preinvasive and early invasive cervical lesions

Question 1

what is the normal cervix anatomy

Answer 1

4cm in length (pinky size)

external cervical os is 1 cm in diameter

Question 2

origin of pap smear

Answer 2

dr papanikolau did smears of his wife’s cervix every day and compared it to other women with cervical cancer

Question 3

epidemiology of cervical cancer

Answer 3

incidence has increased d/2 general increase in promiscuity

mortality has reduced d/2 early dg from pap smears

3rd most common cancer in women after ovarian and endometrial

Question 4

why is the hpv vacc (Gardasil) given in adolescence

Answer 4

optimum response of the vaccine occurs oin adolescent years

Question 5

when is CIS dg vs when cervical cancer

Answer 5

CIS: 25

cervical cancer: 52

Question 6

how is a sample from the endo cervix taken

Answer 6

brush through the opening into the canal

Question 7

how is a sample from the exocervix taken

Answer 7

with a spatula

Question 8

when is the first pap smear taken

Answer 8

21 years of age is the first pap smear

cytology only

Question 9

how often should pap smears be taken

Answer 9

every 3 years after the first if the results are normal

until 30

Question 10

routine pap smear for ages 30 - 65

Answer 10

pap smear every 3 years

if additional hpv testing is done the next pap is in 5 years

Question 11

routine pap smear for 65y/o

Answer 11

discontinued IF

• never had an abrnormal pap smear
• rx from CIN 2+ was over 20 years ago

Question 12

routine paps for hysterectomy pts

Answer 12

discontinue paps IF

• hysterectomy was not done d/2 cancer
• no abnormal pap in 2o years

Question 13

which women are advised to continue paps

Answer 13

Women w/ RF for cervical cancer e.g.

• immunocomp/HIV
• exposure to Diethylstilbestrol in utero
• chronic steroid use

Question 14

list the abnormal cytology results from pap smears

(intraepithelial lesions)

Answer 14

1. ASCUS (atypical sq cells of undetermined sig)
2. LSIL (low grade sq intraepi lesion)
3. ASCH (atypical sq cells, can’t exclude HSIL)
4. HSIL ( high grade sq intraepi lesion)
5. AGC (atypical glandular cells)

Question 15

what does ASCUS MEAN

Answer 15

abnormal cells on cytology but unsure about what they are

• HPV test is done
• colposcopy done ONLY IF high risk hpv found

Question 16

what is LSIL

Answer 16

CIN 1

• hpv testing
• colposcopy

Question 17

what is ASC-H

Answer 17

• ominous looking cell but HSIL not confirmed

COLPOSCOPY is mandatory

Question 18

what does it mean if you get HSIL

Answer 18

CIN2/CIN3 LIKLEY

• colposcopy mandartory
• if fertility isn’t wanted then LEEP

Question 19

atypical glandular cells

Answer 19

suggests abnormalities in the uterus

Question 20

how to take biopsy during colposcopy

Answer 20

apply acetic acid and look for abnormal staining in the transitional zone

• area’s that stain white
• cobble stone / mosaic looking areas
• punctated vessels
• abnormal vessel geography
  
  • hair pin loops
  • non tree like

Question 21

how are biopsies taken in during colposcopy

Answer 21

Conization

• Procedure: excision of a cone of cervical tissue that contains parts of both the ectocervix and endocervix
• performed using a cold knife, electrosurgical loop (LEEP), or a laser
  
  • Premenopausal: transformation zone biopsy from ectocervix → shallow cone
  • Postmenopausal: transformation zone biosy from endocervix → deep cone

Question 22

side effects of Conization

Answer 22

1. Intraoperative or postoperative bleeding
2. Cervical stenosis causing infertility
3. Cervical insufficiency during pregnancy
4. Infection, uterine perforation

Question 23

why do we need biopsy

Answer 23

tells the depth of the lesion

determines the therapeutric action

Question 24

how do dysplastic cells appear

Answer 24

Ovoid, eccentric and larger nuclei

Question 25

what is CIN 1 bethseda: LSIL

Answer 25

* Epithelial architecture mostly intact * mitotic figures in lower third of the epithelium * Koilocytes may be present

Question 26

what is CIN II * bethseda * LSIL: w/o hpv16 * HSIL: w/ HPV 16

Answer 26

* Loss of epithelial architecture into as far as the **middle third or 2/3**of the epithelium * Koilocytes may be present.

Question 27

what is CIN III Bethseda: HSIL

Answer 27

* Complete loss of organized epithelial architecture * Irregular nuclei and mitotic figures can be found throughout all epithelial layers. * **Basal membrane is still intact**. Koilocytes may be present.

Question 28

what is CIS

Answer 28

complete loss of all normal architecture abnormal cells reach up to basement membrane w/o penetration

Question 29

therapeutic steps with CIN1

Answer 29

repeat pap + HPV testingin 1 year (gives body a chance for self resolution) 1. normal results: routine pap in 3 years 2. abnormal results for either: repeat colposcopy and biopsy

Question 30

procedures for CINI-III

Answer 30

surgical resection w/ 1. leep 2. cryo

Question 31

what is LEEP

Answer 31

loop electrical excision provedure * thins the functional cervix * different from biopsy as a larger amount of the cervix is removed for rx * further biopsy may be done to ensure clear margins

Question 32

natural progression of CIN 1 lesions

Answer 32

CIN I * 60% Regress spontaneously * 30% persist * 10% progress to CIN IIi * LESS THAN 1% become canceroues

Question 33

natural progression of CIN II lesions

Answer 33

40% regress 35% persist 20% CIN III 5% cervical cancer

Question 34

CIN III progression

Answer 34

30% regress 50% stay CIN III 12-22% cervical cancer