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57 Cards in this Set

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Which oncogenic HPV subtype is the most likely to be persistent?
Type 16
What are the names of the oncogenic genes in the HPV virus? What proteins do they bond to?
E6 --> binds p53 and degrades it. Loss of p53 = damaged cells mutate.
E7 --> binds with pRb (retinoblastoma tumor suppresser) and allows damaged cells to survive (pRb inactivates damaged cels)
What percentage of HPV low risk and high risk subtypes will regress in 3 years?
70% oncogenic types
90% low risk types
When should pap smear testing begin?
3 years after sexual intercourse initiation or age 21.
What are ACOGs recommendations for pap smear screening?
annual until 30, after 30 women with 3 negatives can undergo q3 yr testing
At what age should HPV testing be started?
What if someone over that age has a negative pap and negative HPV test?
Age 30 (per 2006 consensus guidelines).
If both pap and HPV neg, rescreen 3 yrs.
What is someone has a negative pap but a positive HPV test?
repeat both tests in 1 year.
1 year after a negative Pap and positive HPV test, a patient is retested and the same results occur. What is the next step?
colposcopy
When should one stop screening for cervical ca?
ACS - age 70.
USPSTF - age 65
ACOG - continue to screen women who are sexually active with multiple partners or women with history of abnormal tests.
A woman has a hyst and has always had normal pap smears. Does she need vaginal paps?
What about a women who has a hyst for dysplasia?
normal paps --> no need for vaginal pap.
h/o high grade CIN --> can d/c screening after 3 consecutive neg tests.
A woman has an ASCUS pap. What are the three options for triage of this result?
Repeat cytology at 6 & 12 mos, colpo, or HPV testing.
ASCUS pap followed by negative pap smears at 6 and 12 mos. Next surveillance?
Routine screening.
ASCUS pap followed by another ASCUS pap
Colposcopy
ASCUS pap,--> negative colpo
If HPV unknown, repeat pap 12 mos.
If HPV +, Pap at 6 and 12 mos
OR HPV testing in 12 mos

If HPV + or repeat paps positive, repeat colpo.
ASCUS pap, HPV testing negative.
ASCUS pap, HPV positive
repeat pap 12 mos.
if +, colpo.
LSIL pap, negative colpo.
Pap at 6 &12 or HPV in 12
What is the management of LSIL or ASCUS during pregnancy?
NO ECC. Defer colpo til 6 wks PP ok. If they have initial colpo that is negative, no further colpo or pap during pregnancy.
What are the options for an HSIL pap?
Colposcopy or immediate LEEP (not in adolescents or pregnant women)
HSIL pap, negative satisfactory colpo.
Negative unsatisfactory colpo.
If neg satisfactory colpo --> Colpo/pap q6 mos for 1 year, diagnostic excisional procedure, or re-review material.

If neg unsat colpo --> must have diagnostic excisional procedure.
HSIL pap, satisfactory negative colpo --> repeat colpo at 6 and 12 mos negative--> #1

Repeat colpo HSIL -> #2
1) routine screening
2) Diagnostic excisional procedure
HSIL pap in an adolescent
observe, repeat colpo in 6 mos and 1 yr. CIN 2 most statistically likely, and usually will regress.
What percentage of individuals with HSIL have invasive cancer?
2%
Pap results in AGUS or AGC-NOS; next step?
colpo with ECC + HPV DNA testing + EMB (if >35 or risk factors)
AGUS pap ---> negative colpo -> what next?
triage based on HPV testing.

HPV +/unknown --> repeat pap/HPV in 6 mos (x4)

HPV neg --> pap/HPV 1 year
AGUS pap --> negative colpo, HPV positive --> Pap and HPV negative at 6 mos -->?

Pap ASC or > or HPV positive at 6 mos
routine screening.

repeat colpo.
HSIL pap in an adolescent
observe, repeat colpo in 6 mos and 1 yr. CIN 2 most statistically likely, and usually will regress.
What percentage of individuals with HSIL have invasive cancer?
2%
Pap results in AGUS or AGC-NOS; next step?
colpo with ECC + HPV DNA testing + EMB (if >35 or risk factors)
AGUS pap ---> negative colpo -> what next?
triage based on HPV testing.

HPV +/unknown --> repeat pap/HPV in 6 mos (x4)

HPV neg --> pap/HPV 1 year
AGUS pap --> negative colpo, HPV positive --> Pap and HPV negative at 6 mos -->?

