Dr. Lubna maghur MRCOG

1
Benign and premalignant disease of the cervix

• Dr. Lubna maghur MRCOG

2
Introduction

• Benign diseases of the cervix are common and are
  unusually asymptomatic or cause minor symptoms
  but must be differentiated from malignancy.
• Cervical cancer is the second commonest cancer in
  women. It is proceeded by a premalignant form
  years before its invasion.
• Screening for premalignant disease of the cervix
  markedly reduces the deaths from cervical cancer.

3
objective

• To understand the normal cervical epithelium
• To be able to define metaplasia and dysplasia.
• To understand the concept of cervical screening.
• To outline the principles of colposcopy.
• To outline the management of CIN

4
Epithelium of the cervix
5

• Transformational zone
• The area of cervix between the old and new
  squamo-columnar junction. It is the area of risk
  of developing premalignant and malignant disease
  of the cervix.

6
Benign diseases of the cervix

1. Cervical ectropion.
2. Nabothian follicle.
3. Genital warts.

7
Cervical ectropion (erosion)

• Physiological presence of columnar epithelium on
  the ectocervix.
• Increases in pregnancy and OCP.
• May lead to vaginal discharge and PCB.
• Management includes reassurance, exclude other
  cause, and if distressing coagulation.

8
Nabothian follicle

• Endocervical glands in the transformational zone
  become covered with squamous cells and forms
  mucus filled cysts.

9
Premalignant disease of the cervix
Cervical cancer
Normal cervix
10
HPV infection

• DNA virus.
• Over 100 different types and subtypes of this
  virus.
• Common infection effecting epithelial surface.
• Genital HPV is divided into
• Low risk type (HPV 6,11) cause genital warts.
• High risk types (HPV 16, 18, 31, 33, 45, 56).
• HPV is a common infection while cervical cancer
  is a rare disease.

11

• Factors that increase risk of transmission
• Smoking.
• Increasing parity.
• Early age of intercourse.
• Oral contraceptive pills.
• Immunity.

12
Cervical intraepithelial neoplasia

• Metaplasia change of epithelium from one cell
  lining (columnar) to another (squamous).
• Dysplasia abnormal epithelial cells that fail to
  maturate. (hyperchromasia, larger, variable size,
  mitosis).
• it may be mild, moderate or severe

13
Classification of CIN
CIN1 Normal CIN 1 (condyloma) CIN 1 (mild dysplasia) CIN 2 (moderate dysplasia) CIN 3 (severe dysplasia/CIS) CIN 3 (severe dysplasia/CIS) Invasive cancer
Histology of squamous cervical epithelium1
14
Bethesda system

• Low grade squamous intraepithelial lesion (LSIL)
  HPV infection, CIN I.
• High grade squamous intraepithelial lesion
  (HSIL) CIN II, CIN III.

15

• Outcome of CIN
• Spontaneous regression.
• Progression to invasive cancer.
• Progression from one stage to another takes
  years.
• Detection and treatment of CIN prevents cancer
  cervix.

16
Screening for CINcervical smear

• Screening for dyskariosis by obtaining cervical
  cytology.
• Cervical screening should be carried out every
  3-5 years in all sexually active women from 20-60
  years of age.
• There is a 10-15 chance of false positive or
  false negative results.

17
Management of cytology results
Smear Risk of having HSIL Management If next smear is negative
Normal 0.1 Repeat in 3-5 years Routine
Inflammatory lt6 Repeat in 3-5 years Routine
Borderline 20-30 Repeat 6 months Repeat 1 year then 2 then routine. Colposcopy if 3 borderline.
Mild dyskaryosis 30-50 Repeat in 3 months Or refer for colposcopy Repeat 1 year then 2 then routine. Colposcopy if 3 borderline.
moderate dyskaryosis 50-70 Colposcopy Repeat after treatment
Severe dyskaryosis 80-90 Colposcopy Repeat after treatment
Invasion suspected 50 invasion Urgent colposcopy
18
Colposcopy

• Is the inspection of the cervix with a low
  powered microscope.
• Magnifies the cervix 4-20 times.
• The patient is put in lithotomy position.
• Passing a bivalve speculum gently into the vagina.

19

• Inspection of the cervix and its vasculature.
• Green filter may help studying vasculature.
• Abnormal vascular structure includes punctuation
  and mosaicism.
• Acetic acid test application of 3 acetic acid
  stained the abnormal area. The degree of staining
  correlates with severity of the lesion.
• Schiller test application of Lugols iodine
  stains the normal cervix brown.
• Colposcopy gives a clinical diagnosis.
• Punch biopsy from the abnormal area gives a
  histopathological diagnosis.

20
Management of abnormal colposcopy

• CIN II,CIN III. ?CIN I.
• Techniques for treatment
• Excisional LLETZ, laser cone, knife cone,
  hysterectomy.
• Ablative radical electrodiathermy, cold
  coagulation, cryocautery, laser.
• 90-95 cure rate

21
Adenocarcinoma insitu

• Less common than squamous intraepithelial
  neoplsia.
• Has same risk factors.
• Can not be reliably screened by colposcopy.
• Does not have particular colposcopic features.
• Divided into high grade and low grade.
• Characterized by skip lesions.
• Treatment by large cone biopsy.

22
Human papilloma virus vaccine

• The first vaccine that intends to prevent cancer.
• 2 forms of vaccine are available
• Bivalent 16, 18
• Quadrevalent 6, 11, 16, 18.
• Now licensed in a number of countries.

23
Summary

• Benign diseases of cervix are harmless but
  malignancy should be excluded.
• Cervical intraepithelial neoplasia proceedes
  cancer cervix by years.
• Screening for CIN reduces mortality from cancer
  cervix.
• Those with positive screening test should be
  referred to colposcopy for diagnosis and
  treatment.