Colp climate module

Question 1

What are the 2 subfamilies of HPV?

Answer 1

Papillomavirinae and Polyomavirinae

Question 2

Structure of the HPV genome

What are the 3 regions?

Answer 2

• the long control region (LCR) without coding potential
• early proteins (E1-E8)
• late proteins (L1 and L2)

Question 3

Role of p53 tumour suppressor gene

Answer 3

It promotes cell arrest or apoptosis when activated by unscheduled induction of DNA replication

Question 4

HPV lifecycle in the cervix

Answer 4

The HPV lifecycle is restricted to the cervical epithelium; there is no viraemia.

The virus is thought to infect the basal cell layer of the epithelium via microabrasions.

It then uses the host cell machinery to replicate viral DNA and express virally encoded proteins.

1. Infection of basal cells
2. Episomal viral DNA in cell nucleus
3. Viral DNA replication
4. Viral assembly
5. Shedding of virus laden epithelial cells

Early proteins = steps 1-3
Late proteins = step 4

Question 5

What proportion of HPV cancers do types 16&18 account for?

Answer 5

70%

Question 6

HPV accounts for __% of these cancers?

• Cervical?
• Anal?
• Vulval/vaginal/penile?
• Oropharyngeal?

Answer 6

99.7% of cervical cancers
90% of anal cancers
40% of vulval, vaginal and penile cancers
12% of oropharyngeal cancers

Question 7

What proportion of HPV infections lead to cancer?

Answer 7

<2%

Question 8

What is the lag period between HPV infection and cancer?

Answer 8

15 years

Question 9

What % of people will acquire HPV over a lifetime?

Answer 9

76%

Vast majority of infections are transient

>5 sexual partners increases risk

Question 10

Acquisition and clearance rates in women aged 51?

Answer 10

Acquisition rates higher, clearance rates lower

HrHPV types 16 and 18 have highest persistent infection rates

Question 11

Differences between the innate and adaptive immune system?

Answer 11

Innate immune system:
- Activated by cell death, is not antigen specific, has no memory and its cardinal sign is inflammation.

• Adaptive immune system is antigen specific, builds up memory and has two arms, a humoral arm to produce antibodies and a cellular arm, including T-cell help (TH) for antibody production and cytotoxic T-cells (CTL).

These two systems have a close interaction. The key player in this interaction is the antigen-presenting cell (APC).

The APC bridges innate and adaptive immunity,

Question 12

How does the APC work?

Answer 12

the APC carries information from the innate to the adaptive immune system and presents two pieces of information to the adaptive immune system:

Firstly, it will present the antigen itself
Secondly, it will transmit information on the type of pathogen the antigen originates from, e.g. whether it is a RNA or DNA-virus, a bacterium, etc… through ‘molecular barcode readers’, the Toll-like receptors
Following stimulation, APCs are activated to become dendritic cells in the lymphoid organs and tissues, where they secrete cytokines and present virus-like particle (VLP) antigens to T-cells.

T-helper cells provide ‘help’ to cytotoxic T-cells (which can lyse virally infected cells) and to B-cells which produce antibodies – important for prevention of viral infection.

T- and B-cells migrate to infected tissues where they perform their respective effector functions and generate immune memory.

Question 13

How does HPV evade the immune system?

Answer 13

• viral lifecycle occurs entirely within epithelium
• No viraemia
• No cell death
• No inflammation
• Local immunosuppression caused by viral proteins

Question 14

Typically, after HPV infection how long to develop:

• CIN 1
• CIN 2
• CIN 3
• Cancer

Answer 14

• CIN1: 3 months
• CIN 2: 6 months
• CIN 3: 1-2 years
• Cancer: Typically 10-20 years but can be as fast as 1-2 years

Question 15

Co-factors that increase the risk of progression to cervical cancer?

Answer 15

• environmental, e.g. smoking
• sexual exposure, e.g. parity, multiple partners, early onset of sex
• hormonal, e.g. long-term use of oral contraceptives
• immunosuppressive, e.g. HIV, transplant recipients
• long-term systemic steroid users

Question 16

Cervical cancer incidence

Answer 16

the third most common cancer in women and the seventh overall,

More than 85% of the global burden occurs in developing countries where it accounts for 13% of all female cancers.

Question 17

Necessary requirements for a screening test?

Answer 17

The test needs to be effective
Prevent a significant number of deaths from the disease
Cost effective
Acceptable to patient
Sensitive and specific

Question 18

Incidence of cervical cancer in Australia?

Answer 18

7 per 100,000

Question 19

Management if glandular abnormality found?

