Dr.

Capatoy

Clinical and Anatomic Pathologist

HPV Cervical Cancer

(What Every Woman Should Know; and men too!) Did you know that cervical CA is caused by certain types of a common virus? HUMAN PAPILLOMAVIRUS (HPV) Cytoscreen to determine cervical CA HPV More than 100 types of HPV identified Most are relatively harmless o Common warts found on hands and feet For most people, body s own defense mechanism will clear the virus. About 30 types affect thte genital area o Low risk types 6 & 11 can cause genital warts and abnormal cervical changes (abnormal PAP) o High risk types 16 & 18 can cause cervical CA and abnormal cervical charges How common o A lot more common than you think o At least 50% of sexually active people can get HPV, most people don t have it Epidemiology o Lifetime risk for sexually active man and women is at least 50%  By 50 years of age at least 80% of women will have acquired HPV infection o Estimated incidence: 6.2 million per year o Estimate prevalence: 20 million o In sexually active individuals: 16-24 years of age: 9.2 million are currently infected o An estimated 74% of new HPV infection occur in this age group  In studies of women, <25 years of age, prevalence rates ranged from 28-46%  Of estimated 50-80 % of women who will acquire an HPV infection in their lifetime  Up to 50& of those infections will be a high risk type Consequences o For most people, HPV is cleared by the body s defense system o Over 80% HPV infections are transient, asymptomatic and resolve spontaneously o However, some people may not clear the virus and the consequences depend on the type of HPV involved.

Causes genital warts o Most easily recognized signs of genital HPV infection o Appear within weeks or months after infection usually within 3 months o 2/3 of those who have sexual contact with a partner with genital warts will develop warts o Soft, moist, flesh colored, clusters, raised or flat, small or large o In women: vulva, cervix, vagina, anus o In men: scrotum, penis, anus Recurrent respiratory papillomatosis o RRP  Affects children and adults  Usually caused by HPV types 6 or 11 o Papillomas are stratified squamous epithelial masses that can obstruct the airway of not removed o Although histologically benign, RRP causes significant mortality Abnormal Cervix o Cells that have changed in appearance o Can be the first consequences of HPV o The more severe the abnormality, the more likey that cancer could develop in the future o CIN 1, 2, 3 mild, moderate, severe dysplasia o CIN cervical intraepithelial neoplasia Can lead to more than an infection Can cause cancer: o Cervical o Vulvar o Vaginal o Penile o Anal Most HPV infections of not progress to cancer Cervical Vaginal Vulva Penile >99% >50% >50%

Outcomes of HPV infections Genital warts o Regression o Therapy High risk: cervical infection o CIN 1/2 regression o CIN 2/3 cervical cancer or regression Progression of abnormal cervical cells o Most often, the change from pre-cancerous cells to cervical cancer can take a number of years, although in rare cases it can happen within a year. **PAP smear before it goes to the basal membrane and spread and causes infection Natural History of HPV and precancerous lesions For every 1M women with any HPV infection o 100,000 will develop cervical cytological abnormality o 8,000 will develop CIN III (in situ) o 1,600 will develop Cervical cancer Cancer of the cervix o Lower part of the uterus that connects to the vagina A serious condition that takes over hundred thousands of friends, wives, mothers, daughters, sisters from us every year Half of the women afflicted are 35-55 Y.O Many of these women may not realize that they were probably exposed to one of the high risk HPV types during their teens or 20s Signs of CA o Abnormal vaginal bleeding o Bleeding after sexual intercourse o Unusual vaginal discharge o Pelvic pain Every year approximately 500K women worldwide are diagnosed with cervical cancer Worldwide, every 2 minutes,a monal dies of cervical cancer Worldwide: o 231K die of cervical cancer every year o 12% of all cancers in women o S?? o Projection In the Philippines o Incidence rate remains unchanged from 1980-1995 per 100K women Routes:

56% of Filipino women with cervical CA will die within 5 yeears  44$ overall survivalrate

What can you do to decrese chances? Research shows that genital HPV is passed on by: Genital contact with a person who has genital HPV incliding: o Vaginal sex with a person who has genital HPV o Aranl sex with a person who has genital HPV NO research shows that genital HPV is passed on by: Toilet seats Kissing on the mouth, hugging Personal hygiene Acquiring HPV infections The risk starts right from sexual debut Prevalence is greatest (approx 20%) in women aged less than 25 years Acquisition may be by skin-to-skin genital contact penetrative intercourse is not necessary to be become infected HV infection is easily transmited

