Premalignant conditions of the cervix

Transformation zone

Is that part of the cervix that extend from the widest part of the skin that was originally columnar epithelium into the current SCJ

This is characterized by Nabothian follicles (retention cyst s of endocervical glands that have covered by advancing squamous epithelium.

The ectocervix is covered by squamous stratified epithelium

The canal of the cervix , is lined by single columnar epithelium, the point where these two epithelium meet is called squmocolumnar junction.

The SCJ during infancy lies just at the external os

At puberty & pregnancy the SCJ is said to roll out onto the ectocervix.to be seen (red area)

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Transformation zone

TerminologyDysplasia and cervical intraepithelial neoplasia (CIN) are different terms or names for the same condition. Dysplasia simply means abnormal tissue development; while dysplasia is still sometimes used to mean CIN, the term is not used as frequently as in the past. Squamous intraepithelial lesions (SIL) is another term that is used with regard to CIN, and describes the type of cervical cells that undergo changes in 80% of cervical neoplasia. Both terms--dysplasia and CIN--remain in use today. Cervical intraepithelial neoplasia (CIN) is now used to describe what was once called dysplasia

Cervical intraepithelial neoplasia (CIN) is now used to describe what was once called dysplasia

• CIN I = minimal dysplasia

• CIN II = moderate dysplasia

• CIN III = severe dysplasia or carcinoma in situ

• CIN III, severe dysplasia and carcinoma in situ are all different names for the same thing--early cervical cancer. While approximately one-third of all cases of CIN I will resolve in time, the rest will progress. All degrees of CIN, however, require immediate colposcopy.

• Introduction

• Cervical intraepithelial neoplasia (CIN) is a condition characterized by new growth (neoplasia) in the normal tissue (epithelium) of the cervix. A diagnosis of CIN means that abnormal tissue has been detected in a woman's cervix. In addition to CIN, other types of lower genital tract neoplasias reported in women with HIV include vulvar intraepithelial neoplasia (VIN) and perianal intraepithelial neoplasia (PIN or AIN, anal intraepithelial neoplasia).

• CIN is much more common than the other types of genital neoplasia in women with HIV. The tissue changes that signify CIN are premalignant, or precancerous; CIN is essentially a precursor to invasive cervical cancer. CIN may be mild, moderate or severe.

• The abnormal tissue of CIN is collectively composed of cells that have undergone abnormal, individual changes, and which have formed lesions in the cervix. Cervical lesions can regress (grow smaller and disappear), persist or progress to early cervical cancer, more formally called cervical carcinoma in situ, and finally invasive cervical cancer. Moderate or severe CIN (high-grade SIL, CIN II-III) is more likely to persist or progress. Mild CIN (low-grade SIL, CIN I) often regresses without any treatment, overcome by a successful immune system defense.

• Signs and Symptoms• Cervical dysplasia often produces no symptoms and is

usually discovered during an annual Pap smear. Occasional signs and symptoms of the condition can include:

• Genital warts • Abnormal bleeding • Spotting after intercourse • Vaginal discharge • Low back pain �• It is important to note that these symptoms are not

unique to cervical dysplasia and they may indicate a different problem.

Risk Factors The following may increase an individual's risk for developing cervical dysplasia:

Human papilloma virus (HPV) infection Genital warts Smoking Early onset of sexual activity (younger than 18 years old) Multiple sexual partners Having a partner whose former partner had cervical cancer History of one or more sexually transmitted diseases, such as

genital herpes or HIV Other causes of immunosuppression, such as HIV or the use of

chemotherapeutic medications to treat cancer Long-term use (5 or more years) of birth control pills Being born to a mother who took diethylstilbestrol (DES) to

become pregnant or to sustain pregnancy (this drug was used many years ago to promote pregnancy but it is no longer used for these purposes)

Dysplasia The process of metaplasia can be disrupted by external influences&

can lead to disordered squamous epithelium called dysplastic epithelium ( HPV ,smoking , immune suppression may act as coagent

Dysplasia *Lack of normal maturation of cell as they move from basal layer to superficial

layer

*Large nuclei more variable in size &shape *more actively dividing nuclei.Dysplasia are now referred to as cervical intraepithelial neoplasia ( CIN)CIN graded mild ,moderate or sever depending on 1- severity of atypia 2- thickness of epithelium involvedCIN1 ,deepest 1/3 of the epithelium from the basal layer is involved .CIN2 affects 2/3 of the thickness of the epitheliumCIN3 no maturation throughout the full thickness.Simpler classification ( Bethsda system)Low grade squamous intraepithelial lesion (LSIL) CIN1High grade squamous intraepithelial lesion ( HSIL) CIN2 ,CIN3

Cytology Exfoliative cervical cytology is a technique developed by Papanicolaou

to collect the cells that had been shed from the skin of the cervix ,spread them on a glass slide & stain them .

