CERVICAL DYSPLASIA AND ABNORMAL PAP
ESSENTIAL DESCRIPTION Precancerous epithelial alterations in the transformation zone of the uterine cervix are known as cervical dysplasia, also known as cervical intraepithelial neoplasia (CIN), and they are virtually always linked to human papillomavirus (HPV) infections. The term "CIN" refers to a variety of histologic diagnosis. - CIN I: moderate dysplasia; low-grade lesion; the lowest third of the squamous epithelium only exhibits cellular abnormalities. - CIN II: moderate dysplasia; high-grade lesion; the lower 2/3 of the squamous epithelium alone exhibits cellular abnormalities. - CIN III, or carcinoma in situ, is a high-grade disease characterised by severe dysplasia and cellular alterations that affect the entire thickness of the squamous epithelium. Affected systems: reproductive Child Safety Considerations Only 0.1 percent of cervical cancers develop before the age of 20. When compared to starting screening at age 21, screening anyone with a cervix younger than 21 years old (regardless of sexual history or debut) had no effect on cervical cancer incidence or mortality. Aspects of Geriatrics Anyone with a cervix who is older than 65, has had an adequate amount of screening in the past, and has no history of CIN II+ in the previous 20 years should not be checked for cervical cancer. Three consecutive negative cytology-only results, two consecutive negative HPV testing results, negative cytology "cotesting" with negative HPV results within 10 years before the termination of screening (with the most recent test within the last 5 years), are all considered adequate prior screening. Even if this pushes screening past the age of 65, routine screening should continue for at least 25 years at 3-year intervals with HPV testing or cotesting after spontaneous regression or proper care of a high-grade precancerous lesion. pregnant women's issues Squamous intraepithelial lesions can advance during pregnancy, however they frequently recover after delivery. Colposcopy is only performed on high-risk patients to rule out the existence of invasive cancer. Pregnancy is not a time for CIN therapy unless cancer has been detected or is suspected. EPIDEMIOLOGY The fourth most prevalent form of cancer among women overall is cervical cancer. Cervical cancer is now the 20th leading cause of cancer-related death in the US as of 2021. Between the ages of 25 and 29, CIN III incidence increases, while invasive disease incidence peaks 15 years later. Ages 35 to 44 are the most typical ranges for cervical cancer occurrence. More than 15% of instances of cervical cancer in people over 65 (who did not receive routine screening) occur in this age group. Incidence It was predicted that 14,480 new instances of cervical cancer will be identified in 2021, and 4,290 women would pass away from the condition. Because of the widespread use of cervical cancer screening tests, the incidence of cervical cancer has fallen by more than 50% in the United States during the past 40 years. Prevalence High-grade dysplasia prevalence has considerably decreased in HPV-immunized individuals, according to numerous research conducted in populations across the globe. PATHOPHYSIOLOGY AND AETIOLOGY Most sexually active men and women will contract at least one kind of HPV at some point in their lives since HPV is so widespread. High-risk HPV types: Cervical cancer is frequently caused by the oncogenic virus types 16, 18, 31, 33, 35, 45, 52, and 58. About 70% of all cervical malignancies are linked to HPV 16 and 18. The majority of HPV infections are transitory and go undetected in 1 to 2 years. Women are at a higher than average risk of acquiring precancerous lesions because of persistent illnesses. Women over 30 are less likely to successfully treat a new HPV infection than younger women. Low-risk individuals: Genital warts can be brought on by the commonly seen low-risk HPV virus strains 6, 11, 42, 43, and 44. Low-grade squamous intraepithelial lesions (LSIL) and CIN I can be caused by HPV 6 and 11, which account for 90% of benign anogenital warts. HIV infection and other immunosuppressive diseases are risk factors. Diethylstilbestrol exposure during pregnancy; smoking; having several partners; and some link with low socioeconomic position, high parity, oral contraceptive use, and inadequate nutrition. DURATIONAL PREVENTION Immunisation has not yet been proven to reduce cervical cancer, but it does reduce high-risk HPV infections and CIN II/III cervical pathology for at least 5 to 7 years. Within a few years, it's conceivable that invasive cancer