasia?
- CIN 2
- CIN 3
- Dysplastic changes involve up to half of the epithelial thickness (moderate dysplasia or CIN 2)
- Dysplastic changes involve more than half of the epithelium ( Severe dysplasia or CIN 3)
- Dysplastic changes involve the entire thickness of the epithelium (Severe dysplasia /Carcinoma in situ or CIN 3/CIS)
35
Describe the HPV life cycle
- Virus infects metabolically active cells: metaplastic squamous epithelial cells
- Low grade lesions (LSIL): replicative infections of HPV; virus NOT integrated into host DNA
- High grade lesions (HSIL): viral DNA integrated into host DNA; result in neoplastic cells;
- NOT concerned with replication; therefore, no koilocytes; disrupts function of Rb, p53
36
What are the HPV types responsible for **common warts** (most often)?
Types 2 and 5
37
What are the HPV types responsible for **condyloma acuminatum** (most often)?
Types 6 and 11
38
What are the HPV types responsible for **laryngeal papillomatosis** (most often)?
Types 6 and 11
39
What are the HPV types responsible for **HSIL and squamous cancer** (most often)?
Types 16, 18, 31, 33 (also 35, 39, 45, 51)
40
What are the HPV types responsible for **anogenital dysplasia and cancer** (most often)?
Type 16
41
Which type of HPV is the most common cancer causing strain?
**Type 16** is the most prevalent high risk viral type
(if you add in **18**, you've got most of them covered, **70%** of cervical cancers worldwide)
