{"id":2611,"date":"2020-08-13T16:15:18","date_gmt":"2020-08-13T16:15:18","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=199"},"modified":"2021-05-09T20:53:11","modified_gmt":"2021-05-09T20:53:11","slug":"52-cervical-disease-and-neoplasia","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/overview\/52-cervical-disease-and-neoplasia\/","title":{"rendered":"52. Cervical Disease and Neoplasia"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/b6txEZIyzys\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration = 9:21<\/p>\n<input type='hidden' bg_collapse_expand='69e9b59e924e99033240463' value='69e9b59e924e99033240463'><input type='hidden' id='bg-show-more-text-69e9b59e924e99033240463' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b59e924e99033240463' value='Hide Transcript'><button id='bg-showmore-action-69e9b59e924e99033240463' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b59e924e99033240463' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic 52 cervical<br \/>\n00:02<br \/>\ndisease and neoplasia globally cervical<br \/>\n00:05<br \/>\ncancer is the second most common cancer<br \/>\n00:07<br \/>\namong women it is the most common cause<br \/>\n00:09<br \/>\nof mortality from gynecologic malignancy<br \/>\n00:11<br \/>\naccounting for 250,000 deaths per year<br \/>\n00:14<br \/>\nin the United States cervical cancer<br \/>\n00:16<br \/>\nincidence and mortality have decreased<br \/>\n00:18<br \/>\nsubstantially it is now thought of as a<br \/>\n00:21<br \/>\npreventable cancer that is caused by a<br \/>\n00:23<br \/>\nvirus called human papilloma virus or<br \/>\n00:25<br \/>\nHPV the objectives of this video are to<br \/>\n00:27<br \/>\ndescribe the pathogenesis and risk<br \/>\n00:29<br \/>\nfactors for cervical cancer list the<br \/>\n00:31<br \/>\nguidelines for cervical cancer screening<br \/>\n00:33<br \/>\ndescribe the initial management for a<br \/>\n00:35<br \/>\npatient with an abnormal pap smear<br \/>\n00:36<br \/>\ndescribe the symptoms and physical<br \/>\n00:38<br \/>\nfindings of a patient with cervical<br \/>\n00:40<br \/>\ncancer there are over 100 types of HPV<br \/>\n00:43<br \/>\nand 30 affect the anal genital tract 15<br \/>\n00:46<br \/>\nof these 30 are high-risk HPV types and<br \/>\n00:49<br \/>\nthe majority of cervical cancers are<br \/>\n00:50<br \/>\ncaused by four of these 16 18 31 and 45<br \/>\n00:54<br \/>\nlow risk HPV types are not associated<br \/>\n00:56<br \/>\nwith cancer and low risk type 6 and 11<br \/>\n00:58<br \/>\nare associated with genital warts HPV<br \/>\n01:01<br \/>\ninfection so let&#8217;s take a moment now to<br \/>\n01:04<br \/>\ndiscuss cervical anatomy the cervix is<br \/>\n01:06<br \/>\ncovered by both squamous and columnar<br \/>\n01:08<br \/>\nepithelium the squamous columnar<br \/>\n01:11<br \/>\nJunction or scj where these two meet is<br \/>\n01:13<br \/>\nan important landmark where over 90<br \/>\n01:15<br \/>\npercent of lower genital tract cancers<br \/>\n01:17<br \/>\narise the squamous epithelium is on the<br \/>\n01:19<br \/>\nvaginal side of the scj and the columnar<br \/>\n01:21<br \/>\nepithelium is on the endocervical side<br \/>\n01:24<br \/>\nof the suj during menarche there is an<br \/>\n01:26<br \/>\nestrogen surge and this causes the<br \/>\n01:28<br \/>\ncervix to mushroom and drag the<br \/>\n01:30<br \/>\nglandular or columnar epithelium of the<br \/>\n01:32<br \/>\nEnder cervix onto the vaginal exposed<br \/>\n01:34<br \/>\nportion of the cervix thus the scj at<br \/>\n01:37<br \/>\nmenarche will be at or close to the<br \/>\n01:39<br \/>\nvaginal part of the external awesome as<br \/>\n01:41<br \/>\nthe woman ages the scj recedes up the<br \/>\n01:45<br \/>\nendocervical canal the transformation<br \/>\n01:51<br \/>\nzone is this area between the old scj<br \/>\n01:53<br \/>\nand the new scj depicted by this area<br \/>\n01:56<br \/>\nwith the pink stripes this is the area<br \/>\n01:59<br \/>\nwhere columnar epithelium is replaced by<br \/>\n02:01<br \/>\nsquamous