Sexual Genital contact: o Sexual o Genital o Manual o Oral Non sexual o Extragenital  Formites? y Undergarments y Surgical gloves y Biopsy forceps o Vertical mother neonates (at birth) Risk factors for HPV infection

respiratory pappillomatosis

Females o Young age (peak 20-24) o Young age at first sexual intercourse o Greater number of lifetime and recent sex partners

o o o Male o o o

Sex with a new partner Male partner sexual history Uncircumcised male partner Young age (peak 25-29) Greater number of lifetime and recent sex partners Being uncircumcised

PAP SMEAR -get cells from cervix ACOG* Guidelines for cervical cancer screening 2003 <30 y.o o Annually >30 y.o o Annually o 3 consecutive negative results, repeat after 2-3 years Did you know that Cervical CA is 5 times higher in woman who are not regularly screened 60% and 80% of women who are newly diagnosed with invasive cervical cancer had not had a pap test within the 5 years before being diagnosed And many had never had at all Limitations of cervical screening Adenocarcinomas may be detected Current approaches to prevention of HPV infection

Sexual behavior of young Filipinos 57% of first sex experiences reported were not planned or were something they did not want to happen at the time About 1/5 or 23% of young people have engaged in premarital sex o 31.1% in boys vs 15.4% of girls Age of first sex is getting younger 1.2% of both young males and females have already engaged in sex before they turn 13 Before age 18, probability of engaging in sex increased sharply for males 28% vs 12% among females. While majority of young Filipinos, are sticking to one sexual partner, about 34% have multiple sex partners o Represents 1.6M of the country s 15-27 y.o Established and Potential Cofactors Involved in HPV Carcinogenesis HPV ESTABLISHED o High parity o OCS (oral contraceptives) o Smoking o HIV o Cervical cancer POTENTIAL: o Co-infection with other STIs o Diet o Endogenous hormones o Genetic factors Another important thing to remember is that the chances of recovery are better when the cancer is found early Simple test that can detect abnormal cervical cells

Abstinence o Total abstinence from all genital contact is the most affective HPV prevention method Be Faithful o Lifetime mutual monogamy o However if one partner is not monogamous, both are at risk Condom o Condom use may help reduce risk, but is not fully protective Circumcision Doctor consult o Prophylactic vaccination 0 available since 2006 o There is a growing and only partially met need for the control of cervical cancer o Since HPV infection has been ID as the necessary cause of cervical cancer a vaccine that protects against that infection has the potential to meet that need. Components of the Quadrivalent HPV Vaccine Vaccine can greatly reduce low and high grade cervical dysplasia and genital warts Take Home Messages

Every women is at risk fo oncgenic HPV infection which may cause cervical CA It is a mahor health, psychological adnsocial burden in women everywhere The best possible cvaccination against verciacal cancer will combine the broadest coverage of oncogenic HPV types

Physical skills Physical effort Mental Emotional Working conditions DECISION AND JUDGEMENTS

Cytoscreening of PAP Smears JOB PURPOSE The post holder will be employed as a trainee cyto-screener, working towards qualification as cytology screener, working within national health service cervical screening programme (NHSCSP) guidelines Providing services to women within the screening programme, diagnosing negative unsatisfactory Microscopically recognize the range of normao and abnormal cells, ID abnormalities thereby helping to prevent the development of cervical cancer that--MAIN DUTIES/RESPOSIBILITIES Screening and reporting of cervical smear specimens using knowledge, skills, and competencies attained through the 20year training programme Each specimen reuid Where an abnormality is detected to makesdfoisdfjlas Training Annually proficiency tests and national circulating slides Attend regular update courses to maintain diagnostic accuracy COMMUNICATIONS AND RELATIONSHIPS Working as part of a team Post holder wil communicate complex information to other clinicians KNOWLEDGE, TRAINING, EXPERIENCE REQUIRED TO DO THE JOB Gain practical and theoretical knowledge Minimum of 2 years in house training, supplemented by the courses delivered by the school When qualified, participation in the proficiency testing scheme External and internal QA schemes Update training according to guidelines Local and national scientici--Own initiative Constant internal QC Participation in team discussions MOST CHALLENGING AND DIFFICULT PARTSOF THE JOB Extent of concentration required for screening microscopically over prolonged periods of time Maintaining confidence after an abnormality being picked up which you had not detected

