Cervical intraepithelial neoplasia and fallopian tube carcinoma

Click to edit Master subtitle style Lopez, Julianne MD-MBA 070032

4/18/12

Cervical intraepithelial neoplasia

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4/18/12

Case:

A 20-year-old G3P0030 obese female comes to your office for a routine gynecologic exam. single, (+) currently sexually active, (+)history of five sexual partners in the past, (+) age of coitarche: 15 three first-trimester voluntary pregnancy terminations. control: Depo-Provera & condoms treated for chlamydia last year

(+)

(+)

Birth (+)

Denies

any prior history of abnormal Pap smears.

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Question #1:
All of the following factors in this patients history are risk factors for cervical dysplasia except a. Young age at initiation of sexual activity b. Multiple sexual partners c. Previous history of chlamydia d. Use of Depo-Provera e. Smoking
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Question #1:
All of the following factors in this patients history are risk factors for cervical dysplasia except a. Young age at initiation of sexual activity b. Multiple sexual partners c. Previous history of chlamydia d. Use of Depo-Provera e. Smoking
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Risk factors for cervical cancer:

-

Genital infection with high risk HPV type (16 & 18) Early onset of sexual activity Multiple sexual partners Cigarette smoking Immunocompromised state (HIV, chemotherapeutic agents) Low socioeconomic status

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Question # 2:
Whats the appropriate next step?
a. b.

Do a pap smear Since gynecological exam is normal, advise her to do regular follow up Do a cervical biopsy Request for HPV DNA testing

c. d.

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Question # 2:
Whats the appropriate next step?
a. b.

Do a pap smear Since gynecological exam is normal, advise her to do regular follow up Do a cervical biopsy Request for HPV DNA testing

c. d.

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Recommendations for screening: PAP smear

ACOG 2009 recommendations:
all

women onset of sexual activity or at the age of 21 should undergo pap smear for cervical cancer screeningry

Interval:

Done annually negative for 3 consecutive years, can be done once every 2-3 years

If

Source: ACOG pratice bulletin number 109, 2009

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Importance of screening:
Risk Pap

of cancer is 5x higher in women who are not screened smear detects cancerous and precancerous cells

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Bethesda system for reporting cervical cytology:

-

Adequacy of sample: satisfactory / unsatisfactory Squamous cell abnormalities Glandular cell abnormalities Other cancers (lymphoma, metastatic, sarcoma)

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Bethesda system for reporting cervical cytology:

-

Adequacy of sample: satisfactory / unsatisfactory Squamous cell abnormalities Glandular cell abnormalities Other cancers (lymphoma, metastatic, sarcoma)

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Bethesda system for reporting cervical cytology:

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Sample bethesda report:

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Terminology for cervical cytology and histopathology:

4/18/12 Source: http://www.medscape.org/v

Terminology for cervical cytology and histopathology:

4/18/12 Source: http://www.medscape.org/v

Histopathology: Comparison

Source:

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Question # 3:
A pap smear was done which showed High grade squamous intraepithelial lesion. Whats the appropriate next step?
a. b. c. d. e.

Repeat the Pap smear in 4 to 6 months Perform a cone biopsy Order HPV testing Do random biopsies of the cervix Perform colposcopy
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Question # 3:
A pap smear was done which showed High grade squamous intraepithelial lesion. Whats the appropriate next step?
a. b. c. d. e.

Repeat the Pap smear in 4 to 6 months Perform a cone biopsy Order HPV testing Do random biopsies of the cervix Perform colposcopy
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First step in the evaluation of a woman with abnormal cervical cytology report:

4/18/12 Source: kat and lentz comprehensiv

colposcopy
Inspection Apply

of the cervix using a low grade microscope acetic acid visualize cervix
MOA:

acetic acid enhances and marks a precancerous lesion or cancer by turning it whitish blue (acetowhite change)

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Management: CIN 1
High

rate of regression and low rate of preogression

Ostor et al 1993 Spontaneous 57 regression Progression 11 to CIN 2/3 Progression 0.3 to cancer Meinikow et al 1998 47.4 20.8 0.15
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Management: CIN 1 (ASC-US, ASC-H, LSIL)

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Management: CIN 1 (ASC-US, ASC-H, LSIL)

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Management: CIN 2&3

Lesion

is more evident on colposcopy

Lesions

more likely to persist or progress than to regress

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Management: CIN 2&3

Lesion

is more evident on colposcopy

Lesions

more likely to persist or progress than to regress

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Question #4:
You obtain cervical biopsies, which come back without any abnormalities. What is the next appropriate step in the management of this patient?
a. b. c. d. e.

Cryotherapy of the cervix Laser ablation of the cervix Conization of the cervix Hysterectomy Re-Pap in 3 to 6 months
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Question #4:
You obtain cervical biopsies, which come back without any abnormalities. What is the next appropriate step in the management of this patient?
a. b. c. d. e.

Cryotherapy of the cervix Laser ablation of the cervix Conization of the cervix Hysterectomy Re-Pap in 3 to 6 months
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Management: CIN 2&3

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Management: CIN 2&3

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treatment
Ablative

methods

Cryotherapy thermoablation

Excisional
LEEP Cold

methods

knife conization

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Fallopian tube carcinoma

Click to edit Master subtitle style Lopez, Julianne MD-MBA 070032

4/18/12

Fallopian tube carcinoma

Rarest Almost More

of primary malignancies (0.3%)

all are papillary serous histology, arising from the tubal epithelium common are metastatic lesions arising from the ovary, uterus or GI tract

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Etiology and age distribution:

Risk

factors: tuberculous salpingitis, chronic PID, infertility, low parity, tubal endometriosis 54-65 years old

Age:

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Signs and symptoms:

Abnormal Palpable Crampy Watery

vaginal bleeding (47.5%)

adnexal mass (61%) lower abdominal pain (39%)

discharge (20%)

Latskos

triad: intermittent serosanguinous discharge + colicky pain + mass (pathognomonic of fallopian tube cancer) tubae profluens expulsion of watery fluid from the vagina by contraction of a distended tube blocked at the distal end
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Hydrops

Diagnosis:
(+)

abnormal cervical cytology (10-40% in women with fallopian tube cancer)

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Diagnosis:
(+)

abnormal cervical cytology (10-40% in women with fallopian tube cancer)

Classic

ultrasound findings: fluid filled tubular or ovoid mass with internal papillations, mural nodules, septations, separate from the uterus and ovaries. Ascites present

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Pathological examination:
Diagnostic 1.

criteria:

The main tumor lies in the tube and arises from the endosalpinx The histologic pattern reproduces the epithelium of tubal mucosa (papillary) Transition can be demonstrated between the malignant and nonmalignant epithelium The ovaries and uterus must be normal or contain less tumor than the fallopian tube

2.

3.

4.

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Staging and natural history:

Most

frequent pattern of spread: peritoneum

Lymphatic

spread: pelvic nodes + paraortic nodes + retroperitoneal nodes (most commonly involved node)

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Management:
Surgical

management

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Cervical intraepithelial neoplasia and fallopian tube carcinoma

Click to edit Master subtitle style Lopez, Julianne MD-MBA 070032

4/18/12