30 A 37 Year Old Woman with Post Coital Bleeding

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  • 30 A 37 Year Old Woman with Post Coital Bleeding

    1. 1. A 37-Year-Old Woman With Post-Coital Bleeding A Powerpoint companion to: LABORATORY MEDICINE CASEBOOK. An introduction to clinical reasoning Jana Raskova, MD Professor of Pathology & Laboratory Medicine Stephen Shea, MD Professor of Pathology & Laboratory Medicine Frederick Skvara, MD Associate Professor of Pathology & Laboratory Medicine Nagy Mikhail, MD Assistant Professor of Pathology & Laboratory Medicine UMDNJ-Robert Wood Johnson Medical School Piscataway, NJ Eugene G. Martin, Ph.D. Associate Professor of Pathology & Laboratory Medicine
    2. 2. History and Presentation  37 year old woman seen in physician’s office complaining of a two week history of post-coital vaginal bleeding.  Previous history – Two normal pregnancies. Family history unremarkable  Physical Exam:  Slightly overweight female in no acute distress  BP: 120/85  HR 85 bpm - regular  Temperature – 98 o F  Chest and abdominal examination uremarkable.  Colposcopy  Cervix – White patches following the application of acetic acid, a well as distinct vascular punctuation pattern.  PAP smear obtained. Previous PAP reviewed.
    3. 3. PAP SMEAR  Kilocytic atypia:  Mature squamous cells,demonstrating a large perinuclear, lightly stained area.  Surrounding peripheral cytoplasm normal  Slightly enlarged nuclei  Stains much more intensely.  Chromatin appears relatively  No secretory or malignant cells present PAP smear One Year Earlier Normal PAP smear  Normal mature squamous cells Small, pyknotic nuclei No perinuclear halo Yellow color is due to cytoplasmic glycogen
    4. 4. PAP SMEAR  Mature squamous cells,demonstrating a large perinuclear, lightly stained area.  Surrounding peripheral cytoplasm stains much more intensely.  Chromatin appears relatively normal PAP smear: One Year Earlier PAP smear: Current  High Nuclear/cytoplasmic ratio  Variation in nuclear size anisokaryosis  Irregular nuclear membranes  Hyprchromatic nuclei  Course chromatin pattern DX: Severe dysplasia or CIN III High-Grade squamous intraepithelial lesion - HGSIL
    5. 5. Cervical Biopsy: HPV In-Situ Hybirdization for types 16 and 18  Note Purple precipitate indicating the site of hybirdization between target and probe DNA
    6. 6. Human Papilloma Virus  HPV types 6,11,42 and 44 – associated with development of low risk benign condylomas  Majority of low-grade cervical intraepithelial cells (CIN 1) exhibit features of HPV infection.  Only a small percentage develop cervical carcinoma  HPV 16,18,31 and 33 - associated with development of high risk cervical carcinoma.  Oncoprotein E6 of HPV types 16, 18 transforms cells in culture by inactivation of human suppressor gene p53.  15% of cervical carcinoma IS NOT associated with HPV
    7. 7. Cervical Biopsy  Normal maturation visible  Hyperchromatic basal cells  Flattened squamous surface cells  Clear areas represents normal glycogen deposition Norma H&E x78l Patient H&E x78  Squamous epithelium – no evidence of maturation  Loss of cell polarity  Nuclei – hyperchromatic  Nuclear size variable PATTERN: Severe dysplasia or Carcinoma in situ
    8. 8. Predisposing factors for cervical carcinoma  Sexual behaviors  Early age at first intercourse  Multiple sexual partners  Male partner with previous multiple sexual partners  Non-sexual risk factors  Cigarette smoking  Use of oral contraceptives  Lack of circumcision in male partners  Family history of cervical carcinoma
    9. 9. Treatment Considerations –  CIN: Cervical Cone Biopsy  Genital warts:  Liquid N2  Laser  Electrocautery  Imiquinoid cream  Podophyllin  Podofilox  Treatment eliminates the wart, but not the virus!  Complications:  Although most HPV infections, fail to progress to cancer, it is important in the presence of cervical dysplasia to have regular PAP smears  1:500 of CIN III will develop invasive carcinoma later  Pregnancy – physical obstruction, modification of the elasticity of the vaginal wall is reduced
    10. 10. Treatment Considerations –  CIN: Cervical Cone Biopsy  Genital warts:  Liquid N2  Laser  Electrocautery  Imiquinoid cream  Podophyllin  Podofilox  Treatment eliminates the wart, but not the virus!  Complications:  Although most HPV infections, fail to progress to cancer, it is important in the presence of cervical dysplasia to have regular PAP smears  1:500 of CIN III will develop invasive carcinoma later  Pregnancy – physical obstruction, modification of the elasticity of the vaginal wall is reduced
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