Pap ASC or > or HPV positive at 6 mos
routine screening.

repeat colpo.
LSIL or HPV + ASCUS --> CIN 1 on colposcopic biopsy.
DO NOT TREAT CIN 1.
Repeat pap in 6 and 12 mos, or HPV testing in 12 mos.
HSIL pap --> CIN 1 on colpo biopsy
If colpo unsat -> diagnostic excisional procedure.
If Colpo satisfactory -> repeat 6 mo colpo&pap, or diagnostic excisional procedure.
Adolescent with ASCUS or LSIL pap
Repeat pap at 12 mos. If HSIL or >, colpo. If <HSIL, repeat cytology 12 mos.
Adolescent with CIN 2 or 3-NOS
If colpo satisfactory, can monitor q6 mos for up to 2 years (24 mos). After 2 negative paps, can return to routine screening.

OR Treat.
When should an adolescent absolutely be treated with a therapeutic procedure?
if CIN 3 specified, CIN2 or 3 persists for 2 years, or colpo is unsatisfactory.
Management of AIS in a woman who desires fertility?
Margins negative -> q6 mo Pap, HPV testing, colpo, ECC.
Margins positive, re-excision to get neg margins.
Lifetime risk of developing cervical cancer?
1 in 135
You biopsy what appears to be a tumor. The result comes back with invasion <3 mm. What should you do?

The result comes back CIN. What should you do?
In both cases, cone biopsy.
Define Stage I, II, III, IV for cervical cancer by organ involvement.
I = confined to cervix
II = spread beyond cervix but NOT to pelvic side wall or distal 1/3 vagina
III = pelvic wall/hydro/lower 1/3 vag
IV = met to other organs (bowel, bladder, beyond)
What is the difference between IA and IB in cervical cancer staging?
IA = microscopic Or invasion<5 mm, spread <7 mm
IB = clinically visible or >5 mm invasion/ >7 mm lateral spread
Cervical cancer : difference between IA1 and IA2
IA1 = invasion < / = 3 mm
IA2 = invasion > 3 to 5mm

On both lateral spread <7 mm
Cervical Ca: difference between IB1 and IB2
IB1 visible lesion <4 cm
IB2 visible lesion >4 cm
Cervical CA: IIA versus IIB?
IIA no obvious parametrial involvement
IIB obvious parametrial involvement
Define Stage I, II, III, IV for cervical cancer by organ involvement.
I = confined to cervix
II = spread beyond cervix but NOT to pelvic side wall or distal 1/3 vagina
III = pelvic wall/hydro/lower 1/3 vag
IV = met to other organs (bowel, bladder, beyond)
What is the difference between IA and IB in cervical cancer staging?
IA = microscopic Or invasion<5 mm, spread <7 mm
IB = clinically visible or >5 mm invasion/ >7 mm lateral spread
Cervical cancer : difference between IA1 and IA2
IA1 = invasion < / = 3 mm
IA2 = invasion > 3 to 5mm

On both lateral spread <7 mm
Cervical Ca: difference between IB1 and IB2
IB1 visible lesion <4 cm
IB2 visible lesion >4 cm
Cervical CA: IIA versus IIB?
IIA no obvious parametrial involvement
IIB obvious parametrial involvement
Can you ever do a cone biopsy for cervical CA? Whats the f/u after?
only for IA1 desiring feritility. Good prognosis if neg margins. Need pap q6mo for several years.
What is the treatment for IA2 cervical ca?
Cone vs trachelectomy vs simple hyst vs radical hyst.

establish diagnosis with cone. data for cone suggests higher rate of recurrence. LVSI positively correlated with recurrence, as well as depth of invasion. Simple vs radical hyst. Depth of invasion <5 mm in one study no nodal mets. Do nodes if LVSI present.
Disease related deaths in IA1 versus IA2?
0.76% versus 1.8 %.
Treatment for IB1 cervical ca?
Radical hyst and radiation equal.
What are indications for post radical hyst radiation?
Positive or close margins, disease extension into parametria, lymph node mets

GOG trial comparing IB tumors with >1/3 stromal inv, LVSI, tumor >4 cm - postop pelvic radiation reduced recurrence risk but did not impact overall survival
Treatment for IB2 cervical ca?
rad hyst ok, but if imaging identifies risk factors (bulky disease, PET shows lateral spread) consider radiation instead
Does chemo-radiation improve survival?
Cisplatin adjuvant increased progression free and overall survival.
What about stage IIA?
Radical hysterectomy ok.
What tumor size is the limit for trachelectomy?
2 cm