2. COLPOSCOPY QUESTIONS Michael R. Downs M.D. October 2004

3. Most common symptom of vulvar dysplasia/cancer  Bleeding  Pruritis  Condyloma  Neuropathic pain  Discharge E C B A D

4. Which of the following is an absolute contraindication to ECC Nulliparous female Multiparous female Pregnant female Menorrhgia None of the above E C B A D

5. Risk factors for cervical cancer include which of the following ? Smoking Immunosuppression Poor, socially disadvantaged Multiple lifetime sexual partners All of the above E C A B D

6. Colposcopic evaluation of this cervix after the application of acetic acid shows findings compatible with: © 1997, 2004 ASCCP. All rights reserved. A)minimal acetowhite epitheliumminimal acetowhite epithelium with regular distinct borders B) acetowhite epithelium with Irregular indistinct borders and fine punctation C) moderate acetowhite epithelium with irregular, indistinct borders and fine punctation D) moderate raised acetowhite epithelium with irregular, indistinct borders, coarse punctation, and a mosaic pattern

7. Based upon this photo, a biopsy is best performed at what location? a.12 to 3 o'clock b.3 to 6 o'clock c.6 to 9 o'clock d.9 to 12 o'clock © 1997, 2004 ASCCP. All rights reserved. A B C D A B C D

8. Which of the following statements is true? D) Lugol’s solution destroys histologic detail of biopsies C) Only industrialized countries have experienced an increase in cervical cancer B) Cervical cancer does not occur in women ≥80 yrs. A) Median age for cervical cancer is 45-50 years

9. In the Bethesda System of grading Pap smears “HSIL” refers to A) CIN I and all dysplasias B) ASCUS C) Severe Cervicitis E) CIN III but not Carcinoma in situ D) Moderate & severe dysplasia,CIN II,III, and carcinoma in situ

10. Preferred management of ASCUS cytology is Repeat Pap smear in 6 months Repeat Pap smear in 12 months Immediate colposcopy HPV DNA testing Cervicography A C D E B

11. In addition to colposcopy and ECC a 37 year old women with a Pap smear indicating AGC-NOS should also undergo which of the following ? HPV – DNA testing Endometrial biopsy Diagnostic excisional procedure Transvaginal sonography A B C D

12. What is the recommended initial management of ASC-H  Repeat cytology in 12 months  Immediate colposcopy  HPV – DNA testing  Repeat cytology at 4 and 12 months D C A B

13. A 24 year old woman with an ASC-US Pap smear and negative HPV-DNA testing should undergo which of the following ? Immediate colposcopy Repeat HPV-DNA testing in 6 months Repeat cytology in 12 months Repeat cytology and HPV-DNA testing in 2 years A B D C

14. A 28 year old woman with HSIL undergoes colposcopy that is satisfactory but reveals no CIN.Review of the Pap upholds the diagnosis. What is the next step ?  Repeat the colposcopy in 6 months  Perform HPV-DNA testing  Perform a diagnostic excisional procedure  Repeat Pap in 6 and 12 months A B C D

15. Which one of the following management options is ‘unacceptable’ for a 49 year old with an AGC-NOS Pap smear? Immediate colposcopy and ECC Endometrial biopsy Repeat cytology All of the above are unacceptable B C A D

16. All the following are acceptable options for initial management of a 17 year old with LSIL EXCEPT ? Immediate colposcopy Repeat cytology in 6 months HPV-DNA testing in 12 months Diagnostic excisional procedure D C B A

17. A postmenopausal woman with an ASC-US Pap smear is treated with intravaginal estrogen, the repeat Pap shows ASC. What is the next step? Repeat cytology in 4 – 6 months Immediate colposcopy HPV – DNA testing Diagnostic excisional procedure A D C B

18. What do the letters ‘SIL’ refer to in the Bethesda system? Serious invasive lesion Simple informal language Surgeons invariably lie Squamous intraepithelial lesion C B A D