Answer 19

Refer for colposcopy

Question 20

Benefits of liquid based cytology over conventional Pap smear?

Answer 20

• lower unsatisfactory rate (in an Australian study the unsatisfactory rate was reported as 3% for conventional smears and 1% for liquid-based cases).
• there is residual material upon which HPV testing may be performed, and that this test may be screened with an imager, which may become increasingly important in a vaccinated population with a lower rate of abnormalities.

Question 21

Histology of the ectocervix

Answer 21

• covered by stratified squamous epithelium
• The junction of the endocervical glandular mucosa with the squamous epithelium of the squamous epithelium of the ectocervix is called the squamocolumnar junction, which does not always lie at the external os, and is often on the ectocervix.
• The epithelial layers are basal/parabasal, midzone and superficial.
• Upper layers contain glycogen, in response to circulating oestrogens.

Normal original squamous epithelium does not become white after application of acetic acid.

Question 22

Histology of the endocervix

Answer 22

The endocervical canal:
- lined by a single layer of mucin-secreting epithelium, which blends with the squamous epithelium of the ectocervix, and at the other end, the endometrial epithelium of the isthmus.

Endocervical epithelium dips into elongated clefts in the stroma, referred to as endocervical glands, which are not true glands, but rather clefts.

Benign glandular mucosa often forms villous or processes that are recognizable as such at colposcopy, and often become whiter after application of acetic acid.

Question 23

Explain reporting of CIN vs LSIL/HSIL?

Answer 23

Cytology reporting: LSIL vs HSIL
LSIL= CIN1 or HPV
HSIL = CIN2/3

Histopathology reporting:

• CIN1
• CIN2
• CIN3

Question 24

Features of CIN1?

Answer 24

• Mild dysplasia
• Dysplastic squamous cells are confined to the deeper epithelial layers (basal one-third)

Histology:

• Presence of koilocytes superficially:
• intermediate squamous cell with enlarged hyperchromatic nuclei (1 or multiple nuclei) surrounded by perinuclear halo
• Nuclear enlargement compared to intermediate squamous cell (increased N/C ratio)
• Dense hyperchromatic chromatin
• Irregular nuclear membranes
• Perinuclear clear halo with a well defined, thick cytoplasmic rim
• Positive P16 staining predicts high grade - higher risk of progression to HSIL

Question 25

Features of CIN2?

Answer 25

Moderate dysplasia (can be subjective) dysplastic squamous epithelial cells and mitotic figures are confined to the deeper two-thirds of the mucosa

Question 26

Features of CIN 3?

Answer 26

Severe dysplasia Dysplasia involves the full thickness of the mucosa. There is no maturation, and often no visible koilocytes, because the entire mucosal thickness is dysplastic. There is no invasion. Also referred to as CIS. Histology: * full thickness nuclear abnormalities (hyperchromasia, coarse chromatin, irregular nuclear contours and inconspicuous nuclei) * high N/C ratio in at least lower two thirds of epithelium * CIN II: cytoplasmic maturation in the upper third of mucosa * CIN III: full thickness basal / parabasal type, no maturation difference across layers * Increased mitotic activity with atypical mitoses * Positive P16 staining predicts high grade

Question 27

Problematic areas in diagnosis (6)

Answer 27

1. Small CIN lesions (need to look carefully at levels in the biopsy) 2. CIN in thin mucosa (difficult to grade) 3. CIN in the setting of atrophy 4. Small/crushed biopsy 5. Overlap of features between reactive/inflammatory process and CIN 6. Correlation of the Pap smear and biopsy findings can sometimes be difficult.

Question 28

3 modalities of colposcopic management?

Answer 28

- Cytology - Colposcopy - Histopathology

Question 29

5 factors that need to be assessed during colposcopy?

Answer 29

Surface contour Blood vessel pattern Acetowhite changes Topography Iodine uptake

Question 30

When to take a cervical biopsy?

Answer 30

When an abnormality is detected, prior to treatment. Only time when it shouldn't/doesn't need to be taken: - Glandular abnormality- cone preferable - where the lesion extends into the endocervical canal out of site (also treated by cone biopsy) - where there are obvious or highly suspicious changes of invasive disease and the patient is to be referred to gynae onc

Question 31

What percentage of LSIL will resolve spontaneously? What percentage will have high grade disease found after further ix?

Answer 31

- 50% spontaneously resolve - 20-50% may have high grade detected at colp- therefore becomes a HSIL

Question 32

Risks of cervical treatment? e.g. LLETZ

Answer 32

early: - infection - bleeding Late: - obstetric- \>10mm or recurrent LLETZ associated with mid trimester loss, PTB, PPROM - cervical stenosis - Recurrence of disease (8-10%)

Question 33

Treatment of glandular disease

Answer 33

- All patients should have colposcopic review due to higher risk of high grade disease - Initial treatment is cone biopsy - If high grade lesion offer hysterectomy

Question 34

What criteria need to be met for an ablative procedure (e.g. LLETZ) to be performed?