epithelium in a process called<br \/>\n02:03<br \/>\nsquamous metaplasia the cells that are<br \/>\n02:05<br \/>\nundergoing metaplasia are vulnerable to<br \/>\n02:07<br \/>\nvarious carcinogens such as HPV<br \/>\n02:10<br \/>\ncolposcopy is how we clinically<br \/>\n02:12<br \/>\nvisualize this<br \/>\n02:13<br \/>\ncervical anatomy a copla scope is a<br \/>\n02:15<br \/>\nbinocular stereo microscope with<br \/>\n02:17<br \/>\nmagnification acetic acid is placed on<br \/>\n02:20<br \/>\nthe cervix which dehydrates cells<br \/>\n02:21<br \/>\ncausing those with large nuclei to<br \/>\n02:23<br \/>\nappear white these white cells will be<br \/>\n02:25<br \/>\nthose undergoing metaplasia or dysplasia<br \/>\n02:27<br \/>\nthis Copas Copic photograph shows a<br \/>\n02:30<br \/>\ncervix treated with acetic acid the<br \/>\n02:32<br \/>\noriginal squamous epithelium is pink and<br \/>\n02:34<br \/>\nsmooth and the columnar epithelium is<br \/>\n02:36<br \/>\nred and irregular here is the old scj<br \/>\n02:39<br \/>\nand the transformation zone with<br \/>\n02:40<br \/>\nsquamous metaplasia is white let&#8217;s now<br \/>\n02:43<br \/>\nfocus on some virology and here is our<br \/>\n02:45<br \/>\ncharacter mr HPV most of the time if he<br \/>\n02:48<br \/>\ninfects a host the infection will be<br \/>\n02:50<br \/>\ntransient and the host immune system<br \/>\n02:52<br \/>\nwill be able to eradicate the HPV before<br \/>\n02:54<br \/>\nit causes change certain risk factors<br \/>\n02:56<br \/>\nwill increase the likelihood that the<br \/>\n02:58<br \/>\nHPV infection will stay if the host is<br \/>\n03:01<br \/>\nimmunocompromised secondary to HIV or is<br \/>\n03:03<br \/>\non immunosuppression medications and<br \/>\n03:05<br \/>\nthere&#8217;ll be a higher incidence of<br \/>\n03:07<br \/>\ninfection and progression cigarette<br \/>\n03:09<br \/>\nsmoking is our second risk factor and<br \/>\n03:11<br \/>\nsmokers have a 3.5 times greater rate of<br \/>\n03:14<br \/>\ncervical cancer than non-smokers the<br \/>\n03:16<br \/>\ncarcinogens from cigarette smoke are<br \/>\n03:18<br \/>\nfound in high concentrations in the<br \/>\n03:20<br \/>\ncervical mucus of smokers other risk<br \/>\n03:22<br \/>\nfactors include anything that will<br \/>\n03:24<br \/>\nincrease the chance of exposure to HPV<br \/>\n03:26<br \/>\nincluding early cor turkey multiple<br \/>\n03:28<br \/>\nsexual partners and sexually transmitted<br \/>\n03:30<br \/>\ndiseases let&#8217;s discuss cervical cancer<br \/>\n03:32<br \/>\nscreening the Pap test is inexpensive<br \/>\n03:35<br \/>\nand not invasive and we are now able to<br \/>\n03:37<br \/>\ntest for HPV at the time of the Pap test<br \/>\n03:39<br \/>\nadding the HPV testing has allowed us to<br \/>\n03:41<br \/>\nspace out the interval between testing<br \/>\n03:43<br \/>\nhowever it could now be confusing for<br \/>\n03:45<br \/>\npatients and medical students so let&#8217;s<br \/>\n03:46<br \/>\nspend a moment to clarify screening<br \/>\n03:48<br \/>\nrecommendations the screening<br \/>\n03:50<br \/>\nrecommendations differ by age here is<br \/>\n03:52<br \/>\nour young patient screening should start<br \/>\n03:54<br \/>\nat age 21 for women between 21 and 29<br \/>\n03:57<br \/>\nyears old Pap test alone should be every<br \/>\n03:59<br \/>\nthree years<br \/>\n04:00<br \/>\nHPV testing is not performed in this age<br \/>\n04:03<br \/>\ngroup for HPV prevalence approaches 20%<br \/>\n04:05<br \/>\nfor teens and women in their early 20s<br \/>\n04:07<br \/>\nfor older woman age 30 to 60 for Pap<br \/>\n04:11<br \/>\ntest and HPV testing every five years is<br \/>\n04:13<br \/>\npreferred or a Pap test alone can be<br \/>\n04:16<br \/>\ntested every three years for women who<br \/>\n04:18<br \/>\nare 65 or older Pap test screening can<br \/>\n04:20<br \/>\nstop if she has adequate negative<br \/>\n04:22<br \/>\nscreening and no history of cervical<br \/>\n04:23<br \/>\ndysplasia greater than cin 2 within the<br \/>\n04:25<br \/>\nlast twenty<br \/>\n04:26<br \/>\nyears it is important to note that more<br \/>\n04:28<br \/>\nthan half of patients to develop<br \/>\n04:29<br \/>\ncervical cancer have not been screened<br \/>\n04:31<br \/>\nappropriately and among women diagnosed<br \/>\n04:33<br \/>\nwith invasive cervical cancer one half<br \/>\n04:35<br \/>\nhave never had a Pap test women who are<br \/>\n04:38<br \/>\nat highest risk of being rarely or never<br \/>\n04:40<br \/>\nscreened for cervical cancer are<br \/>\n04:41<br \/>\nminority women low socioeconomic status<br \/>\n04:44<br \/>\nforeign-born and women with no usual<br \/>\n04:46<br \/>\nsource of health care let&#8217;s move now to<br \/>\n04:48<br \/>\nmanagement of an abnormal pap test Pap<br \/>\n04:51<br \/>\ntests give a cytological result and two<br \/>\n04:54<br \/>\ncommon abnormal cytology ZAR low-grade<br \/>\n04:56<br \/>\nsquamous epithelial lesions or LS il and<br \/>\n04:59<br \/>\nhigh-grade squamous intrepid ileal<br \/>\n05:01<br \/>\nlesions or HSI L a colposcopy is the<br \/>\n05:04<br \/>\nnext step and the biopsies from the<br \/>\n05:06<br \/>\ncolposcopy will give a histologic<br \/>\n05:08<br \/>\ndiagnosis there are two common<br \/>\n05:10<br \/>\nclassification systems for describing<br \/>\n05:12<br \/>\nthe results of Kulpa scopic directed<br \/>\n05:13<br \/>\nbiopsies we&#8217;ll start with the bethesda<br \/>\n05:15<br \/>\nsystem this system describes the<br \/>\n05:17<br \/>\nbiopsies obtained at the time of<br \/>\n05:19<br \/>\ncolposcopy as cervical intraepithelial<br \/>\n05:20<br \/>\nneoplasia<br \/>\n05:21<br \/>\nor CIN and there are CIN 1 2 &amp; 3 these<br \/>\n05:26<br \/>\nare classified by the extent that<br \/>\n05:27<br \/>\ncervical epithelium is replaced by<br \/>\n05:29<br \/>\nabnormal cells CIN 1 has one third of<br \/>\n05:32<br \/>\nthe epithelium involved with abnormal<br \/>\n05:33<br \/>\ncells CIN 2 has 2\/3 and CIN 3 has full<br \/>\n05:37<br \/>\nthickness involvement in 2012 the lower<br \/>\n05:41<br \/>\ninner genital squamous terminology with<br \/>\n05:43<br \/>\nthe clever acronym last was introduced<br \/>\n05:45<br \/>\nin this terminology system the<br \/>\n05:48<br \/>\nhistological biopsy results are<br \/>\n05:50<br \/>\nclassified as either LS il or HS il<br \/>\n05:53<br \/>\nmirroring the same terminology that was<br \/>\n05:55<br \/>\nused for the cytology results lesions<br \/>\n05:57<br \/>\nthat would have been classified as cin 1<br \/>\n05:59<br \/>\nare now LS il most CIN 3 is classified<br \/>\n06:03<br \/>\nas HS il specimens that were CIN 2 or an<br \/>\n06:06<br \/>\nunclear CIN 3 can now be tested with P<br \/>\n06:09<br \/>\n16 immunostaining that helps diagnostic<br \/>\n06:11<br \/>\nreproducibility specimens that are P 16<br \/>\n06:14<br \/>\nnegative are classified as LS il and<br \/>\n06:16<br \/>\nthose that are positive are classified<br \/>\n06:18<br \/>\nas HS il to summarize when a pap smear<br \/>\n06:21<br \/>\nis abnormal that alkyl paska P should be<br \/>\n06:23<br \/>\nperformed the results of the copis copic<br \/>\n06:25<br \/>\ndirected biopsies triage the next step<br \/>\n06:27<br \/>\nof management expectant management can<br \/>\n06:29<br \/>\nbe used for cin 1 or LS il because of<br \/>\n06:32<br \/>\nits high rate of regression and low rate<br \/>\n06:34<br \/>\nof progression immediate treatment is<br \/>\n06:36<br \/>\nneeded for CIN 2 and CIN 3<br \/>\n06:39<br \/>\nor HS IL because of their higher rates<br \/>\n06:41<br \/>\nof progression of cervical cancer there<br \/>\n06:43<br \/>\nare two approaches to immediate<br \/>\n06:45<br \/>\ntreatment ablation for example<br \/>\n06:47<br \/>\ncryotherapy or laser ablation and<br \/>\n06:49<br \/>\nexcisional methods called life cone or<br \/>\n06:51<br \/>\nleap procedure the principle difference<br \/>\n06:53<br \/>\nbetween ablation and excisional methods<br \/>\n06:55<br \/>\nis that ablation provides no diagnostic<br \/>\n06:57<br \/>\ninformation additional factors to<br \/>\n06:59<br \/>\nconsider