HPV Details, Pap Smear, CIN and Ca Cervix😍

Instruments

HPV Details

• Type: Epitheliotrophic.

• Causes warts or verruca

• HPV has 200 subtypes

Histology: 

• Koilocytosis with biopsy indicates CIN 1.

• (Koilocyte is pathognomic for SCC insitu)

Cutaneous involvement:

• HPV 1, 2, 3 → low-risk skin warts
• D: Deep Plantar (HPV 1)
• S: Superficial Plantar (HPV 2)
• P: Plain Warts (HPV 3, 10)

• HPV 5, 8 → high-risk skin warts
• Epidermodysplasia Verruciformis / Tree man syndrome
• chr. 17 defect
• 58 year old tree man with 17 year old girl

• Buschke's Warts

Mucosal involvement:

• HPV 6, 11 → low-risk → mucosal & genital warts (Condyloma Acuminatum)
• Leads to:
• Laryngeal papillomas.
• Genital warts
• Pregnancy → DOC → Trichloracetic Acid
• Mnemonic:
• Pregnant avumbo war (wart) vanna → Ace the war (Trichloroacetic acid)
• 6 ⇔ G (genital warts) ;
• 11 (LL ⇔ Laryngeal papiLLomas)

• HPV 16, 18, 31, 33, 45, 52, 58 → high-risk
• 1618.3133.4552.58
• Cancers caused by HPV:
• Male - penile, oral, anal
• Female - cervix, vagina, vulva
• Cervical cancer
• Most common serotype - HPV 16
• Most malignant serotype - HPV 18
• Most specific serotype - HPV 18
• Most common serotype associated with
• Cervical Squamous cell carcinoma - HPV 16
• Cervical Adenocarcinoma - HPV 18
• Anal cancer
• HPV16
• Oropharyngeal cancer
• HPV16
• Genital cancers / Penile, vulvar, vaginal cancers
• HPV16

Wart Type	Characteristics	HPV Types
Plantar Warts	• On feet; • may be painful • Superficial/mosaic pattern (HPV 2)	Deep: 1; Superficial: 2
Plain Warts / Verruca Plana	• flat-top, hyperpigmented papules on face; • (not hyperkeratotic) • Common in immunocompromised or HIV state	3
Common Warts / Verruca Vulgaris	• Generally painless; • verrucous or hyperkeratotic papules; • asymptomatic; • anywhere on body • Pseudokoebner's phenomenon is positive	4, 2, 27
Epidermodysplasia Verruciformis (EDV)	• Genetic tendency to widespread HPV; • autosomal recessive • Increased SCC risk; • Pityriasis versicolor-like, • Plain warts, • Reddish plaques	5, 8
Anogenital Warts / Genital Warts / Condyloma Acuminata	• Flat base, pointed; • STI • Giant Condyloma Acuminata ↳ Buschke-Löwenstein Tumour • Bushinte lowerside ilu accumulated	6, 11;

---

 

Associated Cancers:

• Female: Cervix, vulva, vagina.

• Male: Penis, anus, oral.

Structure & Function:

---

Protein	Notes	ㅤ
L1 capsid protein	Vaccine development	L → Live vaccine
E1 & E2	Proteins needed for viral replication	2 → To Control
E2	Controller	ㅤ
E4, E5	Cell changes → koilocytes (raisin nucleus + perinuclear halo)	4, 5 Condoms
E6, E7	Carcinogenesis	ㅤ
↳ E6	inactivates p53 (policeman)	6 → 5 → 3; P ⇔ 6
↳ E7	inactivates RB (governor gene)	Seven → S → SRB → RB

---

HPV Vaccines

1. Nonavalent (Gardasil 9, in USA):
• Active against HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58.
• Protects against Genital Warts and all Cervical/Anal/Vulvar/Vaginal Cancer (HPV).

2. Quadrivalent (Gardasil/Cervavac):
• Active against HPV types 6, 11, 16, 18.
• Protects against Genital Warts and Cervical Cancer.
• Mnemonic: 4 vaakku parayamo

Cervavac

• India's first vaccine against cervical cancer.
• Developed by Serum Institute of India, Pune.

3. Bivalent (Cervarix):
• Active against HPV types 16, 18.
• Protects against Cervical Cancer.
• Mnemonic: 2 vari padamo



 

Recent update

• Prevent head & neck & Oropharyngeal cancer by HPV

PYQS for HPV Vaccine

• Ideal Age: 11-12 years.