19. Cervical friability Post coital bleeding Cervical erosion Nabothian cyst Atypical vessels Which of the following is NOT a sign of cervical cancer? D C B A E

20. Which of the following is not contained within the Transformation zone?  Gland openings  Skenes glands  Squamous metaplasia  Nabothian cyst  Squamocolumnar junction E C B A D

21. What is the proper sequence of steps during colposcopy?  Lugol’s, acetic acid, saline  Acetic acid, Monsel’s, ECC  Saline, Lugols, saline, acetic acid, Monsel’s  Saline, acetic acid, Lugol’s C B A D

22. What is the name of the Colposcopic index used to grade severity of cervical lesions ? ASCUS index Bethesda index Lugol’s index Reid’s index Smith’s index of lesions (SIL) E D C B A

23. Criteria for a “satisfactory” Colposcopic Examination include Must see entire transformation zone Entire lesion visualized No evidence of invasive cancer All of the above D A C B A B C D

24. Pap smears are not indicated for Women over age 65 years HIV infected women A 30 yr old female with 3 consecutively normal Pap smears Women after hysterectomy for benign reasons Women from Southwest Arkansas A B C D E

25. In women age 30 years and older that have a normal pap smear and a negative HPV DNA test what is the earliest interval at which they should be rescreened? 1 year 2 years 3 years 4 years There is no reason to do both of these tests at the same time A B C D E

26. Which of the following is not part of the evaluation recommended for a 40 yr old whose pap results are “Atypical glandular cells”? Endocervical curettage HPV DNA testing Colposcopy Endometrial biopsy All of the above ARE indicated A B C D E

27. The Preferred Management Option for AGC Is: A.Reflex HPV-DNA testing B.Repeat cytology C.Colposcopy and endocervical evaluation D.Loop excision A B C D

28. Which Statements Are True Regarding Figures 2 & 3 (more than one is correct) There is a wide transformation zone There are acetowhite lesions present There are atypical vascular patterns present The colposcopy is unsatisfactory Figure 2: Image without filter Figure 3: Image with green filter A B C D

29. The Correct Treatment for Adenocarcinoma in Situ Includes Which of the Following: Cryotherapy Laser vaporization Cold knife conization Loop excision procedure A B C D

30. Regarding HPV – which statement is NOT true? HPV is a necessary factor in the development of cervical neoplasia. Most HPV- infected women develop significant cervical abnormalities As many as 80% of LSIL lesions caused by HPV will regress to normal D). Cervical cytologic changes and external genital warts are caused by different HPV types None of the above are true A B C D E

31. Which of the following regarding cytology screening after total hysterectomy is TRUE Incidence of vaginal cancers is about 1-2/100,000/yr If hysterectomy for benign reasons do not require pap smears 100,000 women would require screening to detect 1 vaginal cancer Screening 100,000 women would result in 200 false positives All the above statements are true A B C D E

32. Screening all women under 25 yrs of age for Chlamydia is recommended by USPSTF Cervical cancer causes 4,100 deaths / year in the US. 25% of cervical cancers occur in women > 65 yrs old Cervical cytologic screening can be stopped at age 70 yrs Almost half of all deaths from cervical cancer occur in women over 65 yrs old A B C D E Which statement is NOT true -

33. Cervical cytologic screening should begin with onset of sexual activity About 10% of cervical cancers occur in women who have not had a pap test within the last 5 years. The green filter on Colposcope is used to highlight vascular patterns. Mosaicism and punctuation refer to specific vascular patterns seen during colposcopy Acetowhite change from Low grade lesions appears and disappears rapidly A B C D E Which statement is NOT true -

34. This patient is a 50 year old woman who had a Pap smear done at another office approximately six months earlier that showed a high grade squamous intraepithelial lesion (HSIL). A smear was repeated a short time later and this was interpreted as atypical glandular cells of undetermined significance (AGC). She was referred for colposcopy. CASE STUDY from ASCCP © 1999, 2004 ASCCP. All rights reserved.

