Question 46#

A 23-year-old woman presents for a routine annual examination. Her Pap smear returns as HSIL.

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

A. Perform a cone biopsy of the cervix

Knowledge of the natural history, epidemiology, and basic science of HPV and precancerous lesions of the cervix is rapidly evolving; in fact, the guidelines have been revised many times over the last 10 years to incorporate this new evidence. Women younger than 21 years should not be screened. The guidelines have changed significantly for the management of abnormal Pap smears in women between the ages of 21 and 24 years. For women aged 21 to 24 years with LSIL cytology results, follow up Pap smear is recommended in 1 year because the risk of malignancy is low and the rate of viral clearance is high. However, for women in this age range with HSIL cytology results, colposcopy is recommended. Approximately 0.5% of Pap smears come back with glandular cell abnormalities such as atypical glandular cells (AGC). These abnormalities can be associated with squamous lesions, adenocarcinoma in situ, or invasive adenocarcinoma. Therefore, any patient with AGS should undergo colposcopy and endocervical curettage. In addition, women older than 35 years, or women younger than 35 with clinical risk of endometrial neoplasia (ie, unexplained vaginal bleeding, chronic anovulation), should undergo endometrial sampling. Women with biopsy proven CIN III should undergo excisional procedure such as a cone biopsy. The indications for a cone biopsy would be as follows: (1) unsatisfactory colposcopic examination (ie, the entire transformation zone cannot be seen), (2) a colposcopically directed cervical biopsy that indicates severe dysplasia or the possibility of invasive disease, (3) neoplasm in the endocervix, or (4) cells seen on cervical biopsy that do not adequately explain the cells seen on cytologic examination (ie, the Pap). A woman with normal cytology but a report of absent endocervical cells suggests that there is adequate cellularity for interpretation but lack of adequate cells from the transformation zone. These women may be at an increased risk for missed disease, but there is not a higher risk for CIN II or higher over time. Therefore, the next step is to perform an HPV test, and if negative, return to routine screening.

Question 47#

A 21-year-old woman presents for her first Pap smear. The following week, the results return as low grade squamous intraepithelial lesion (LSIL).

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

A. Perform a cone biopsy of the cervix

Knowledge of the natural history, epidemiology, and basic science of HPV and precancerous lesions of the cervix is rapidly evolving; in fact, the guidelines have been revised many times over the last 10 years to incorporate this new evidence. Women younger than 21 years should not be screened. The guidelines have changed significantly for the management of abnormal Pap smears in women between the ages of 21 and 24 years. For women aged 21 to 24 years with LSIL cytology results, follow up Pap smear is recommended in 1 year because the risk of malignancy is low and the rate of viral clearance is high. However, for women in this age range with HSIL cytology results, colposcopy is recommended. Approximately 0.5% of Pap smears come back with glandular cell abnormalities such as atypical glandular cells (AGC). These abnormalities can be associated with squamous lesions, adenocarcinoma in situ, or invasive adenocarcinoma. Therefore, any patient with AGS should undergo colposcopy and endocervical curettage. In addition, women older than 35 years, or women younger than 35 with clinical risk of endometrial neoplasia (ie, unexplained vaginal bleeding, chronic anovulation), should undergo endometrial sampling. Women with biopsy proven CIN III should undergo excisional procedure such as a cone biopsy. The indications for a cone biopsy would be as follows: (1) unsatisfactory colposcopic examination (ie, the entire transformation zone cannot be seen), (2) a colposcopically directed cervical biopsy that indicates severe dysplasia or the possibility of invasive disease, (3) neoplasm in the endocervix, or (4) cells seen on cervical biopsy that do not adequately explain the cells seen on cytologic examination (ie, the Pap). A woman with normal cytology but a report of absent endocervical cells suggests that there is adequate cellularity for interpretation but lack of adequate cells from the transformation zone. These women may be at an increased risk for missed disease, but there is not a higher risk for CIN II or higher over time. Therefore, the next step is to perform an HPV test, and if negative, return to routine screening.

Question 48#

A 55-year-old postmenopausal woman has a Pap smear that returns as atypical glandular cells of undetermined significance (AGUS).