our future childbearing plans<br \/>\n07:01<br \/>\nand patient compliance both a cone<br \/>\n07:03<br \/>\nbiopsy and LEEP procedure excised the<br \/>\n07:05<br \/>\ntransformation zone this following video<br \/>\n07:07<br \/>\ncourtesy of dr. rich Lieberman shows a<br \/>\n07:09<br \/>\nleak procedure the cervix has been<br \/>\n07:12<br \/>\ntreated with luke all solution which<br \/>\n07:13<br \/>\nstains normal tissue with iodine<br \/>\n07:14<br \/>\ndysplastic cells appear non stained or<br \/>\n07:17<br \/>\nwhite a loop electrode is used to excise<br \/>\n07:20<br \/>\nthe transformation zone and then a<br \/>\n07:28<br \/>\nrollerball cautery is used to obtain<br \/>\n07:30<br \/>\nhemostasis let&#8217;s move now to cervical<br \/>\n07:38<br \/>\ncancer despite the progress made in<br \/>\n07:40<br \/>\nearly detection and treatment there are<br \/>\n07:42<br \/>\napproximately 11,000 new cases of<br \/>\n07:44<br \/>\ncervical cancer diagnosed annually with<br \/>\n07:46<br \/>\n3870 deaths the average age of diagnosis<br \/>\n07:50<br \/>\nis 50 years old the signs and symptoms<br \/>\n07:52<br \/>\nof cervical cancer a variable and<br \/>\n07:54<br \/>\nnonspecific including watery vaginal<br \/>\n07:56<br \/>\ndischarge intermittent spotting and post<br \/>\n07:58<br \/>\ncoital bleeding the cervix can appear<br \/>\n08:00<br \/>\nnormal and appearance or there can be a<br \/>\n08:01<br \/>\nvisible cervical lesion large tumors may<br \/>\n08:04<br \/>\nappear to replace the cervix entirely<br \/>\n08:05<br \/>\nthe cervical cancer usually arises from<br \/>\n08:08<br \/>\nthe transformation zone here is a<br \/>\n08:10<br \/>\nphotograph of cervical cancer note the<br \/>\n08:12<br \/>\nirregular friable surface of the<br \/>\n08:14<br \/>\ntransformation zone let&#8217;s conclude by<br \/>\n08:16<br \/>\ndiscussing prevention and future<br \/>\n08:18<br \/>\ndirections we began this video by<br \/>\n08:20<br \/>\ndiscussing the high and low risk strains<br \/>\n08:22<br \/>\nof HPV the quadrivalent or Gardasil<br \/>\n08:24<br \/>\nvaccine protects against the low risk<br \/>\n08:26<br \/>\nHPV strains of 6:11 and high risk<br \/>\n08:29<br \/>\nstrains 16 and 18<br \/>\n08:30<br \/>\nthis quadrivalent HPV vaccine has been<br \/>\n08:33<br \/>\nshown to prevent 91% of new infections<br \/>\n08:36<br \/>\ncurrent HPV vaccines are only indicated<br \/>\n08:38<br \/>\nright now for prophylaxis and women who<br \/>\n08:40<br \/>\nreceive the HPV vaccine should still<br \/>\n08:42<br \/>\nfollow regular cervical cytology<br \/>\n08:43<br \/>\nscreening in January 2015 the American<br \/>\n08:46<br \/>\nSociety for colposcopy and cervical<br \/>\n08:48<br \/>\npathology in the Society for gynecologic<br \/>\n08:50<br \/>\noncology recommend<br \/>\n08:52<br \/>\na consideration of primary HPV testing<br \/>\n08:54<br \/>\nfor cervical cancer screening stay tuned<br \/>\n08:56<br \/>\nfor guidelines and recommendations we&#8217;ll<br \/>\n08:58<br \/>\ncontinue to evolve this concludes the<br \/>\n09:00<br \/>\naapko video on cervical disease in<br \/>\n09:01<br \/>\nneoplasia we have discussed the<br \/>\n09:03<br \/>\npathogenesis and risk factors for<br \/>\n09:04<br \/>\ncervical cancer and discuss<br \/>\n09:06<br \/>\nrecommendations for screening and<br \/>\n09:08<br \/>\nmanagement of abnormal pap tests<\/p>\n<p><\/div>\n<hr \/>\n","protected":false},"excerpt":{"rendered":"<p>Duration = 9:21<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":46,"menu_order":52,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2611","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2611","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=2611"}],"version-history":[{"count":2,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2611\/revisions"}],"predecessor-version":[{"id":2859,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2611\/revisions\/2859"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=2611"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}