35. Which of the following is not a colposcopic characteristic of low grade lesions? B) Lacy reticular mosaic vascular pattern C) Indistinct acetowhite, semi-transparent D) Jagged, geographic, feathered, irregular borders E) Satellite lesions A) Sharp distinct margins

36. This slide demonstrates the findings at colposcopy after the application of 5% acetic acid. Which of the following statements is true regarding this patient’s findings? © 1999, 2004 ASCCP. All rights reserved. The exam is satisfactory Findings are suggestive of low- grade disease An atypical vessel is present There is no lesion present that would explain an AGUS Pap smear A B C D

37. During a health maintence exam of a 50 year old patient you notice the lesion shown here on the vulva How should this be evaluated ? Referral to Gyn oncologist Culture for high risk HPV Apply acetic acid to see if it turns acetowhite Wide excision Punch biopsy A E B C D

38. Which of the following options is ‘unacceptable’ for evaluating ASC-US in a postmenopausal woman Repeat pap and HPV in 12 months Immediate colposcopy Immediate HPV DNA testing Intravaginal estrogen therapy for 3 weeks C B D A

39. Which of the following is a TRUE statement Cervical polyps are rarely malignant Vulvar cancer is rarely associated with HPV Unlike Squamous cell cancer of cervix – adenocarcinoma is not associated with HPV About 12-15% of all pap smears are read as ASC-US C B D A

40. Criteria for cryotherapy of the cervix include - Satisfactory colposcopy examination Cervical cancer ruled out Negative ECC Less than 2 quadrants of cervical disease All of the above E C B A D

41. Up to 17% are found to have CIN 2 or 3 on biopsy Almost 30% are caused by the ‘low risk’ HPV About 50% of all women with ASC will have high risk types of HPV About 4% of all pap smears are reported as ASC Which statement about ASC is FALSE - A D B C

42. Post menopausal women Adolescent females History of Gonorrhea HIV positive patients Smokers For which of the following is immediate colposcopy the only acceptable management option for ASC ? A B C E D

43. HPV DNA in 12 months LEEP Colposcopy Repeat pap in 4-6 months Any of the above What is the first step in the workup of LSIL ? A B C D E

44. Insert speculum–GC/Chlamydia culture–pap - bimanual Bimanual exam–Speculum–pap-GC/Ch cultures Insert speculum–pap-GC/Chlamydia culture - bimanual Bimanual exam–Speculum–GC/ Ch culture–Pap What is the proper sequence for performing routine Health Maintenance and Cervical cytology screening for a 21 yr old female? A B D C

45. HPV is a necessary factor in the development of cervical neoplasia. Most HPV- infected women develop significant cervical abnormalities As many as 80% of LSIL lesions caused by HPV will regress to normal. Cervical cytologic changes and external genital warts are caused by different HPV types All the following are true regarding HPV infections EXCEPT ? A B D C

46. 1-2% 15-30% of the time 70-85% of the time Never Only occurs in poor quality labs How often is CIN 2, 3 identified on cervical biopsies taken during evaluations of LSIL ? A B C D E

47. Which of the following regarding cytology screening after total hysterectomy is TRUE Incidence of vaginal cancers is about 1-2/100,000/yr After hysterectomy for benign reasons pap smears are not required Almost 100,000 women would require cytologic screening to detect 1 vaginal cancer Screening 100,000 women would result in 200 false positives All the above statements are true B A C D E

48. Helps to determine who needs colposcopy and who just needs to be followed Is not useful in LSIL since over 80% test positive for high risk HPV types Is only useful when coordinated with a lab that performs high volumes of test Not useful unless HPV DNA test is done in same lab that read the Pap smear Regarding HPV DNA testing in women with LSIL results on Pap smear- which is true? B C D A