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

A. Perform a colposcopy, endometrial biopsy, and endocervical curettage

Knowledge of the natural history, epidemiology, and basic science of HPV and precancerous lesions of the cervix is rapidly evolving; in fact, the guidelines have been revised many times over the last 10 years to incorporate this new evidence. Women younger than 21 years should not be screened. The guidelines have changed significantly for the management of abnormal Pap smears in women between the ages of 21 and 24 years. For women aged 21 to 24 years with LSIL cytology results, follow up Pap smear is recommended in 1 year because the risk of malignancy is low and the rate of viral clearance is high. However, for women in this age range with HSIL cytology results, colposcopy is recommended. Approximately 0.5% of Pap smears come back with glandular cell abnormalities such as atypical glandular cells (AGC). These abnormalities can be associated with squamous lesions, adenocarcinoma in situ, or invasive adenocarcinoma. Therefore, any patient with AGS should undergo colposcopy and endocervical curettage. In addition, women older than 35 years, or women younger than 35 with clinical risk of endometrial neoplasia (ie, unexplained vaginal bleeding, chronic anovulation), should undergo endometrial sampling. Women with biopsy proven CIN III should undergo excisional procedure such as a cone biopsy. The indications for a cone biopsy would be as follows: (1) unsatisfactory colposcopic examination (ie, the entire transformation zone cannot be seen), (2) a colposcopically directed cervical biopsy that indicates severe dysplasia or the possibility of invasive disease, (3) neoplasm in the endocervix, or (4) cells seen on cervical biopsy that do not adequately explain the cells seen on cytologic examination (ie, the Pap). A woman with normal cytology but a report of absent endocervical cells suggests that there is adequate cellularity for interpretation but lack of adequate cells from the transformation zone. These women may be at an increased risk for missed disease, but there is not a higher risk for CIN II or higher over time. Therefore, the next step is to perform an HPV test, and if negative, return to routine screening.

Question 49#

A 35-year-old with an LSIL Pap smear undergoes colposcopy. Directed biopsies return showing severe dysplasia (CIN III).

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

A. Perform a cone biopsy of the cervix

Knowledge of the natural history, epidemiology, and basic science of HPV and precancerous lesions of the cervix is rapidly evolving; in fact, the guidelines have been revised many times over the last 10 years to incorporate this new evidence. Women younger than 21 years should not be screened. The guidelines have changed significantly for the management of abnormal Pap smears in women between the ages of 21 and 24 years. For women aged 21 to 24 years with LSIL cytology results, follow up Pap smear is recommended in 1 year because the risk of malignancy is low and the rate of viral clearance is high. However, for women in this age range with HSIL cytology results, colposcopy is recommended. Approximately 0.5% of Pap smears come back with glandular cell abnormalities such as atypical glandular cells (AGC). These abnormalities can be associated with squamous lesions, adenocarcinoma in situ, or invasive adenocarcinoma. Therefore, any patient with AGS should undergo colposcopy and endocervical curettage. In addition, women older than 35 years, or women younger than 35 with clinical risk of endometrial neoplasia (ie, unexplained vaginal bleeding, chronic anovulation), should undergo endometrial sampling. Women with biopsy proven CIN III should undergo excisional procedure such as a cone biopsy. The indications for a cone biopsy would be as follows: (1) unsatisfactory colposcopic examination (ie, the entire transformation zone cannot be seen), (2) a colposcopically directed cervical biopsy that indicates severe dysplasia or the possibility of invasive disease, (3) neoplasm in the endocervix, or (4) cells seen on cervical biopsy that do not adequately explain the cells seen on cytologic examination (ie, the Pap). A woman with normal cytology but a report of absent endocervical cells suggests that there is adequate cellularity for interpretation but lack of adequate cells from the transformation zone. These women may be at an increased risk for missed disease, but there is not a higher risk for CIN II or higher over time. Therefore, the next step is to perform an HPV test, and if negative, return to routine screening.

Question 50#

A 43-year-old has negative cytology results but absent endocervical cells are reported.

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

A. Perform a colposcopy, endometrial biopsy, and endocervical curettage

Knowledge of the natural history, epidemiology, and basic science of HPV and precancerous lesions of the cervix is rapidly evolving; in fact, the guidelines have been revised many times over the last 10 years to incorporate this new evidence. Women younger than 21 years should not be screened. The guidelines have changed significantly for the management of abnormal Pap smears in women between the ages of 21 and 24 years. For women aged 21 to 24 years with LSIL cytology results, follow up Pap smear is recommended in 1 year because the risk of malignancy is low and the rate of viral clearance is high. However, for women in this age range with HSIL cytology results, colposcopy is recommended. Approximately 0.5% of Pap smears come back with glandular cell abnormalities such as atypical glandular cells (AGC). These abnormalities can be associated with squamous lesions, adenocarcinoma in situ, or invasive adenocarcinoma. Therefore, any patient with AGS should undergo colposcopy and endocervical curettage. In addition, women older than 35 years, or women younger than 35 with clinical risk of endometrial neoplasia (ie, unexplained vaginal bleeding, chronic anovulation), should undergo endometrial sampling. Women with biopsy proven CIN III should undergo excisional procedure such as a cone biopsy. The indications for a cone biopsy would be as follows: (1) unsatisfactory colposcopic examination (ie, the entire transformation zone cannot be seen), (2) a colposcopically directed cervical biopsy that indicates severe dysplasia or the possibility of invasive disease, (3) neoplasm in the endocervix, or (4) cells seen on cervical biopsy that do not adequately explain the cells seen on cytologic examination (ie, the Pap). A woman with normal cytology but a report of absent endocervical cells suggests that there is adequate cellularity for interpretation but lack of adequate cells from the transformation zone. These women may be at an increased risk for missed disease, but there is not a higher risk for CIN II or higher over time. Therefore, the next step is to perform an HPV test, and if negative, return to routine screening.