Week 4 pt 2 Flashcards
Define:
1) Internal os
2) External os
3) Ectocervix
4) Endocervical canal
1) Upper part of the cervix that opens into the endometrial cavity
2) Lower part of the cervix that opens into the vagina
3) Exterior portion of the cervical canal (what we can see)
4) Interior cervical canal leading to the uterus (what we cannot see)
Squamocolumnar junction (SCJ):
1) What is it?
2) What represent the newest and least mature cells in the cervix?
3) What is highest during adolescence and early pregnancy?
4) Where does >90% of metaplasia and cervical neoplasia arise?
1) Area between the original SCJ and active SCJ (transformation zone)
2) Metaplastic cells within the TZ
3) Rate of metaplasia
4) The active (new) SCJ
Give the basics of HPV
1) Most HPV-infected women asymptomatic
2) Most women, especially younger women, can clear the infection in 8-24 months
3) HPV type and persistence of HPV infection appear to be the most important factors in the progression into squamous intraepithelial lesions (SIL)
4) HPV is easily spread via sexual intercourse
6) HPV 16, 18 most commonly cause cervical cancer
13 other HPV types cause remainder of cervical cancer (15 types are high-risk)
5) HPV 6, 11 are associated with genital warts (condylomata acuminata)
List the Cervical CA screening essentials
1) Decrease cervical cancer rates and mortality rates
2) Current and previous cervical cancer screening results
3) Hx of treatment and findings on pathology
4) Abnormal vaginal bleeding? (possible cervical ca present?)
5) Compromised immune system? (increased risk for cervical cancer)
6) Hx of hrHPV vaccination
7) Pregnancy?
Describe how common HPV and cervical CA are
1) HPV infection is very common in young women which is why the new cervical cancer guidelines are based on HPV status and age.
2) BUT invasive cervical cancer is very rare.
Women at increased risk for cervical cancer may be screened more frequently, including what groups?
HIV, patients on immunosuppression therapies, women exposed to DES in utero, and women previously treated for CIN 2, CIN 3, or cancer
ACOG:
1) Women aged ___________ represent around 20% of new cervical cancer cases
2) Reasonable to discontinue screening at either ____ or ___ years of age if they have had three or more negative tests in a row within the past 10 years.
1) 65 and older
2) 65 or 70
*If screening is stopped, risk factors should still be assessed annually, and screenings resumed if indicated.
If a total hysterectomy was for benign causes (i.e., fibroids) and they have NO history of high-grade neoplasia (CIN2, CIN 3, or AIS), can paps be discontinued?
Yes
Give some Pap Techniques
1) Speculum should be large enough to adequately displace the vaginal side walls and allow visualization
-Cervix should be completely visualized
2) Minimal water-based lubricant should be placed on the speculum
3) Pap should be deferred if there is heavy cervical bleeding or active cervicitis
Ideally, a Pap should be completed in the middle of a patient’s cycle (days 9-20)
Give some reasons for a pap test result being unsatisfactory and what you should do next
1) -Specimen rejected/not processed
-Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of a specified reason
2) Retest in 2-4mos recommended
-If retest also unsatisfactory, recommend colposcopy.
-If retest abnormal or negative, follow 2019 ASCCP Guidelines (more on this later)
1) What would a normal pap smear be negative for?
2) What organisms can it detect?
1) Negative for Intraepithelial Lesion or Malignancy (NILM)
2) Trichomonas vaginalis
Candida
Bacterial vaginosis
Actinomyces
Herpes simplex virus (HSV)
What are some other non-neoplastic findings that can be seen on a Pap result?
-Reactive cellular changes associated with
-Inflammation
-Radiation
-Intrauterine contraceptive device
-Glandular cell status post-hysterectomy
-Atrophy
What is another finding that can be seen in a woman ≥45 years of age
Endometrial cells
Abnormal Pap Results: List the 3 categories of Squamous Cell Abnormalities
1) ASC: ASC-US or ASC-H
2) LSIL: Commonly correlates with CIN1
3) HSIL: Commonly correlates with CIN2 or CIN3
Give some examples of abnormal pap results from least to most concerning
1) ASC-US
2) ASC-H
3) LSIL: Low-grade Squamous Intraepithelial Lesions
Includes findings of CIN1 (low-grade dysplasia) and findings consistent with HPV infection
4) HSIL: High-grade Squamous Intraepithelial Lesions
CIN2 and CIN3 lesions (moderate dysplasia, high-grade dysplasia)
5) Carcinoma in situ
6) Squamous Cell Carcinoma
7) Glandular Cell
CIN (cervical intraepithelial neoplasia):
1) Small percentage progress to cervical cancer, usually ______________________
2) The major cause of CIN is infection with what?
1) squamous cell carcinoma (SCC)
2) HPV (16 and 18)
1) CIN 1 (low-grade dysplasia) much less likely to progress to cervical cancer unless ________________ present
2) CIN 2 and CIN 3 (high-grade dysplasia) progression to invasive cancer usually gradual over __________ years
1) high-risk HPV (16 or 18)
2) several
So, our pap smear comes back ABNORMAL… What do we do now?
Follow 2019 ASCCP guidelines
2019 ASCCP Guidelines: Treatment guidelines are dichotomized by younger than _____ years and ______ years or older because of high spontaneous regression rates of HPV infection and CIN 2 and low incidence of cancer in those younger than _______ years
25; 25; 25
2019 ASCCP Guidelines: Providers must know (at minimum) patient’s age and current test results SO recommendations are based on risks of immediate and future CIN 3+ diagnoses; what are the caveats to this?
1) Previous screening history not always known
2) HPV testing guides management options and if positive, should perform reflex testing to determine which type of HPV is positive
Persistent HPV infection necessary for developing precancer and cancer; how is this defined?
Defined as CIN 3+ (CIN 3, AIS, and cancer)
List the first 2 new (2019) principles of cervical CA testing
1) HPV-based testing = basis for risk estimation
-HPV type and duration of infection determine patient’s risk of CIN 3+
2) Current results + past history provides personalized risk-based management for having or developing CIN 3+
-Management recommendations use thresholds of risk which correspond to a risk stratum (a range of risk for CIN 3+). These recommendations include:
a) Routine screening
b) 1yr or 3yr surveillance
c) Colposcopy
d) Treatment
-The level at which the management recommendation changes is at the lower threshold of each risk stratum (Clinical Action Threshold)
List the second 2 new (2019) principles of cervical CA testing
1) Guidelines continue to evolve as more patients of screening age received HPV vaccination
2) Colposcopy practice must follow guidance from ASCCP Colposcopy Standards
-Colposcopy + targeted biopsy = primary method detecting precancers requiring treatment (must detect CIN 2+ if present because managed more aggressively than less concerning results)
Give the continued principles from 2012
1) Screening and management goal is cancer prevention
2) Guidelines apply to all individuals with a cervix.
3) Equal management for equal risk
For example, HPV-positive ASC-US and LSIL cytology have very similar risks of CIN 3+ and are therefore managed similarly
More on risk on the next several slides…
4) Balance benefits and harms
5) Guidelines apply to asymptomatic patients who require management of abnormal cervical screening test results
6) Guidelines differ country to country. These are for the US.
