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pap and colposcopy
R-GU II
44
Medical
Graduate
10/24/2010

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Term
what is the false negative rate for pap smears? what is this due to?
Definition
20% - due to errors in: sampling (missed abnormal cells that were present), screening (cytologist missed abnormal cells in the smear), and interpretation (the cytologist incorrectly identifies cells)
Term
what is the bethesda system?
Definition
an attempt to standardize reporting of cervical cytology (pap smear) results established in 1988.
Term
what is the chief source of abnormal pap smears?
Definition
HPV - which can cause normal cervical cells to progress to invasive CA (takes 3-6 yrs).
Term
what are the high risk HPV types?
Definition
16,18,31,33,35,45
Term
what is the regression rate for young women (< 30) over a 3 yr period w/low risk HPV?
Definition
90%
Term
what is the regression rate for young women (< 30) over a 3 yr period w/high risk HPV?
Definition
70%
Term
what are the american CA society screening guidelines for cervical CA?
Definition
*start: 3 yrs after first vaginal intercourse, but no later than 21. *screening modality: 1x/yr w/conventional cytology or 1x/2 yrs w/liquid based cytology. *at 30, pts w/3 consecutive negative pap smears can screen 1x/2-3 yrs. *at 70, pts w/3 consecutive negative pap smears and no abnormalities in the last 10 years can stop screening. *screening after a total hysterectomy (if sx was for benign reasons) is not necessary.
Term
what is an ASCUS pap smear? what % of pap smears are classified as such?
Definition
ASCUS = atypical squamous cells of undetermined significance. 3-4% of pap smears are classified as ASC.
Term
what needs to be done if a pap smear comes back as ASCUS? what is the risk of malignancy with this result?
Definition
repeat pap smear (may also do colposcopy) and HPV testing (determine risk types). risk of CA in ASC pap is .1-.2% but risk of CIN II-III is 5-17%.
Term
what is the difference between ASCUS/L-HGSIL/CIN classifications?
Definition
CIN I-III are histological terms (referring to 3 levels of dysplasia), ASCUS+L-HGSIL are cytological terms
Term
what are management options if a pap smear comes back as LGSIL?
Definition
*pros of repeating cytology: CIN I may spontaneously regress. *cons of repeating cytology: 53-76% loss to f/u+risk of missing underlying CA. *pro of immediate colposcopy: pts w/significant dx are immediately triaged/reduced loss to f/u. *no need for HPV testing*
Term
what are the guidelines for managing colposcopic bx-proven CIN I?
Definition
there is a 90% chance of spontaneous regression w/CIN I. therefore another pap at 6 and 12 months later OR HPV DNA testing at 12 months. if any of those tests are positive (ASCUS or worse): do another another colposcopy (but just +ASCUS with -HPV or +HPV with -ASCUS, don't need colposcopy, need +HPV and +ASCUS). if 2 consecutive paps are normal - can return to annual pap screening.
Term
what needs to be done for pts with positive CIN I biopsy (from colposcopy)?
Definition
cryotherapy or laser ablation b/c the CIN I was detected in bx - meaning it's not going away.
Term
what needs to be done if a pap smear comes back as ASC-H ?
Definition
ASC-H (atypical squamous cells - cannot rule out a high grade lesion) require an immediate colposcopy, and if negative a repeat pap at 6 and 12 months/HPV testing at 12 months. if any of those paps are positive for ASC-US or higher, repeat colposcopy.
Term
what characterizes HGSIL as a pap result?
Definition
HGSIL accounts for .5% of pap results but 75% are CIN II, III or higher and there is a greater than 50% chance that either will progress to cervical CA.
Term
what is management if a pap smear comes back as HGSIL?
Definition
LEEP excision procedure (loop electrosurgical excision procedure - *good test question*). then repeat pap (w/ or w/o colposcopy) at 4-6 mos and test HPV at 6 mo. if 3+ paps are normal and HPV is normal, then can go back to annual testing (if both cytological abnormalities and HPV, then repeat colposcopy).
Term
what are the 3 categories of atypical glandular cells which may come back on pap smear results?
Definition
AGC-NOS (not otherwise specified), ACG-favor neoplasia, and AIS (adenocarcinoma in situ). if glandular cells are atypical, this means cells are coming down from the uterus/endometrium and are being picked up by the pap smear (requires endometrial biopsy or D&C).
Term
what are the guidelines for responding to AGC pap results?
Definition
ACG-NOS: colposcopy w/endocervical sampling. ACG-NOS in women > 35: colposcopy w/endocervical sampling AND endometrial biopsy. ACG-favor neoplasia: cold knife conization, if no neoplasia found, repeat at 4-6 mo intervals until 4 consecutive negative paps are found.
Term
how do neoplastic cells appear?
Definition
the nucleus becomes enlarged, hyperchromatic, multilobulated
Term
why are cotton-tipped applicators no longer used for pap smears?