Answer 34

- must have a fully visible TZ (type 1 TZ) - must have no evidence of invasive disease on cytology, colpocopy or biopsy - must have no evidence of glandular disease on cytology, colposcopy or biopsy - must have biopsies taken confirming high grade histology - must understand the need for, and agree to, attend follow up - must understand the possible short and long term complications - must not be pregnant

Question 35

Indications for cone biopsy?

Answer 35

1) the TZ is not fully visible (type 3 TZ) and confirmed HSIL 2) there is suspicion of invasive disease 3) there is evidence of glandular disease on cytology, colposcopy or biopsy

Question 36

What is the transformation zone?

Answer 36

area lying between the original squamo-columnar junction and the new squamo-columnar junction

Question 37

Classification of the TZ?

Answer 37

Type 1: Completely on the ectocervix and fully visible; both primary and new SCJ should be visible; may be large or small. Type 2: Has an endocervical component but TZ/new SCJ fully visible. Type 3: Has an endocervical component and entire TZ/new SCJ is not fully visible.

Question 38

Why is it important to classify the TZ for colposcopy?

Answer 38

Understanding the TZ is vital in the management of any patient with CIN as: - the TZ is the area where almost all CIN develops - the entire new SCJ must be seen for a satisfactory colposcopic examination - the entire TZ is ablated or excised when is CIN treated Failure to follow these principles is the most common reason for treatment failures.

Question 39

Name non-neoplastic conditions that can confound appearance at colposcopy?

Answer 39

Infection/inflammation Atrophy Pregnancy decidualisation Polyps/warts Cervical transformation zone Endometriosis Post treatment Ulcers Structural abnormalities

Question 40

Features of low grade disease at colposcopy?

Answer 40

Surface contour: - Flat - Micropapillary - Microcondylomatous - Condylomatous - Hyperkeratosis may obscure LG or HG disease Vascular pattern: - Absent - Normal vessels - Punctation as small fine regular dots only. Acetowhite changes: - Faint pink white to snow/shiny white epithelium - Frequently slowly developing Topography: - Faint, irregular, indistinct, geographic margins - May extend into the endocervical canal - May extend into the vaginal fornices - Satellite lesions Iodine staining: - Negative i.e. no staining may be seen in low grade as well as high grade disease and its significance depends on the presence of other high grade features - Partial uptake, variegated/speckled mustard yellow or light brown - Positive with intense brown staining is most unusual in high grade disease - A mixture of all the above

Question 41

Features of high grade disease:

Answer 41

Surface contour: - Flat - Micropapillary - Microcondylomatous - Hyperkeratosis may obscure in LG or HG disease The following may all be visible in high grade disease as well: - visible/rolled edge - peeling epithelium - ulcerated or fungating lesion may indicate established malignancy Vascular pattern: - Absent - Normal tree-like branching vessels - Punctation - appears as large coarser vessels with less regular spacing - Mosaic - appears as a coarse less regular pattern - Atypical vessels which start/stop, have variable calibre, blood lakes and commas Acetowhite changes: - Dull oyster white / grey but not always - Can be mixed with LG disease - Frequently rapidly developing Topography: - Well-defined, linear, sharp margins - May be mixed with LG features - Extending into the endocervical canal - Extending into the vaginal fornices - Internal demarcations within lesions - Elevated ridge sign Iodine staining: - negative i.e. no staining - partial uptake, variegated/speckled mustard yellow or light brown in any adjacent low grade disease

Question 42

Depth of LLETZ?

Answer 42

Endocervical glands are at 6mm Recommended depth of type 1 excision therefore is 8-10mm \>10mm carries increased risk of PTB

Question 43

Ablative treatment options?

Answer 43

- Radical diathermy: 98% effective, concerns re obstetric sequelae - Cold coagulation - Cryocautery - Laser ablation

Question 44

Post LLETZ treatment instructions?

Answer 44

1. Mild pain normal, seek medical attention if severe 2. May have blood-stained vaginal discharge for 2 to 3 weeks, seek medical attention if heavy 3. No sexual intercourse or tampons for 4 weeks to allow complete healing. 4. Continue OCP if using 5. Can have disruption to period 6. No swimming or baths for 2 weeks. 7. Emphasise importance of follow up due to risk of residual or recurrent disease.

Question 45

Excision treatment options?