49. Increasing abdominal girth Lower abdominal pain Abnormal uterine bleeding New onset urinary incontinence Amenorrhea “Classic” symptom of endometrial cancer is - A B E D C

50. If a woman with HSIL Pap result has a satisfactory colposcopy and biopsies show CIN I what management options is/are acceptable?  Cryotherapy  Diagnostic excisional Procedure  Repeat Colposcopy in 3 months  Total abdominal hysterectomy  Vaginal hysterectomy A C D E B

51. Which statement regarding HSIL is FALSE?  HSIL is uncommon accounting for less than 1% of cytology interpretations  HSIL is associated with 75% chance of CIN 2,3 on biopsy  HSIL includes CIN 2 and 3 and severe dysplasia  HSIL is usually (75% of time) associated with Polycystic Ovary Syndrome D C B A

52. You perform a colposcopic exam of a 27 yr old female with LSIL Pap smear. You see a small acetowhite area with irregular borders and no vessels and biopsy it. You also do an ECC. Pathology results show normal cervical tissue and negative ECC results. Which of the following options is acceptable?  Repeat Pap at 6 and 12 months  Cryotherapy  Minimal LEEP to remove transformation zone  HPV testing  None of the above E D C B A

53. A 32 yr old female sees you for evaluation of HSIL pap smear. Her colposcopy shows a dense acetowhite lesion with sharp borders and prominent mosiacism that extends up into the endocervical canal and can’t be seen in it’s entirety. Biopsy shows CIN III. What is the next step ? Hysterectomy Cryotherapy Diagnostic excisional procedure Repeat colpo in 3 months Refer to Hospice E D A B C

54. What finding on Transvaginal ultrasound of post menopausal female should increase your suspicion of endometrial cancer? Endometrial stripe >5mm Uterine fibroids Polyps in uterine cavity Blood in uterine cavity All of the above A B C D E

55. Most common precursor to Endometrial cancer is - ASCUS LSIL HSIL Endometrial polyps Endometrial hyperplasia A B C D E

56. A post menopausal woman with uterine bleeding should: Be started on HRT for 4 to 6 months Be tested for diabetes mellitus Have a Ca-125 level drawn as baseline Tested for vonWillebrands Undergo endometrial biopsy E D C B A

57. The most common type of endometrial cancer is? Adenocarcinoma Papillary serous Squamous cell Mucinous cell B C D A

58. Which of the following is not a risk factor for Endometrial cancer? Diabetes Oral contraceptive pills Hypertension Obesity Polycystic Ovary Syndrome A C D E B

59. Indications for conization include which of following? Suspected microinvasion Positive ECC Adenocarcinoma in sito Lack of correlation between cytology and biopsy histology All of the above D C B A E

63.  E C B A D

64. Which of the following statements is false regarding the TRANSFORMATION zone? A) Junction where squamous and columnar epithelium meet B) May contain Nabothian cysts C) Was once covered with columnar epithelium D) Is the area between original squamocolumar junction(SCJ) and present SCJ E) Area is excised during cervical cone biopsy

65. E) Punch biopsy Lichen sclerosus represents a specific dermatological entity. It is most commonly seen in the genital area in women. It may also be found on other sites of the body.Lichen sclerosus is primarily a disease of the postmenopausal woman, but can be seen at any age and monly is even seen in children.Pruritis most common symptom.Not associated with increased risk of SCC.

66. © 1999, 2004 ASCCP. All rights reserved. Answer: C There is a large atypical vessel at 4 o’clock, located in a field of dense acetowhite epithelium and there is another in the endocervical canal near the 9 o’clock position. The exam is not satisfactory. In fact, even with the use of an endocervical speculum, the extent of the lesion could not be seen. The colposcopic finding of dense acetowhite epithelium is not consistent with a low-grade lesion, so answer b is incorrect. Answer “d” is incorrect since up to 50% of patients with an AGC Pap smear may have an associated squamous lesion that is either the cause of, or is related to the AGC smear.

