National screening unit NZ guidelines

• long latency - taking average 10-20yrs to develop

• HPV 16&18 cause up to 70% cervical cancer

  • Garasil

• in NZ 160 women diagnosed with cervical cancer

  • 60 die

HrHPV = high risk hpv

16,18,31,33,39

Liquid based cytology

• =SurePath and ThinPrep

• do not use wooden spatula

• reduction in rate of unsatisfactory smears, shorter time for interpretation

• ability to use same sample for HPV

• use water based lubricant - sparingly trying to avoid tip of speculum( can use warm water)

• transferred into vial cf. glass slide

• ideal sample = squamous cells which line the ectocervix and small number of endocervical glandular cells = indicates squamocolumnar junction sampled

• if looks abnormal or abnormal symptoms then colposcopy

• indications for cytobrush:

  • repeat smears on patients with abnormal

  • anatmoy of canal has been altered

  • repeating smear where previously no endocervical cells were obtained

  • abnormal bleeding

• to avoid bleeding only rotate 1/4 - 1/2 turn

when to screen + how often

• recommended fora ll women who are or who have ever been sexually active

• 3 yearly from 20yo - 69yo

• first smear or more than 5 years b/w smears:

  • second smear recommended one year after first then 3 yearly

• >69yo good quality smears difficult to obtain

• 65 low risk of developing cervical cancer

Normal Smear:

• if negative: recall 3 years unless:

  • if first smear: follow-up 1 year (or 5yrs b/w smears)

Unsatisfactory smear:

• inadequate for some reason

• three main types:

  • taking smear; inadequate sampling of cells, contact bleeding, poor fixation, unwanted artefacts

  • clinical factors: bleeding, inflmamtion, cyolysis

  • laboratory technical factors

• reported as a non-result

• 3 unsatisfactory: recommend colposcopy to exclude high-grade lesion

• use liquid based cytology technique for collection and transport following unsatisfactory

• recommendation:

  • repeat within 3 months

  • refer colposcopy after 3 consecutive

women with abnormal smears

Low-grade squamous abnormalities: ASC-US + LSIL

• cervical cancer very rare outcome of a low-grade abnormality

  • if cancer diagnosed:

    • under-calling on index cytology

    • true progession

• risk CIN2/3 similar with LSIL and atypical squamous cells of undertmined significance (ASC-US).

  • both show similar high regression rates

  • managed similarily

• manifestation of viral infection

• resolve spont \<30yo majority

• recall 12/12 aged 20-29 as median time for clearance = 6-18mo

• >30yo HrHPV increase risk of developing high-grade lesion

  • infection more likely to be persistant

  • HPV triage hreater benefit than repeated cytology to asses underlying risk of HSIL

• symptoms/appearacne of cervix abnormal refer colposcopy

• low grade = low risk

Guidance: asc-us/lsil

• 20-69 with abnormal smear within last 5:

  • refer colposcopy

• 20-29 no abnormal smear within last 5 yrs:

  • repeat smear 12 months

• >30yo with no abnormal smear

  • offered HPV test

    • if reflex HrHPV -ve:

      • repeat 12 months

        • if negative:

          • return normal screening

    • if positive:

      • refer colposcopy

• if 12 month repeat:

  • HSIL/ASC-H:

    • colposcopy

  • ASC-US/LSIL

    • colposcopy

  • negative

    • smear 12 months

• if colposcopy:

  • satisfactory and normal:

    • 2x annual smears:

      • if both negative

        • resume routine screening

      • if either abnormal:

        • colposcopy

  • Satisfactory and abnormal

    • target biopsy

  • Unsatisfactory

    • cytology

      • if low grade:

        • repeat colpsocopy and cytology 12 months

Histologically confirmed LSIL

• treatment not recommended

• smears 12 & 24 months

• if both -ve

  • return to routine

• if either positive;

  • refer back to colposcopy

High-grade squamous abnormalites

• CIN2/CIN3

  • moderate dysplasia

  • severe dysplasia/carcinoma in situ

• women with untreated CIN3 are at high risk of cervical cancer

• cin2 more heterogenous

• CIN2 = threshold for treatment

  • except \<20yo

    • lieklyhood of regression = high

  • and pregnancy

Recommendation

• ASC-H or HSILL

  • refer colonoscopy and biopsy

• if biopsy:

  • satis and abnormal

    • biopsy

  • satis and normal or negative biopsy

    • cytology review

    • if review confirms high-grade

      • repeat colpsocopy and cytology in 3/12

        • if N

          • repeat 12 months

        • if LSIL

          • review MDT

        • if HSIL

          • treatment

  • unsatisfactory

    • cytology recommemended

      • if HSIL

        • knife cone biopsy

      • ASC-US or LSIL

        • MDT

• LLETZ

  • failure rate = 10%

  • risk of further high-graade disease and invasive cancer increases with age

Management of previous CIN2 or 3

• HrHPV = high sensitivity for detecting persistent CIN2/3 post treatment

  • allows for shortening of surveillance period

• Routine f/u:

  • treated for CIN 2 or 3 should have colposcopy and smear 6-12mo

  • any symptoms managed

  • cervical smear 12mo after then annually until 70

  • HrHPV can be used to identify women at risk of persistent or rcurrent lesions

cervical glandular abnormalities

• represent 15-20% invasive cervical cancer

• less effective at preventing cervical adenocarcinoma cf. squamous

  • limitation of cervical smear test

• HrHPV: cervical adenocarcinoma and AIS (in-situ) in \~90%

• not uncommon for atypical glandular cells (AGC) associated with underlying neoplastic condition

• all glandular abnormalaties referred to gynae

Pregnancy

• no CI taking smears

• routine delayed until after pregnancy

  • unless overdue

• risk of progression of CIN2/3 to invasive cancer during pregnancy is low

• high probability that high grade lesion will persist

• continued colposcopic and cytlogical during pregnancy (20-30/40) and post partum

post meno-pausal women and women >40 with noraml endometrial cells

• benign endometrial cells in post-menopausal women may be associated with significant endometiral pathology

  • further assessment required

• normal cells;

  • correllate with uterine symptoms

• atypical endometrial cells

  • high correlation

  • urgent referral for colposcopy

immunocompromised women

• annual screening

• abnormal - any grade

  • colposcopy

previous hysterectomy

Sub-total hysterectomy (cervix remains) for benign regions

• routine screening

Total hysterectomy

• normal cytology/histology 5yrs preceeding hysterectomy do not require vaginal vault cytology

• unkown - baseline vaginal vault cytology

  • if Normal then no further

• previous CIN1

  • 3 yearly vaginal vault cytology until age 70yo

• CIN2/3

  • guidelines for high grade

    • annual vaginal vault until age 70yo

  • genital malignancy

    • oncologist surveillance

HPV testing

• majority of high-risk HPV infections clear within 2 years

  • are of little clinical significance

• high NPV (\~99%)

• more sensitive for detecting risk of High grade lesions than conventioanl cytology - more specific test

ASC-US or LSIL >30yo:

• -ve ‘reflex’ test: very unlikely to have signifiant lesion

  • repeat cytology 12/12

    • if negative -> normal 3 yearly

• +’ve -> colposcopy

High grade lesion

• increase risk of further high gradde disease and cervical cancer

• better id women @ risk

• HrHPV+cytology @ 12 months after treatment and annually until women negative both tests x 2 12/12 apart

  • then 3 yearly interval

Post colposcopy with discordant results

• single colpsocopic exam can miss signifiant lesions

• HrHPV - cytology Pos

  • if ASC-H