Term
| what is the false negative rate for pap smears? what is this due to? |
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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) |
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Term
| what is the bethesda system? |
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Definition
| an attempt to standardize reporting of cervical cytology (pap smear) results established in 1988. |
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Term
| what is the chief source of abnormal pap smears? |
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Definition
| HPV - which can cause normal cervical cells to progress to invasive CA (takes 3-6 yrs). |
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Term
| what are the high risk HPV types? |
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Definition
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Term
| what is the regression rate for young women (< 30) over a 3 yr period w/low risk HPV? |
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Definition
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Term
| what is the regression rate for young women (< 30) over a 3 yr period w/high risk HPV? |
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Definition
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Term
| what are the american CA society screening guidelines for cervical CA? |
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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. |
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Term
| what is an ASCUS pap smear? what % of pap smears are classified as such? |
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Definition
| ASCUS = atypical squamous cells of undetermined significance. 3-4% of pap smears are classified as ASC. |
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Term
| what needs to be done if a pap smear comes back as ASCUS? what is the risk of malignancy with this result? |
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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%. |
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Term
| what is the difference between ASCUS/L-HGSIL/CIN classifications? |
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Definition
| CIN I-III are histological terms (referring to 3 levels of dysplasia), ASCUS+L-HGSIL are cytological terms |
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Term
| what are management options if a pap smear comes back as LGSIL? |
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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* |
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Term
| what are the guidelines for managing colposcopic bx-proven CIN I? |
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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. |
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Term
| what needs to be done for pts with positive CIN I biopsy (from colposcopy)? |
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Definition
| cryotherapy or laser ablation b/c the CIN I was detected in bx - meaning it's not going away. |
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Term
| what needs to be done if a pap smear comes back as ASC-H ? |
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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. |
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Term
| what characterizes HGSIL as a pap result? |
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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. |
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Term
| what is management if a pap smear comes back as HGSIL? |
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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). |
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Term
| what are the 3 categories of atypical glandular cells which may come back on pap smear results? |
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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). |
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Term
| what are the guidelines for responding to AGC pap results? |
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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. |
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Term
| how do neoplastic cells appear? |
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Definition
| the nucleus becomes enlarged, hyperchromatic, multilobulated |
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Term
| why are cotton-tipped applicators no longer used for pap smears? |
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Definition
| b/c the cells would just get stuck in the cotton and it was too hard to transfer them out. |
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Term
| what are the two kinds of cells in the cervix? where does CA most often occur? |
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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. |
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Term
| where is the squamocolumnar junction in different women? |
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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. |
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Term
| how are histological biopsies graded? |
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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). |
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Term
| what is the purpose of colposcopy? |
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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. |
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Term
| how is the cervix graded according to color (to direct colposcopy)? |
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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). |
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Term
| when looking at a cervical lesion via colposcopy, why would you put in a endocervical speculum? |
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Definition
| to see how far the lesion extends into the cervical canal (want to see the borders of the lesion). |
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Term
| why is the cervix painted with lugol's solution (potassium iodide)? |
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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. |
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Term
| what is mosaicism as observed on colposcopy? |
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Definition
| a pattern due to abnormal blood vessels in the stroma - seen in more advanced lesions |
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Term
| what is punctation as observed on colposcopy? |
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Definition
| this is visualized under a blue green filter and looks like someone stuck the cervix w/a needle several times |
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Term
| how is a high-grade CIN and higher grade CIN differentiated in colposcopy? |
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Definition
| high grade CIN: gray-white and dull, higher grade CIN: gray-white and oyster shell shiny. |
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Term
| what are common characteristics of high grade lesions on the cervix? |
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Definition
| *close to the SCJ, on the *anterior lip (2x more common than posterior lip), and larger |
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Term
| how long does it take for low grade cervical lesions to progress to CA? |
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Definition
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Term
| how obvious is invasive cervical CA? |
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Definition
| usually visible w/the naked eye |
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Term
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Definition
| the appearance of invasive CA when it mimics an orange peel |
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Term
| what is cryotherapy used to tx? |
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Definition
| mild dysplasia (freezes in ~ 3 min) |
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Term
| why should you wait to repeat a pap until 6 mos after cryo? |
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Definition
| b/c the cervix has to heal and if you do a pap in between, the reparative cells will confuse things |
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Term
| what needs to be determined before using laser sx to treat a cervical lesion? |
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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. |
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Term
| what is the LEEP procedure? |
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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 |
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Term
| in conclusion, if you have ASCUS, what do you need to do? |
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Definition
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Term
| in conclusion, if you have LGSIL, ASC-H, HGSIL, or AGC what do you need to do? |
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Definition
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Term
| what should be done for pregnant pts w/abnormal paps? |
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Definition
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Term
| what is usually done for post-menopausal pts with abnormal paps? |
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Definition
| 2-3 weeks of estrogen cream (r/o atrophic changes) then repeat the pap |
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Term
| what ratio of women w/pap screenings will still develop cervical CA? w/o? |
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Definition
| w/pap 1:135, w/o pap 1:20-30 |
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Term
| what kind of vaccine is gardasil? what does it prevent? |
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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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