PREINVASIVE CERVICAL DISEASE

DYSPLASIA
Cervical Intraepithelial Neoplasia (CIN)
BETHESDA SYSTEM
System
Def: Lesion in which part
Intraepithelial dysplastic atypia occurring
ACSUS
LSIL
HSIL
CANCER
of the epithelium is
within the metaplastic epithelium of the
replaced by cells showing transformation zone.
varying degree of atypia.
Mild
Moder8 Severe CIN Cancer OSCJ Original squamocolumnar junction.
dysplasia dysplasi dysplas
NSCJ New squamocolumnar junction
a
ia
TZ Transfomation zone area between OSCJ &
NSCJ.
CIN 1
CIN 2
CIN 3
OVERVIEW
RISK FACTORS
Cervical neoplasia originates within TZ.
Persistent HPV infxn of high risk types.
Low risk HPV (types 6 & 11) are associated with low-grade
Young age at first coitus
cervical lesions (condyloma acuminata and CIN1)
Multiple sexual partners. Sex partner with multiple sex
High risk HPV (type 16, 18, 31, 33 or 35) associated with
partners.
high-grade cervical lesion (CIN2,3 and Cancer).
Young age at first pregnancy.
HPV type 16 is the type universally detected with the
Multiparity.
greatest frequency in high grade lesion & cervical ca. 50%
Low socioeco status
SCC, 30% adenoca, & >80% preinvasive lesions.
AT least 35% pt with CIN3 will dev invasive ca within 10yrs , Smoking & OCP
Genital warts
whereas lower grades may spontaneously regress.
Exogenous / endogenous immunosuppresion
SCREENING
PAP SMEAR
COLPOSCOPY
Before Colposcopy
Both the end
Stereoscopic binocular microscope of low
Complete hx and general exam.
cervical canal and
magnification, usually 10x to 40x.
A clinical and speculum examination of the cervix,
the ectocervix
vagina
should be sampled
Indications for colposcopy:
and vulva.
when taking the Pap - Abnormal cervical smear
A 3% to 5%acetic acid solution is liberally applied to
smear
- Abnormal findings on adjunctive
the
The false negative screening tests (HPV testing and
cervix using soaked swap
rate for Pap smear
cervicography)
- The abnormal findings are acetowhite epithelium &
for high grade
-If the cervix is clinically abnormal or
abnormal vascular patterns (mosaicism and
lesions is 20%
suspicious on naked eye exam.
punctuation)
New automated
- Unexplained IMB or PCB
Lugols iodine application to the cervix is called
liquid based slide
- Persistent vaginal discharge
shillers test

preparation systems
to decrease the false
negative rate

- Personal history of in utero DES exposure,

vulvar or vaginal neoplasia.

-Normal ectocervix and vaginal squamous epithelium

contains glycogen and stains mahogany-brown
Normal columnar and squamous metaplasia and
neoplastic epithelium do not contain glycogen, and
appear mustard yellow
Satisfactory Colposcopic Examination: If the new SCJ
& entire TZ are seen.

EVALUATION FOR ABNORMAL PAP SMEAR

Any patient with a grossly abnormal cervix should have a punch biopsy performed regardless of the results of Pap
smear
Patients with ASCUS found in their smear may have a repeat smear in 6 months or HPV testing
About 6-10% of patients with an ASCUS smear will have high-grade CIN on colposcopy, 90% of these can be detected by
HPV testing for high-risk types
The colposcopic hallmark of CIN is an area of sharply delineated acetowhite epitheilum, or/and abnormal vascular
pattern: punctuation and mosaicism
Micro invasive carcinoma: extremely irregular puncate and mosaic patterns are found.
If colposcopic examination is satisfactory, punch biopsy from the suspicious area with end cervical curettage specimen.
Diagnostic cone biopsy of the cervix is indicated if:
- colposcopic examination is unsatisfactory
- Endocervical curettings show a high-grade lesion
- Pap smear shows a high-grade lesion that is not confirmed on punch biopsy
- Pap smear indicates Aden carcinoma in situ
- Microinvasion is present on punch biopsy
TREATMENT OF ABNORMAL INTRAEPITHELIAL NEOPLASIA CIN
Low Grade Lesions (CIN1) - Repeat smear in 6 month interval until normal then back to the normal screening program.
High grade lesions (CIN 2,3):
1. Loop Excision of The Transformation Zone (LLETZ), relatively cheap, it can be performed on an outpatient basis under
local anesthesia, and tissue is obtained for histologic evaluation.
2. LASER, destruction of the TZ by CO2 laser, ablation can be performed as an outpatient procedure with local anaesthesia,
expensive.
3. Cryosurgery, relatively painless outpatient procedure without anaesthesia, cheap, high failure rate for large lesions,
copious vaginal discharge for several weeks.
4. Electrocoagulation, Requires general anesthesia, cervical stenosis may occur, success rates up to 97%.
5. Cervical conization: (cold knife or laser)
-mainly diagnostic but it may be used for treatment, cure rates are as high as with hysterectomy for high grade lesions.
-Major complications: Bleeding, infection, cervical stenosis and incompetence.
Simple hysterectomy is rarely necessary, it may be applicable when sterilization is desired in a patient with CIN III or
when there is concomitant uterine or adnexal disease.