• Age Group (Good): 9-26 years.
• Cervavac can be given only till 26 yrs due to lack of testing

• High Risk Age: 27-45 years.

• C/I: Pregnancy.

• WHO SAGE Recommendation:
• 9 to 20 years old: 1 or 2 doses.
• Over 21 years old: 2 doses.
• HIV positive: 3 doses.

• Common Side Effect: Syncope.

• Vaccines made from: L1 capsid proteins.

HPV Vaccine can be given to:

• HIV Positive Females.

• HIV Positive Males.

• Sexually active females.

• Boys.

• HPV testing before vaccine: Not recommended.

ACOG Protocol

Screening Guidelines

• Recommended Age Ranges
• ACOG (American College of Obstetricians and Gynecologists):
• Screening Duration: 21-65 years
• WHO (World Health Organization):
• Screening Duration: 30-50 years
• (Identified as High-Risk Age Group)

• Most sensitive: HPV DNA

• Most specific / Least sensitive test: PAP

• Most cost effective: VIA

ACOG Protocol Overview (For countries with good resources)

• Screening Begins: 21 years (Irrespective of sexual activity).

• Method: Pap Smear.
• Least sensitive
• Repeat every 3 years.

• From 30 years onwards:
• Pap + HPV DNA (Cotest).
• Repeat every 5 years till 65 years.

• Abnormal Pap in previous 10 years: 
• Screen until 75 years.

• Post-hysterectomy: 
• Stop screening.

WHO Screening (Even for countries with limited resources)

• Age to Start: 30 years.

• Age to Stop: 50 years.

• HPV DNA testing every 5 - 10 years is preferred over VIA
• Even for countries with limited resources
• D/t high sensitivity

• VIA
• Most cost effective → 3 yearly
• 2nd preferred

• See & Treat Approach:
• HPV DNA Testing → positive → LLETZ.
• VIA Test → positive → LLETZ.

• See, triage and Treat (Better):
• HPV DNA → If positive → VIA (Visual Inspection with Acetic Acid)
• If positive → Rx: LLETZ.

• Pap smear - Least sensitive

Guideline: 

• HPV +VIA > HPV > VIA.

• If HPV DNA Positive & VIA Negative: 
• Repeat HPV after 1-2 years.

• If HPV DNA Negative:
• Repeated in general population: 5-10 years.
• HIV positive: 3-5 years.

• If VIA Negative: 
• Repeat after 3 years.

WHO Goals for 2030

• 90% girls vaccinated by age 15.

• 70% females >= 30 years screened for cervical cancer.

• 90% of those with positive test treated.

WHO Recommended Treatment

• LLETZ/LEEP

Pap Smear (Cervix)

Vaginal Epithelial Study
(Squamous / Ectocervix)

• Sample: Lateral wall of vagina.

• Epithelium: Stratified squamous (3 cell types).

Maturation index: PIS

• 100/0/0: Menopause.

• 0/40/60: 1st half of menstrual cycle (MC).

• 0/60/40: 2nd half of MC/pregnancy.

• C → B → A
• C: No. of superficial cells.
• B: No. of intermediate cells.
• A: No. of parabasal cells.

Other Normal Cells in Pap Smear

Endometrial Cells

• Endometrial sheds → Endometrial cells → Exo dusted → Exodus

• Sometimes seen, especially Day 1-5 of menstruation.

• Appearance: 3D ball cluster.

• Exodus:
• Dense center, light periphery;
• Shed Day 6-10.

Endocervical Cells

• Tall, columnar cells.

• Vertical view: "picket fence" or "butterfly fence" appearance.

• Top view: "honeycomb appearance".

Cervical Mucous Study

ㅤ	Estrogen	Progesterone
Consistency	Profuse, watery, elastic	Thick, scanty, viscous
Known as	Spinnbarkeit (Stretching ⊕) Spin → Loose	Tack (Stretching ⊝) Tack → katti
ㅤ	ㅤ	ㅤ

Ferning

• Seen under microscope on D8
• ↳ Proliferative phase

• Disappears by D18 of cycle

• If ferning persist by D18, indicates Anovulation

Endometrial Glands

• Endometrial Biopsy → Not commonly done for ovulation.

• Timing: D26 (Pre-menstrual phase).