CYTOLOGY
The most successful application of clinical cytology is diagnosing cervical abnormalities before they develop into invasive cervical carcinoma Used for screening and follow up of cervical carcinoma, particularly squamous carcinoma Cytology smears are sensitive to abnormalities, although there is variable interpration on any particular smear; the most impt factor is to detect an abnormality and to start an approirate management plan Specimens should be obstained and prepared by trained individuals False negative tests are often Papanicolaou PAP Stain Fix quickly and stain carefully; air dried smears are inadequate Stains keratinized cells or thick specimens orange (benign or malignant) Stains metabolically inactive cells pink, such as superficial cells Stains ribosomes blue green, particularly in parabasal cells, mesothelial cells and metaplastic squamous cells Alcohol dried; better for nuclear detail. Smearing of the exocervical sample with a wooden spatula Some may have a longer bigid extremity for a better antivervival sampling Smearing of the endocervical sample Spray fixation: immediate during a few seconds (1-2 seconds), with a spray/slide distance around 20cm (approx 7inches) Fix: 5-15 minutes (if dipped in the container)

DEMANDS OF THE JOB

Liquid based cytology Can use residual material to prepare cell blocks and for immunohistochemistry Major companies are Cyt?? Approved by US and drug administration in 1997 Thin prep appears to be superior to convention Oao test in detecting Very clean The in thing!! Quite expensive Very clear, very nice Adequacy description: Air Drying Artifact Enlarged pale nuclei with loss of nuclear detail. Air dried nuclei flatten out and do not take up stain very well. This leads to enlarged pale appearance. Cytoplasm is also degenerated and evaluation of cells is difficult. Associated with ASCUS in permenopausal women Mau cause discrepant diagnosis of LSIL or less for HSIL smears Bethesda System 2001 Specimen type o Indicate:  Conventional smear (pap smear)  Liquid-based preparation (LBP)  Other preoarations o Diff-Quick stain in cervical cytology  An air-dried, giemsa-type stain  Better for background material or to assess adequacy of endocercival smears to detect C. trachomatis  Used for FNAB, not for cervical smears. Specimen adequacy o Satisfactory  Presence or absence of endocervical--o Unsatisfactory  Specimen rejected/not processed (specify reason) y No labeled, broken slide  Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of: y Obscuring blood, inflammation, etc.  Assessment of Adequacy: 1. Adequate number of squamous cells 2. Presence or absence of endocervical cells should be reported

3.

Specimen with more than 75% of cells obscured by inflammation and bacterial is unsatisfactory (however should still report presence of abnormal cells

Squamous cells  Conventional smear - 8,000  LBS 5,000 o Endocervical/transformation zone component at least 10  Honeycomb appearance o Metaplasia - transformation of mature cell type to another mature cell type  Columnar to squamous o Obscuring factors  50-75% obscured = unsatisfactory o Any specimen with abnormal cells is by definition a satisfactory evaluation o Sample reporting  Satisfactory for evaluation. No Endocervical/t-zone compoennet is ID o General Categorization (optional)  Negative for intrapethelial lesion or malignancy  Epithelial cells abnormalty-----sadhasdkasInterpretation/result o Automated review  If case examined by automated device specify device and result o Ancillary testing  Provide a brief description of the test methods and report the result so that it is easily understood by the clinician o Educational notes and suggestions (optional) o NILM Organisms  T. vaginalis y Oval or pear shaped y Nucleus is thin and elliptical must be ID to diagnose this infection y Flagella are never seen in pap smear y Infection is associated with itching, foul-smelling yellow-green discharge, clinically  Fungal organisms consistent with Candida spp. y Pseudohyphae (sticks) and yeast (stones) y Clinical findings include itching and discharge (thin, watery, or characteristic white cottage-cheese like) y Candida cannot be specified based on morphology, a culture needs to be performed y Pap spear sensitivity is approx 80%  Shift in flora suggestive of bacterial vaginosis y Gardnerella vaginalis is a gram (-) comma-shaped cocobacillus o

Bacteria tend to agglomerate onto squamous cells (ie clue cells ) y Have a velvety surface, obscured cell edges and are covered by small coccobacilli y Profuse foul smelling (fishy), yellow-gray discharge, with itching and burning y Bacterial vaginosis is a polymicrobial process. Actinomyces y Associated with IUD use y Variably gram (+) long thin filamentous bacteria that are reddish, branch are irregularly beaded, and radiate from a central area y Associated with fuzzy masses of bacteria (dust bunny) Cellular changes consistent with Herpes simplex virus y Multiple nuclei, molded and marginations of the chromatin y Multinucleated cells have ground glass appearance to accumulations of viral particles which causes peripheral margination. y (+) dense, intranuclear, Cowdry-type viral inclusion y High neonatal morbidity and mortality high risk for CIN/SIL Can be multiple bacteria from multiple sexual partners y

