Lecture 2: Pap Smear, Cervical Dysplasia, Cancer

Question 1

Which strains of HPV cause the majority of cancers?

Answer 1

HPV 16, 18, 31, and 45

Question 2

What are the risk factors for cervical neoplasia?

Answer 2

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

Question 3

What are the pap smear screening guidelines based on age?

Answer 3

• 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 4

What are the pap smear screening guidelines following hysterectomy?

Answer 4

No screening

Question 5

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

Answer 5

3 years when unknown

Question 6

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

Answer 6

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

- Organisms

• Other non neoplastic findings: inflammation, radiation, IUD
• 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

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

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 vs. 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 w/ LSIL and no HPV test or LSIL with a positive HPV test?

Answer 11

Colposcopy

Question 12

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

Answer 12

• Immediate loop electrosurgical excision

or

• 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 the abnormalities you are looking for on Colposcopy?

Answer 14

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

Question 15

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

Answer 15

• 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 16

What are the 2 ablative techniques for cervical neoplasia?

Answer 16

• Cryotherapy
• Laser ablation

Question 17

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

Answer 17

• ↑ 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 18

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

Answer 18

• Watery vaginal bleeding
• Postcoital bleeding
• Intermittent spotting

Question 19

How is cervical carcinoma staged?

Answer 19

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

Question 20

How is microinvasive cervical carcinoma managed clinically?

Answer 20

Cold knife cone or hysterectomy

Question 21

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

Answer 21

Radical hysterectomy w/ LN dissection

Question 22

How is bulky disease cervical carcinoma managed clinically?

Answer 22

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

Question 23

How is stage IIb and greater cervical carcinoma managed clinically?

Answer 23

External beam radiation and concurrent cisplatin based chemotherapy

Question 24

What are the recommendations for the HPV vaccine?

Answer 24

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

Question 25

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

Answer 25

- **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 26

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

Answer 26

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

Question 27

List 6 AE's associated with HPV vaccination?

Answer 27

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