67. The Correct Treatment for AIS Includes Which of the Following: C. Cold knife conization: Correct The preferred method of excisional of biopsy is cold knife conization. While Loop excision is sometimes performed, a higher rate of recurrence of adenocarcinoma in situ has been found in patients undergoing Loop electrosurgical excision procedures as opposed to cold knife conizations. 5

68. C. Colposcopy and endocervical evaluation: Correct Atypical glandular cells have been associated with a greater risk for cervical neoplasia than other categories (ASC or LSIL), with between 9-54% of women having biopsy-confirmed cervical intraepithelial neoplasia. Up to 8% of patients will have an adenocarcinoma in situ and up to 9% in various series have been found to have invasive carcinoma. 3 With an interpretation of adenocarcinoma in situ cytologically, there is nearly a 50-70% risk of adenocarcinoma in situ, and as high as a 40% risk of invasive cervical adenocarcinoma. 4 The total number of abnormal Pap smears with glandular lesions is generally < 1%. The Preferred Management Option for AGC Is:

69. Figure 2: Image without filter Figure 3: Image with green filter A.There is a wide transformation zone: True In these colposcopic photographs, at 12 o'clock there are acetowhite lesions present. There is a very wide transformation zone and abundant glandular tissue. With the use of the red- free filter, one can see subtle atypical vessels within the glandular regions. Which Statements Are True Regarding Figures 2 and 3 :

70. Figure 2: Image without filter Figure 3: Image with green filter B.There are acetowhite lesions present: True In these colposcopic photographs, at 12 o'clock there are acetowhite lesions present. There is a very wide transformation zone and abundant glandular tissue. With the use of the red- free filter, one can see subtle atypical vessels within the glandular regions. Which Statements Are True Regarding Figures 2 and 3 :

71. Figure 2: Image without filter Figure 3: Image with green filter C.There are atypical vascular patterns present: True In these colposcopic photographs, at 12 o'clock there are acetowhite lesions present. There is a very wide transformation zone and abundant glandular tissue. With the use of the red- free filter, one can see subtle atypical vessels within the glandular regions. Which Statements Are True Regarding Figures 2 and 3 :

77. Reid’s index

78. A Sharp distinct margins

79. A) Cervical polyps are rarely malignant IS

81. B) Skenes glands THE CORRECT ANSWER IS :

82. D Nabothian cyst

83. D saline, acetic acid, Lugol’s

84. A) Squamous intraepithelial lesion

85. D) Moderate & severe dysplasia, CIN II,III, and carcinoma in situ

86. Median age for cervical cancer is 45-50 years A

87. Answer: D The colposcopic evaluation is seen in the slide after the application of acetic acid. The lesion is best described as a moderately opaque, acetowhite epithelial lesion with irregular, indistinct borders with mosaicism and punctation. The punctations are large and have a large intercapillary distance suggesting a high-grade lesion. This is an unsatisfactory colposcopy. The CORRECT ANSWER IS -

88. Based upon this photo, a biopsy is best performed at what location? a.12 to 3 o'clock b.3 to 6 o'clock c.6 to 9 o'clock d.9 to 12 o'clock © 1997, 2004 ASCCP. All rights reserved. Answer: A Based upon the colposcopic examination, a biopsy was performed between the 12 and 3 o'clock position in the area of the mosaicism and punctation.

89. Good choice – but it is not the only correct answer. See if you can select all the correct responses.

90. E) All of the above

91. C) Pregnant female

92. THAT’S RIGHT !! B) Pruritis

93. SORRY – Wrong answer TRY AGAIN

95. Based upon this photo, a biopsy is best performed at what location? a.12 to 3 o'clock b.3 to 6 o'clock c.6 to 9 o'clock d.9 to 12 o'clock © 1997, 2004 ASCCP. All rights reserved. Answer: A Based upon the colposcopic examination, a biopsy was performed between the 12 and 3 o'clock position in the area of the mosaicism and punctation.