CERVICAL CANCER
INTRODUCTION
SYMPTOMS
FINDINGS
INVESTIGATIONS
Worldwide, cervical ca is the most
Abnormal vaginal bleeding is Usually normal general
CBC, LFT, KFT
common cause of cancer death in
the most common
exam.
CXR, Pelviwomen.
presenting sx.
In advanced disease,
abdominal CT
Mean age for cervical ca is 51.4yrs,
Postcoital bleeding in
enlarged inguinal or
Bx of lesion
with the number of pt evenly divided
sexually active women, IMB, supraclavicular LN, edema of Cystoscopy &
between age groups 30-39 and 60-69.
PMB.
the legs, ascites, pleural
proctoscopy for
Most common type is SCC (80%),
Asymptomatic until quite
effusion, hepatomegaly.
clinical staging.
adenocarcinoma & adenoquamous
advanced in women who are Pap smear may be normal in
PET scan to
account for 20-25%, others are rare.
not sexually active.
up to 50% of cases (false
delineate the
Persistent vaginal discharge, negative)
extent of disease
PATTERN OF SPREAD
pelvic pain, leg swelling &
Pelvic exam in early disease
at the primary site
1. Direct invasion into cervical stroma,
urinary frequency are
may be normal, esp if lesion
and in LN.
corpus, vagina and parametrium.
usually seen in advanced
is endocervical.
2. Lympathic permeation & mets.
disease.
Visible disease may be
3. Hematogenous dissemination.
Vesico-vaginal &
ulcerative, exophytc or
rectovaginal sx.
necrotic.
TREATMENT
Stage IA IA1 Total abdominal / vaginal hysterectomy.
- Cone bx alone may suffice if pt wants to preserve fertility, as long as cone margins free from disease &
endocervical curetting -ve.
IA2 Modified radical hysterectomy and pelvic LN dissection.
- If wants childbearing, large cone biopsy or radical trachelectomy & pelvic LN dissection are offered.
Stage IB a) Radical Hysterectomy & Bilateral pelvic lymphadenectomy Removes uterus, adjacent portions of vagina,
cardinal ligaments, uterosacral ligaments & bladder pillars. Spares ovaries, can surgically stage, prevent chronic
radiation. Most common complication: Bladder dysfunction, 1-2% permanent. Most serious complication: ureteric
fistula or stricture 1-2%. Lower limb lymphoedema 15-20%.
b) Radiation Therapy Begins by external radiation to shrink central tumor & cavitary lesion. Also done postop
for pt with LN mets, or inadequate surgical margins. Addition of chemo to radiotherapy improves survival.
Stage II
IIA with minimal involvement of vaginal fornix - Radical surgery or chemo radiation.
IIA IVA Pelvic chemo is the rx of choice.
Stage
Palliative radio or chemotherapy.
IVB
Recurre
Chemotherapy Limited effectiveness. Most active drug is cisplastin.
nt or
Pelvic exenteration Removal of pelvic viscera (uterus, tubes, ovaries, bladder, rectum) - For pt who have

Mets

central recurrence following irradiation.

Radiotherapy if initial disease treated by surgery only.
PROGNOSIS
Directly related to clinical staging. With higher stage, nodal mets escalate, & 5yr survival diminishes.
COMPLICATIONS OF RADIOTHERAPY

ACUTE
Acute cystitis Hematuria, urgency,
frequency.
Proctosigmoiditis Tenesmus, diarrhea,
passage of blood & mucus in stool.
Enteritis Nausea, vomit, diarrhea,
colicky ab pain.
BM depression.

CHRONIC
Radiation enteropathy: Proctosigmoiditis (pelvic pain, tenesmus, diarrhea,
rectal bleeding), ulceration (rectal bleeding & tenesmus), rectovaginal
fistula (stool thru vagina), Rectum or sigmoid stenosis (progressive large
bowel obstr), Small bowel injury (cramping ab pain, vomit, diarrhea)
Vaginal vault necrosis - Severe pain in vaginal vault & profuse discharge.
Urologic injury: Hemorrhagic cystitis, Vesicovaginal & Ureterovaginal
fistula (constant urine leakage), Ureteric stenosis (hydronephrosis)