UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER Aurora Boulevard, Quezon City DEPARTMENT OF GYNECOLOGY PAPERCASE

2 Passed by: Lea Patricia A. Garcia 1. What is your diagnosis: Chronic endocervicitis February 18, 2014

2. What diagnostic tests will you request for to confirm dx: wetmount-Sensitive indicator of cervical inflammation, in the absence of inflammatory vaginitis Expected findings are >10 WBCs per high-power field of vaginal fluid (leukorrhea), trichomonads, clue cells, pH >4.5, fishy amine odor with application of 10% KOH Nucleic Acid Amplification Tesing-Urine, vaginal swab (self obtained), cervical swab, or combined with cervical cytology screening. Cervical specimens have the greatest sensitivity, but urinary and some vaginal swabs also have comparable predictive power. Rectal swabs may not be approved by regulatory agencies for use with NAAT. Expected findings are positive for Chlamydia trachomatis or Neisseria gonorrhoeae Thayer Martin Agar culture-Less sensitive test for Chlamydia trachomatis or Neisseria gonorrhoeae. Sensitive for detection of C trachomatis, N gonorrhoeae, orTrichomonas vaginalis HSV type 2, or Mycoplasma genitalium. Papsmear- Recommended if presentation is within the recommended screening interval. Inflammatory changes are associated with chlamydial or gonorrheal infections but are not specific or sensitive enough for empiric therapy.

3. Differentiate precancerous cervical pathology, their course and management Depth of Invasion Management CIN 1 The least risky type, Preceded by Atypical Squamous Cells of represents only Undetermined Significance (ASC-US) mild dysplasia, or abnormal 1. Human papillomavirus deoxyribonucleic cell growth. It is confined to acid (HPV DNA) testing the basal 1/3 of the 2. Repeat cervical cytology epithelium. This usually 3. Colposcopy corresponds to infection with 4. Excision or ablation HPV, and may be cleared by Preceded by High-Grade Squamous Intraepithelial immune response, though it Lesion (HSIL) or Atypical Glandular Cells Not can take several years to Otherwise Specified (AGC-NOS) clear. 1. Diagnostic excisional procedure 2. Colposcopy and cytology CIN 2 Moderate dysplasia confined to the basal 2/3 of the epithelium Severe dysplasia that spans more than 2/3 of the epithelium, and may involve the full thickness. This lesion may sometimes also be Initial Management 1. Excision and ablation 2. Diagnostic excisional procedure (alone, if recurrent CIN 2,3) Follow-up after Treatment 1. HPV DNA testing 2. Cytology 3. Colposcopy and cytology

Cin 3

referred to as cervical carcinoma in \situ.

4. Colposcopy with endocervical sampling 5. Repeat diagnostic excisional procedure 6. Hysterectomy (only if recurrent or persistent CIN 2,3)

4. Should the findings be Adenocarcinoma, well-differentiated, what is the next course of action? -staging- MRI of the pelvis -PET/CT of the whole body -CT of chest/abdomen/pelvis with IV oral contrast -Preparation for surgery- CBC, bleeding parameters, LFT, CXR, ECG, crossmatching, electrolytes -Total Abdominal Hysterectomy with bilateral salphingo oophorectomy (with possible bilateral LN dissection) 5. Is the disease preventable? What is the role of immunization? What is the current recommendation for the frequency of papsmear? -yes it is preventable thru cervical cancer vaccine -Immunization thru cervical cancer vaccine is highly recommended, ( against HPV 16 and 18) since HPV infection is the a major risk factor for developing cervical cancer. HPV 16 and 18 are the 2 most common highrisk types. Other high-risk types include 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82. Host polymorphisms and general health status (poor nutrition, smoking, HIV, chronic immunosuppression) interact with this risk factor. -Upon reaching the age of 21, women should get a pap smear for cervical cancer detection regardless of whether they have been sexually active at an earlier age or not. But, this should be done once every three years only.