 

Stages	Features
Early proliferative ↳ Estrogen	• Simple tubular glands • Telescoping of gland • Pseudostratification (Nuclei at different levels)
Early secretory ↳ Progesterone	• Subnuclear vacuolation: First sign of ovulation on biopsy (D17 - D18)
Late secretory ↳ Progesterone	• Corkscrew glands • Sawtooth appearance • Secretions in gland

Instruments

Pap Smear Methods

Adequacy Criteria (Bethesda Group)

Steps

• Use posterior vaginal wall retractor

• Take the sample

• Make smear on a slide

• Fix the smear

Pap Stain Details

• Fixative: 95% ethanol.

• Papanicolou Composition: HOPE mnemonic
• H: Hematoxylin.
• O: OG6 (Orange & Green color stains).
• E: EA50 
• Eosin Y +
• Azure
• Light green
• Bismark Brown
• Mnemonic: Pap smear → H&E (Hematoxylin, Eosin Y) used in Obs and Gyne (OG6)

• Eosin B is a counterstain that stains the cytoplasmic components of cells pink or red.

• It provides additional contrast and helps distinguish cell boundaries.

Conventional Method: Pap Smear

• Spatula: 
• Ayre spatula to take specimen from transformation zone > Squamocolumnar Junction

• Cytobrush: Takes specimen from endocervix.

• Fixative: 95% ethyl alcohol +/- 5% ether.

• Mnemonic: Papa () ethyl alcohol () etheril () ozhichu kudichu

• Absolute Contraindications: None.

• Relative Contraindications: Bleeding.

• Important Note: Do not air dry the slide.

• Best Time: Periovulatory phase.

Liquid Based Cytology

• Advantages:
• Done using
• Cervical broom (Ayer broom / Cervex brush) >>
• Cervical brush (Cytobrush)
• Can be used during menstruation.
• Can perform both Pap Smear and HPV DNA testing from the same sample.
• Better pick up rate.

• Fixative: Methyl alcohol

HPV DNA Testing

• Can be done from age: 30 years.

• Earliest age: 25 years.

• Detects: High risk HPV.

• Cannot tell: Subtype.

• When to combine Pap + HPV: Co-test.

• When HPV DNA done after abnormal Pap: Reflex HPV testing.

• Tests for HPV subtype:
• Onclarity Test.
• Cobas Test.
• Partial genotyping.
• Mnemonic: Clarity (onclarity) lum Basslum (Cobas) kelkunna tape (typing → genotyping) venam → HPV detect cheyyan
• Mnemonic: OCP kazhich HPV vannu

VIA (Visual Inspection with Acetic Acid)

• Procedure: Apply 3-5% acetic acid to cervix.

• Normal Areas: Appear Pink (unstained).

• Dysplastic Areas: Appear White/Acetoacetate area (stained).

• Metaplastic Areas: Appear Grey.

Pap Smear Reporting and Management

Note:

• HSIL: High grade squamous cell lesion

• LSIL: Low grade squamous cell lesion

• ASC-H: Atypical squamous cells where HSIL cannot be ruled out.

• ASCUS: Atypical squamous cells of undetermined significance.

• AGCUS (Atypical glandular cells of undetermined significance):
• Possibilities:
• Adenocarcinoma of cervix.
• Endometrial cancer spread to cervix.

• Post coital bleeding

• Pap smear report: HSIL/ASCH
• Next step → Colposcopy + Biopsy + Endocervical curettage
• Colposcopy → Cannot see endocervix
• Can see exocervix and transitional zone;
• ECC is done to access endocervix

• LSIL ≥ 25 years
• Next step → Colposcopy + Biopsy

• ASCUS / LSIL < 25 years
• Next → Repeat papsmear → 1-2 years (bcz uncertain)

• ASCUS > 25 years
• Next
• Colposcopy + Biopsy OR
• HPV DNA Testing (Reflex DNA Testing)
• If positive → Colposcopy

• AGCUS
• It could mean
1. Adenocarcinoma of endocervix
2. Endometrial carcinoma spread to cervix
• So next do
• Colposcopy + Biopsy +
• ECC +
• Endometrial biopsy

NOTE

• Pap smear → HSIL +

• Colposcopy → CIN 1 or Normal

• Disparity b/w Pap and Biopsy →
• Next step
• Cone biopsy/conisation
• ECC can also detect Endocervical patholgies → but need cone biopsy to confirm
• So best answer → Cone biopsy > ECC

• ECC Positive:
• Nest step:
• Cone Biopsy (because we are suspecting Adeno Ca in situ)
• If cone biopsy shows adenocarcinoma in situ → Hysterectomy.

Colposcopy & Biopsy:

• Magnification power: 30 times.

• Visualizes exocervix & TZ.

• (Cannot visualize endocervix).