Answer 45

LLETZ or Cone

Question 46

Technique LLETZ

Answer 46

For loop excision replacing ablation, deep excision is not required and an 8 or 10mm deep loop will provide adequate excision. After infiltration of local anaesthetic/vasoconstrictor, an appropriately broad loop is used taking into account the width of the lesion and proximity of the vagina. If the vagina is close, a less broad loop in 2 passes will prevent the vagina being touched inadvertently which causes extreme pain. The treatment should always be performed looking through the colposcope. Passing the loop from posterior to anterior is usually the simplest method. Ball diathermy haemostasis and Monsell's controls bleeding in most instances.

Question 47

Technique cone

Answer 47

Cone biopsy may be done by scalpel excision, laser excision or wire excision. The depth of excision will be determined by the indications for the procedure, the age of the patient and her child-bearing intentions. If suture repair is performed it is important to ensure the os remains open after completion. In the majority of cases, endocervical curettage is performed though the results of this may be difficult to interpret.

Question 48

Complications of excision/ablative treatment?

Answer 48

Immediate complications during surgery: - Bleeding - Inadvertent damage to surrounding tissues- vagina, bladder, rectum Immediate complications post surgery - Secondary bleeding - Infection - Malodorous discharge - Pain Long-term consequences Appearance: - Scarring Cervical Stenosis: - Menstrual symptoms - dysmenorrhea - Haematometra or pyometra - Inadequate colposcopy at follow up - transformation zone not visible Contributing factors to cervical stenosis: - Amount of tissue removed - Menopausal status - Depo Provera Cervical incompetence: - Mid-trimester abortion Adverse pregnancy outcomes: - Pregnancy loss / preterm birth / Premature rupture of membrane (PPROM) Infertility: - Treatment for CIN does not appear to impair fertility. Recurrence / Residual Disease of Cervical intra-epithelial neoplasia (CIN): - The reports from randomised and non-randomised studies suggest that most surgical treatments have around 90% success rate

Question 49

Which techniques have higher adverse obstetric outcomes?

Answer 49

Cone biopsy with cold knife Likely laser cone Radical diathermy LLETZ not as bad but sequential LLETZ or \>10mm also have

Question 50

Approach to assessment at colposcopy.

Answer 50

- Assess cervix on low power magnification - Adequate or inadequate view of cervix (e.g. due to vaginal stenosis) - Identify outer and original SCJ - Identify TZ type 1, 2 or 3 - Apply 3-5% acetic acid and assess acetowhite change as minor or major, using low and then high power - Assess signs of invasion: abnormal/fragile vasculature, irregular surface, exophytic lesion, ulceration/necrosis, tumour - Apply lugols/schillers aqueous iodine - assess iodine staining of area of suspicion - Location of lesion (inside/outside TZ, Clock face position) - Size of lesion (quadrants affected and percentage of cervix) - Any other benign or suspicious findings - Assess vagina, vulva, perinatal areas - Consider anoscopy if findings suspicious for high grade lesion

Question 51

What are the features of minor and major acetowhite changes on colposcopy?

Answer 51

Minor - subtle/thin acetowhite change - Irregular/ill defined border - Fine mosaicism - Fine punctation Major - dense acetowhite - Rapid change to acetowhite - Coarse mosaicism - Cuffed crypts/ glands - Coarse punctation - Sharp border - Ridge sign

Question 52

What is the swede score? What are the factors assessed? How is it interpreted?

Answer 52

- A scoring system for colposcopy findings that detect high grade change with 95% specificity (score\>8) - Assesses (score 0-2 for each): 1) surface contour, 2) vascularity, 3) acetowhite change, 4) iodine uptake, 5) topography/lesion size Score 1-4 = low risk HSIL Score 5-7 = biopsy to check Score 8-10 = high risk HSIL

Question 53

What are the 2 main types of treatment for HSIL?

Answer 53

ABLATION (CO2 lazer, radical diathermy, cold agglutination, cryotherapy) - if depth \>12mm required (i.e. TZ 2/3) - consider excision EXCISION (LLETZ, NETZ, cone biopsy, hysterectomy)

Question 54

What decides depth of excision?

Answer 54

Transformation zone. Excision 1 / TZ 1 = 8-10 or 12mm Excision 2 /TZ 2 = 12-15mm Excision 3 / TZ 3 = \>15mm (same as conisation) - also for suspected invasive disease OR atypical glandular cells Failure to choose adequate depth will increase risk that primary SCJ is not removed and that abnormal cells persist.

Question 55

What proportion of HSIL become invasive cancer?

Answer 55

30% become invasive cancer over 5-10 years