Dr T Allameh

Gyn Oncologist

CERVICAL CANCER SCREENING

Infection with human papillomavirus (HPV) is the

primary cause of cancer of then cervix and its

precursor lesions.

Persistent high-risk oncogenic HPV infection is

the principal risk factor for the development of

CIN.

In the vast majority of cases, HPVinfection will

clear in 9 to 15 months

Specific high-risk HPV types account for about 90% of high-grade intraepithelial lesions and cancer (HPV-16, -18, -31, -33, -35, -39, -45, -51, -52, -56, -58, -59, and -68).

HPV-16 is the most common HPV found in invasive cancer and in CIN 2 and CIN 3.

Malignant transformation requires the expression of E6 and E7 HPV oncoproteins.

High-risk HPV testing is a critical component of the triage

for equivocal (ASC-US)

cytology, as a component of co-testing with simultaneous

cytology, and as a standalone

primary screening modality.

Evidence-based guidelines recommend that cervical cancer screening

not begin until age 21 years, regardless of sexual history.

For women 21 to 29 years, the recommendation is screening with

cytology every 3 years.

From 30 to 65 years contesting with conventional cytology and high-

risk HPV testing every 5 years or cytology alone every 3 years are

appropriate alternatives. After the age of 65 it is

appropriate to discontinue screening in women with

a negative screening history as

documented by

either 3 negative cytology results

or 2 negative co-tests in theprevious 10 years

HIGH RISK HPV

The usefulness of high-risk HPV testing in the

assessment of atypical squamous cells of unknown

significance (ASC-US) Pap test results is well

established, and aids in

the identification of 90% of the patients with CIN

2 or 3 lesions

ASC-H

Women with atypical squamous cells-high grade (ASC-H)

should be

referred to colposcopy because of

the underlying risk of CIN 2 and/or 3, and should not be

triaged with high-risk HPV testing

COLPOSCOPY

Colposcopy is required for the evaluation of

a low-grade squamous intraepithelial lesion (LSIL)

cytology.

Any woman with a cytology consistent with high-grade

squamous intraepithelial lesion (HSIL) must undergo

colposcopy and directed biopsy.

COLPOSCOPIC EXAMINATION

visualization of squamocolumnar junction, identification of

acetowhitening

or other lesion(s),

and an overall colposcopic impression (normal/benign, low grade,

high grade, cancer).

CIN1

CIN 1 is a histopathologic manifestation of HPV infection, not a cancer precursor.

For CIN 1 that persists for 24 months or more, a patient with an adequate

colposcopic examination may be given the choice of

continued surveillance or

destruction of the transformation zone with ablation or excision.

HSIL

CIN 2 and CIN 3 lesions are neoplastic precursors and

grouped for the purposes of diagnostic reporting and

treatment.

Women, 25 years of age and older, with adequate

colposcopy and histologic documentation of CIN 2 and/or

CIN 3 require

destruction or excision of the transformation zone.

the preferred treatment OF CIN2 AND CIN 3 is LEEP.

Ablative therapy using cryotherapy, laser ablation, or any

other technique is not appropriate if there is evidence of

microinvasive or invasive cancer on cytology, colposcopy,

endocervical curettage (ECC), or biopsy.

AIS

Adenocarcinoma in situ (AIS) is a cancer precursor,

and the preferred management

for women who have completed childbearing and have a histologic

diagnosis of AIS on a specimen from a diagnostic excisional procedure

is hysterectomy

Loop excision should not typically be used before a high-grade intraepithelial

lesion is identified with histopathology

However, treatment after an HSIL cytology maybe appropriate among populations for whom colposcopic

follow-up is not possible

CONIZATION

Conization is indicated for diagnosis in women with CIN 3

or atypical glandular cell (AGC)-adenocarcinoma in situ,

but hysterectomy is the treatment of last resort for

recurrent high-grade CIN.

Table 16-3 Comparison of Screening Guidelines From the American Cancer Society,

American Society of Colposcopy and Cervical Pathology and American

Society Clinical Pathology, the American College of Obstetricians and

Gynecologists, and the U.S. Preventive Services