Normal squamous epithelium have small nuclei that flattened & pyknotic.

Abnormal ( dysplastic cells ) having*large nuclei *cytological atypia*high N/C ratio this can be put in 1-mild dyskariosis (smear should be repeated) 2-moderate dyskariosis (colposcopy ) 3-sever dyskariosis (colposcopy )Three normal smears are required before a women can be returned to

routine screening after a smear showing mild dyskaryoisisAbnormal changes in glandular cells or borderline nuclear changes in

glandular cells , such women are always referred to colposcopy

Pap Smear Technique

Video

Inspect

• Spread labia• Discharge• Ulcers• Growths

Anatomy

Vaginal Speculum

Warm Speculum

• Warm water

• Not too hot

• Lubricates speculum

Insert Speculum• Spread labia• Keep labia apart• Blades remain closed

until fully inserted

Squamo-Columnar Junction

• Junction of pink cervical skin and red endocervical canal

• Inherently unstable

• Key portion of the cervix to sample

• Most likely site of dysplasia

Ayers Spatula

• Concave end to fit the cervix

• Convex end for vaginal wall and vaginal pool scrapings

Sample Cervix

• Use concave end

• Rotate 360 degrees

• Don’t use too much force (bleeding, pain)

• Don’t use too little force (inadequate sample)

Cytobrush

• Insert ~ 2 cm (until brush is fully inside canal)

• Rotate only 180 degrees (otherwise will cause bleeding)

Make Pap Smear• As thin as possible

• Properly labeled

Spray with Fixative• Within 10-15 seconds

• Allow to fully dry before packaging

• Cytologic Fixative (hairspray works acceptably also)

The sensitivity of cervical cytology is about 50% but, because CIN takes about 10 years, missed lesions are detected on second or 3rd subsequent sample .

The specificity of cervical cytology is about 90%.

ColposcopyBinocular operative microscope with magnification of 5-20 X .

It has been used to examine the cervix in detail to identify CIN & premalignant invasive cancer.

the cervix is first examined for

1- abnormal vessel pattern ( punctate, mosiasim)

2-acetic acid (3-5%)

3- Schiller`s test

Normal epithelium take the dye brown colour.

Schiller`s test is negative

1- columnar epithelium

2- abnormal squamous epithelium

3- immature normal squamous epithelium

Usually colposcopic derived biopsy will be taken from the most abnormal epithelium to confirm the diagnosis .

if the transformation zone extends up to the canal out of the view colposcopy is unsatisfactory

• ENDOCERVICAL CURETTAGE (ECC)

• ECC is sampling the cells inside the cervix (i.e. the endocervical canal), higher than the colposcopist can see. This involves scraping inside the cervical canal with a small sharp instrument and collecting the cells, mucus, and bloody material in preservative for histological analysis. Some colposcopists sample the endocervix with an endocervical brush instead, or may use an endocervical brush to remove the tissue, if an ECC is done.

• Treatment for CIN• Ideally, the natural immune response would be

powerful enough to eradicate any low-grade CIN or tissue abnormalities.

• Observation and repeat Pap smears and biopsies can confirm such spontaneous self-correction. Currently, there is no treatment per se for CIN I, which either resolves or progresses to CIN II, which is treated.

• If CIN does not resolve but instead progresses, or is detected at CIN stage II or III, treatment is needed to prevent the development of invasive disease.

• CIN lesions may be treated on an outpatient or inpatient basis.

Outpatient techniques include

*laser vaporization or excision ** loop electrosurgical excision procedure (LEEP);

Inpatient techniques include

*cone biopsy or cervical (cold knife) conization, which involves removing a cone-shaped portion of the cervical tissue,

** simple hysterectomy. Some strategies, like LEEP or cone biopsy, combine diagnosis and

treatment by removing all abnormal tissue. CIN II-III often can be treated with outpatient techniques; higher-grade CIN likely requires inpatient treatment.

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Fig. 6 Punctation seen with carcinoma-insituand microinvasion.

Fig. 8 Loop diathermy apparatus

If a hysterectomy is performed because of abnormal smears, annual vault smears should be performed.

• There is growing evidence to suggest psychosexual morbidity following investigation. Patients need to be approached with confidence and sensitivity.

CIN III

• The recurrence rate about 9% after 10 years & 4 times invasive carcinoma than normal population.

• Smears should be repeated every year in the 1st 10 years after treatment

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