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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