prevention will be proven. Girls, boys, and anybody with a cervix should ideally start receiving HPV vaccinations before having their first sexual encounter. According to the Advisory Committee on Immunisation Practises (ACIP), adolescents between the ages of 11 and 12 should receive the HPV vaccine, however children as young as 9 can begin receiving it. Gardasil 9: In October 2018, the FDA approved it for use in both genders and in both sexes between the ages of 9 and 26 and via shared clinical decision between the ages of 27 and 45. It is 88% effective in preventing dysplasia caused by HPV types 16 and 18, which account for 75% of cases of cervical cancer, as well as types 6 and 11 (anogenital warts), and it offers protection against five additional HPV types, which are responsible for 25% of CIN II Vaccine schedule: If the first dose was administered before the age of 15, only 2 doses, spaced 6 to 12 months apart, are needed to finish the series. If vaccination started on or after the age of 15, receive three doses at 0, 2, and 6 months. 3 doses are required in immune-compromising disorders. Use of condoms is a safe sex practise. Advise people to stop smoking. With or without co-testing for HPV, the primary screening test for cervical cellular abnormalities has been the Pap smear. For women between the ages of 30 and 65, the U.S. Preventive Services Task Force advises either primary HPV testing with an authorised assay rather than cotesting at 3-year intervals. Depending on the availability of assays, clinicians will decide which screening and testing technique is the most practical. – Recommendations for screening by age and source (see algorithm "Pap, Normal and Abnormal in Nonpregnant Women Ages 25 Years and Older" and separate algorithm "Pap, Normal and Abnormal in Women Ages 21-24 Years"). - Don't screen if you're under 21. – The guideline for screening frequency varies by age and screen. 21 to 29 years: Cytology screening every three years. For patients under the age of 25, screening should be done every three years with cytology or every five years with primary HPV testing using an assay method that has been specifically authorised for primary HPV testing. Every five years, conduct a primary HPV test or cotest on those aged 30 to 65 (1)[C]. If cotesting or HPV-only testing are not available, cytology every three years is likewise acceptable. Do not examine anyone over 65 who have had sufficient prior screening and are not at high risk. Patients who have undergone hysterectomy procedures that included cervix removal and who have no prior history of CIN II+ should not be screened Patients with a history of CIN II+ or who are receiving therapy should maintain screening for at least 25 years after receiving a CIN II+ diagnosis Patients who are HIV-positive: Those who have had three consecutive normal annual Pap tests should be screened every three years, and those under the age of 30 should have cotesting every three years. DIAGNOSIS HISTORY typically asymptomatic until an aggressive illness develops MEDICAL ANALYSIS External HPV lesions are occasionally seen during a pelvic exam. Check for bleeding or not, exophytic or ulcerative cervical lesions. DISTINCTIVE DIAGNOSIS Cervicitis, whether acute or chronic; cervical glandular hyperplasia; and uterine cancer DETECTION & INTERPRETATION OF DIAGNOSIS According to the most recent data, there are no clinically significant differences between liquid-based cytology and traditional cytology when it comes to identifying cervical cancer precursors. A cervical sample from a traditional Pap smear is plated with fixative onto a microscope slide. A thin-layer preparation and collection method is called ThinPrep. Use a cytobrush and an extended tip spatula to ensure that a sufficient sample of the ecto- and endocervix is obtained. ● When HPV and cytology tests are combined (cotesting), the sensitivity and specificity for dysplasia are close to 100% and 92.5%, respectively. Compared to cytology alone, cotesting allows for an earlier identification of CIN III+ and cancer. For those with cervix ages 25 years, it is preferred to test for high-risk HPV using an assay specially approved for primary screening without cytology, particularly for underscreened or unscreened groups. When HPV or cotesting is not practical, the 2019 ASCCP recommendations state that cytology screening alone is likewise appropriate. Components of the cytology report include the specimen's type (a traditional Pap smear or a liquid-based sample), suitability (the presence of endocervical cells), and classification (the absence of