Repair: cervical cytology Common source of diagnostic error Changes seen with inflammation, radiation, chemotherapy, trauma Micro: cohesive monolayered sheets of cells with well defined or indistinct borders, polarity, uniform nuclei, finely granular and evenly distributed chromatin Immediate cell nucleus o Standard reference or internal control o Nuclear area of 35um2 or 7-8um diameter = rbc o Chromatin pattern Intermediate squamous cells cervical cytology o Predominate in lurteal ohase o Cytoplasm is polugonal, transparent, basophilic, flat/thin (due to keratin); nucleus is about the size of a red blood cell, is vesicular, round/oval; nuclear texture and size is reference o Lie beneath the superficial layer o The cytoplasm is generally cynophillic o The nucei are found o Multilayered

Superficial cells o The superficial cells have the large nucei to cytoplasmic ratio. They are eosinophilic, their nuclei are pyknotic, dark and regular in size. o They have uniform borders with no discernable chromatin pattern Midcycle smear (ovulatory phase): eosinophillic superficial squamous cells, clean background Luteal phase with marked cytolysis and abundant Doderlein bacilli. Naked nuclei from intermediate cells and cytoplasmic debris. Parabasal cells cervical cytpology o Associated with atrohy, post-partum or prolonged use of depotmedroxyprogesterone acetate o Cytology: cytoplasm is round, dense, basophilic; nucleus is vesicular, central, active, round; may see naked nuclei; higher N/C ration and smaller size than intermediate cells o Finely granular chromatin o Nuclei have a delicate membrane and no visible nucleolus o The n/C is much higher than that of the --Other: Endometrial cells o During menstrual cycle days 6-10 (proliferative phase or exodus phase) o Reports of associated endometrial pathology in postmenopausal women with benign endometrial cells at pap smear VS ?? association o Most associated carcinomas are in women age 45+ o Under 40 y.o, not menopaused, presence of endometrial cells: no specific recommendations. o After 40, after menopause may be associated with benign hormonal alteration or abnormality or cancer. Squamus epithelial cell abnormalities o Nuclear enlargement  Reactive  to 2x o ASCUS  2 to 3x o Dysplastic  More than 3x o Dysplastic cell  Big and dark nuclei o Grade dysplasia  Amount of cytokasm N/C ratio o Nuclear membrane irregularities

Comparative features of repair and cancer Nucleus hypochrmatic; pale,fine, even chromatin Micronucleoli, every cell irregular shapes Order (architecture) disparity of features Background is clean with inflammatory cells Cells more cohesive Hyperchromatic, dark, course, irregular

Results 35 laboratories were surveyed from feb 2004-nov 2005 Majority of the labs are in cebu city(80%) Fewest in lapu lapu 18 laboratories had one pathologist 3 labs had cytoscreeners Rest had no cytoscreeners Discussion

Tumor diatheiss

Tumor diathesis Associated with invasive carcinoma; SIL or benign backgrounds are usually clean

All the anatomic laboratories were located only within 3 cities: cebu, mandaue, lapulapu No anatomic lab was found in the province and other cities of cebu Only 3 labs in cebu had cytoscreeners o 1 local city government lab:  1 med tech with training from UP-PGH, june-aug 1982 o 2 government hospital labs  Resident physicians undergoing training Recommendation

HPV LSIL HSIL

peri-neuclear halo, coilacytosis??? low grade squamous intra epithelial lesion high grade Inflammatory smear containing many parabasal cells with enlarged nuclei wih irregular chromatin High N/C ratio Sheet of paraabasal and abasal cells with enlarged and hyperchromatic nuclei and irregular nuclei outlines Standardization of pap smear testing is recommended through the process of creating a cervical cytology practice guideline

If detected early, dysplasia can be treated before the cells become cancerous How long does it take for cervical cancer to develop? 10-15 years before invasive cancer develops. As the cells change, they first become pre-cancerous AKA as dysplasia Significance: Directory is a big help for the referral system in the cervical cancer control prpgram Information from the---