Definition
b/c the cells would just get stuck in the cotton and it was too hard to transfer them out.
Term
what are the two kinds of cells in the cervix? where does CA most often occur?
Definition
superficial squamous (ectocervix) and columnar (endocervix). CA most often occurs at the *squamocolumnar junction, where most of the cellular activity takes place - columnar cells are changing into squamous cells. this physiologic metaplasia is vulnerable to HPV causing dysplasia.
Term
where is the squamocolumnar junction in different women?
Definition
in 1/3 of pts, the squamocolumnar junction lies just within the endocervix, in 1/3 it coincides with the external os, and in 1/3 it is found on the ectocervix. the squamocolumnar junction *moves back and forth through out the entire lifetime of the female under the influence of the female hormone estrogen* (possible test question). i.e. a pregnant pt's squamocolumnar junction is found on the ectocervix and a postmenopausal pt's would be inside the cervical canal.
Term
how are histological biopsies graded?
Definition
CIN I: lower 1/3 of epithelium is abnormal (mild dysplasia), CIN II: 2/3 of epithelium is abnormal (moderate dysplasia), and CIN III: entire epithelium from basement membrane all the way up to the surface is abnormal (severe dysplasia). if there is severe dysplasia+crowding = CIN III and CA in situ. (invasive is when the abnormal cells get into the stroma).
Term
what is the purpose of colposcopy?
Definition
to determine the location, extent, and severity of diseased epithelium (detected via abnormal cytology) via selected biopsies of suspicious areas - determined to be suspicious by grading according to color, margins, vessels, surface contour, and iodine uptake.
Term
how is the cervix graded according to color (to direct colposcopy)?
Definition
paint the cervix w/acetic acid - dehydrates the cells' cytoplasm and makes the nuclei stand out and precipitate keratin. CIN I is light white, CIN II is heavier white, and CIN III is thickest white. (there should be a correlation between the pap smear, what you see when you look at the cervix and the biopsy result).
Term
when looking at a cervical lesion via colposcopy, why would you put in a endocervical speculum?
Definition
to see how far the lesion extends into the cervical canal (want to see the borders of the lesion).
Term
why is the cervix painted with lugol's solution (potassium iodide)?
Definition
normal cells contain glycogen, which has an affinity for iodine. normal cells will turn brown with lugol's solution but abnormal cells lack glycogen and don't take up stain.
Term
what is mosaicism as observed on colposcopy?
Definition
a pattern due to abnormal blood vessels in the stroma - seen in more advanced lesions
Term
what is punctation as observed on colposcopy?
Definition
this is visualized under a blue green filter and looks like someone stuck the cervix w/a needle several times
Term
how is a high-grade CIN and higher grade CIN differentiated in colposcopy?
Definition
high grade CIN: gray-white and dull, higher grade CIN: gray-white and oyster shell shiny.
Term
what are common characteristics of high grade lesions on the cervix?
Definition
*close to the SCJ, on the *anterior lip (2x more common than posterior lip), and larger
Term
how long does it take for low grade cervical lesions to progress to CA?
Definition
10-20 yrs
Term
how obvious is invasive cervical CA?
Definition
usually visible w/the naked eye
Term
what is peau d’orange?
Definition
the appearance of invasive CA when it mimics an orange peel
Term
what is cryotherapy used to tx?
Definition
mild dysplasia (freezes in ~ 3 min)
Term
why should you wait to repeat a pap until 6 mos after cryo?
Definition
b/c the cervix has to heal and if you do a pap in between, the reparative cells will confuse things
Term
what needs to be determined before using laser sx to treat a cervical lesion?
Definition
that no invasive CA is present. the entire transformation zone/squamocolumnar junction needs to be visualized and there should be a correlation between the cytology, colposcopy and the histology.
Term
what is the LEEP procedure?
Definition
a wire dyothermy device; once you step on the foot pedal, the wire gets hot and can scoop out a more advanced lesion with the wire
Term
in conclusion, if you have ASCUS, what do you need to do?
Definition
check for HPV
Term
in conclusion, if you have LGSIL, ASC-H, HGSIL, or AGC what do you need to do?
Definition
colposcopy
Term
what should be done for pregnant pts w/abnormal paps?
Definition
bx and cone bx
Term
what is usually done for post-menopausal pts with abnormal paps?
Definition
2-3 weeks of estrogen cream (r/o atrophic changes) then repeat the pap
Term
what ratio of women w/pap screenings will still develop cervical CA? w/o?
Definition
w/pap 1:135, w/o pap 1:20-30
Term
what kind of vaccine is gardasil? what does it prevent?
Definition
recombinant and quadrivalent (against types 6, 11, 16 & 18). gardasil is 100% effective in preventing CIN II, III and adenocarcinoma in situ (AIS).
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