intraepithelial lesions, malignancies, or abnormalities of the epithelial cells, such as squamous/glandular lesions) System of Bethesda 2014 (cytologic grading) Atypical squamous cells (ASC) are epithelial cell abnormalities in squamous cells, which cannot rule out high-grade squamous intraepithelial lesions (HSIL) in ASCH. Moderate/severe dysplasia, CIN I, mild dysplasia, and HPV Atypical glandular cells (AGCs), which are not further characterised, favour neoplasia in cases of CIS, CIN II, and CIN III. Adenocarcinoma in situ (AIS), other diagnostic techniques for adenocarcinoma Clinical intervention for cases younger than 25 years relies on the immediate risk of CIN III+ (1)[C]. For women aged 21 to 24, different algorithms from the 2012 ASCCP guidelines are offered below. ASC-US: (25 years of age or older) Tests for HPV are Option 1 (recommended). If HPV positive, take clinical intervention based on the risk for CIN III+ right away (1),(4)[C]. Repeat cotesting at 3 years if HPV testing is negative (4)[C]. Repeating the cytology at a year is Option 2 and is acceptable (4)[C]. If the imminent risk of CIN III+ is known and the repeat cytology ASC is larger, perform a colposcopy or take other therapeutic steps. If a second cytology test comes out negative, move on to routine screening. LSIL (25 years of age): colposcopy is necessary for ASC-H (25 years of age). - Repeat cotesting at one year (recommended) for LSIL with negative HPV test results. If the second cotest is negative, the third cotest should be performed. If the cotest is positive, either get a colposcopy or do it again in a year. - LSIL with a negative HPV test or a positive HPV test: Colposcopy is recommended. - Colposcopy is preferred for LSIL in pregnancy, but postpartum colposcopy is acceptable - Colposcopy is likely for HSIL/CIN II or III+/AGCs/atypical endometrial cells (21 years), but clinical action ultimately depends on immediate CIN III+ risk - Clinical action is only taken for age 25 years/special populations/rarely screened/status posttreatment/history of CIN II, CIN III, AIS, or invasive cancer ASCCP's smart phone app for treatment incorporates 2019 guidelines: Pap smear and postcolposcopic diagnoses and therapies are guided by algorithms in the evidence-based management phone application, which is accessible online at https:// www.asccp.org/ mobile-app and https:// www.asccp.org/ management-guidelines. UNSPECIFED MEASURES Office evaluation and observation, smoking reduction, safe sex practises, and immunisation promotion are all encouraged. MEDICATION Treat the organism or condition indicated on the results of an infected or reactive Pap smear. Treatment options for condyloma acuminatum: See "Condylomata Acuminata" chapter. SURGICAL AND OTHER PROCEDURE For non-pregnant patients with an immediate CIN III+ risk of >60%, expedited treatment that omits colposcopy biopsy is advised. However, shared decision-making is crucial for patients with an immediate CIN III+ risk between 25% and 60% as well (1). For CIN I, observation is preferred over treatment (1). For some patients, colposcopy can be postponed, and repeat HPV testing or cotesting in a year is advised if the chance of developing CIN III+ right away is minimal (4%). For histologic HSIL (CIN II or CIN III), ablative treatment is favoured to excisional treatment. Excision is advised for AIS. CONTINUING CARE AFTERCARE RECOMMENDATIONS Women should resume screening with HPV testing or cotesting after treatment (excision or ablation) for HSIL, CIN II or III, or AIS and initial posttreatment management every three years for at least 25 years (1). PATIENT EDUCATION HPV vaccination, smoking cessation, protected sexual activity, and routine Pap smear screening in accordance with recommendations PROGNOSIS The rate of remission in CIN is high and the rate of progression to invasive cervical cancer is slow: Lesions in CIN II and III may regress by up to 43% and 32%, respectively. Over a 30-year period, CIN III has a 30% chance of developing invasive cancer, but only around 1% if it is treated. CIN III starts to intrude: Early-stage lesions are treatable with excellent outcomes and few recurrences. The survival percentage for cervical cancer patients after five years is 66.3%. For patients with a diagnosis of localised illness, the 5-year relative survival rate is 91.9%. COMPLICATIONS Cervical stenosis, cervical incompetence (which can result in preterm labour), and scarring that affects cervical dilatation in labour can all be brought on by aggressive cervical surgery.
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