• Procedures:
• Apply 3-5% acetic acid:
• Biopsy areas that look white.
• Switch on green filter:
• Biopsy from abnormal blood vessels
• (Reticular/mosaic/punctate areas).

Cone Biopsy/Conization:

• Done in OT ↓ GA.

• Indication: 
• Suspicion of adenocarcinoma of cervix
• Microinvasive cancer
• ECC positive
• Pap smear/colposcopy biopsy doesn't correlate
• Via colposcopy if
• Limit of lesion not visible
• TZ not visible

• Cone shaped area is removed

Cervical Intraepithelial Neoplasia (CIN)

• CIN is a premalignant lesion of the cervix.

• Indicates presence of dysplasia (abnormal cell growth).

Grading

• CIN 1:
• Dysplasia involving ≦1/3rd cervical epithelial thickness.
• Low malignancy risk (~1%).

• CIN 2:
• Dysplasia involving 1/3rd – 2/3rd of cervical epithelial thickness.
• Medium malignancy risk (~5%).

• CIN 3:
• Dysplasia involving ≥2/3rd of cervical epithelial thickness
  (but not entire epithelium).
• High malignancy risk (15-30%).

• Carcinoma-in-situ (Ca-insitu):
• Dysplasia involves entire epithelium.
• Overlying membrane is intact.

• Invasive Cervical Cancer: 
• Overlying membrane is disrupted.

Diagnosis of CIN

• Screening Test: 
• Pap Smear (Cytologic test) → Only diagnoses dysplasia

• Confirmatory Test: 
• Biopsy (tissue diagnosis) → Detect Epithelial involvement

Age Peaks

• Cervical Intraepithelial Neoplasia (CIN):
• Peak Age: 21-30 years

• Carcinoma in Situ (Ca-insitu):
• Peak Age: 30-35 years

• Invasive Cancer
• Peak Ages:
• 35-39 years
• 60-65 years

Management of CIN

CIN 1:

• Observation for 2 years

• if unresolved → Can consider Cryoablation (done in OPD, no anesthesia needed).
• Cryoablation
• Passing CO2 or Liquid nitrogen at very low temperature using Cryogun → Crystallises intracellular water → Lead to destruction of dysplastic cells
• Remove 5mm deep epithelium
• Side effect
• Persistent watery discharge → Never bleeding
• Disavantage
• No tissue specimen

CIN 2/3:

• LEEP (Loop electro excisional procedure)

• LLETZ (Large loop Excision of transitional zone).

• F/u for 2 yrs → if not resolved → cryotherapy

LEEP/LLETZ:

• Procedure:
• OPD Procedure.
• No admission needed.
• Approximately 10 minutes procedure.
• Wire loop used for cutting & coagulating tissue simultaneously.
• Minimal bleeding.
• Cuts 10 mm deep epithelium.
• Tissue sample obtained for Histopathological Examination (HPE).

• Note: Hysterectomy is NOT done for CIN.

CANCER CERVIX

• Normal uterocervical length is 7 - 8cm on an average

• Uterus: 3x2x1 cm

Squamous Cell Carcinoma

• Most Common (m/c) Type of Cancer Cervix:
• Large Cell Non-Keratinising Type: 
• m/c type within squamous cell.
• Large Cell Keratinising Type.
• Small Cell: 
• Poor prognosis.

• m/c Association: HPV 16.

• Mnemonic: Squamous - sixteen

Adenocarcinoma

• Second m/c Type.

• m/c in: Young females.

• Risk Factor: Oral Contraceptive Pills (OCP).

• m/c Association: HPV 18.

• m/c Site: Endocervix.

• Mnemonic: Adeno → Eighteen

m/c Site

• Transitional zone.

m/c Age

• 35-39 years & 60-64 years.

Symptoms

• Irregular Bleeding: 
• m/c symptom.

• Post Coital Bleeding: 
• Most specific symptom.

• Dirty Vaginal Discharge.

• Pyometra: 
• m/c Ca causing pyometra: Ca cervix.

• Postmenopausal Spread.

• Dyspnea, Cough, Hemoptysis, Chest Pain: Lung metastasis.

• Sciatica, Hematuria, Lymphedema: 
• Pelvic sidewall involvement.
• 3b

• m/c Cause of Death: 
• Renal failure.

Most common route of spread:

• Direct > Lymphatic > Hematogenous.

Drainage

• Mnemonic: HOPE

• Hypogastric (internal iliac) nodes.

• Obturator node.

• Paracervical node (sentinel node).

• External iliac nodes.

• Cervix does not drain into superficial lymph nodes:
• Not included in radiotherapy.

Risk Factors Overview

• HPV: Main cause.

• Early Sexual Activity: First coitarche under 18 years.

• Early Pregnancy: First pregnancy under 20 years.

• Multiple Partners: Increased exposure.

• Multiparity: Having multiple children.

• HIV: Weakens immune system.

• Low Socio-Economic Status: Impacting access to healthcare.

• Smoking: Damages cells.

• OCP (Oral Contraceptive Pills)

• No role → as not estrogen dependent
• Late Menopause/Early menarche
• Familial Inheritance
• HRT
• IUCD

• Most important cancer in females:
• Breast Ca

Pathology Cervical Cancer

Tadpole Cell:

• Indicates squamous cell carcinoma of the cervix.

• Microscopy: Cell with very big head and very tiny tail.

• Kidney Failure after SCC → came with HOPE (LN, PAP stain) → Direct aspirate (Direct spread) cheythu → 16 (HPV 16) tadpoles (Tadpoles SCC) kitti

Investigations

Prognostic Markers

• Staging > Lymph nodes.

Diagnostic Method

• Cervical biopsy.

• Microinvasive cancer on LEEP → Cone biopsy.

Staging

Clinical & Radiological Investigations

Staging Specific Notes

• Spread to uterus:
• Does not change staging.

• Bullous edema of bladder:
• Not a metastasis.

• Metastasis of bladder:
• Requires histopathological evidence.

FIGO Staging

• Memorise:
• 1b3 → visible > 4cm
• 2a2 → visible, > 4cm, spread to upper vagina
• 3b → pelvic side wall/ureter

• 3b → Uremia →
• m/c/c of death in Ca Cervix
 

Management Principles

1. Surgery:

• Surgery allows ovarian preservation
• Reason: Radiation causes premature ovarian insufficiency (POI)
• Ovaries can be preserved safely if uninvolved
• Ovary is the most radiosensitive organ

• Can be done till Stage 2A1 and 1b2 (Tumor size <4 cm)

• Surgery can’t be done if:
• If tumor size ≥ 4 cms
• 1B3 (≥ 4cm x 0.5 cm) AND
• 2A2 onwards
• Chemotherapy → Radiotherapy

Surgery by Patient Age:

Radical Trachelectomy:

• Removal of cervix + 80% parametrium.

• Uterus stitched to vagina.

• Followed by abdominal cerclage (internal, due to injury during cervix removal).

• Contraindication: 
• Tumor size ≥2 cms.

• Subsequent labor only through LSCS.

• Indication
• Young females who desire future child-bearing.
• Tumor size < 2 cm.

• Post-Procedure Delivery
• LSCS.

2. Radiotherapy:

• Indication
• Stage 1B3;
• Stage 2A2 to 4

Radiosensitizer

• Increases sensitivity to Radiotherapy (RT).

• Given prior to RT.

• Cisplatin > 5 Fluorouracil.

• Side Effects
• Vaginal fibrosis (difficult intercourse).
• Ovarian failure (ovary is the most radiosensitive organ).
• RT not preferred in early stages.

• Sis Pack → Uterus

• Sis Fuck → Cervix

Radiotherapy Types

a. Teletherapy

• Indication: Given first to shrink tumor size

• Source of radiation:
• Outside body
• External beam radiotherapy (EBRT)
• Pelvic lymph nodes involvement.
• Extended EBRT:
• Paraaortic lymph nodes involvement.

• Isotope:
• Cesium
• Mnemonic: Seize the growth

• Other features:
• 50 Gy total
• 5 times a week
• 2 Gy per sitting
• 5 weeks

b. Brachytherapy

• Indication: Following teletherapy.

• Isotope:
• Iridium 192.

• Source of radiation:
• Inside body.
• Intracavitary therapy.
• Uses Colpostat/Tandem.

• Other features:
• Point A:
• 8 Gy
• parametrial node
• Point B:
• 6 Gy
• obturator nodes

Post-Surgery Management

High Risk

• Features:
• Margin positive.
• Parametrium positive.
• LN metastasis positive.

• Management:
• Post-operative chemoradiation.

Intermediate Risk

• Features (any 2 positive):
• Large tumor size.
• Lymphovascular involvement.
• Deep stromal invasion.

• Management:
• Post-operative radiotherapy.

Low Risk

• Features: No listed positive risk factors.

• Management: No post-operative treatment.