Immature metaplasia

layers

Basal

Para basal

Intermediate

Superficial

CIN /Pre invasive cervical cancer stage 0

Part or full thickness of stratified squamousepithelium replaced by dysplastic cells

Basement membrane intact

DYSPLASIA-Loss in uniformity & architecturalorientation of cells

Dysplasia

Increased N/C ratio

Hyperchromatism

Peripheral condensation

Mitotic figures

Loss of polarity

CIN

Arises by atypical metaplasia of reserve cells

Exposure to high risk HPV

Aneuploidy characteristic

Variably progresses to invasive cervical cancer

RISK FACTORS

Average age 35-45 years. Precancerous lesions 10-15 years earlier

Early coitus

Multiple sexual partners

Early delivery

Multiparity, poor birth spacing

Poor personal hygeine

Poor socioeconomic status

Coexistence of STD

Immunosuppression

OCP, DES, Smoking, alcohol

HPV

High risk types

16, 18,31, 33

GRADING

PAP CLASS SYSTEM

SCHEME 1 WHO

SCHEME 2RUCHART

SCHEME3BETHESDA

CLASS 1 NEG NEG WNL

CLASS 2 INFL ATYPIAKOILOCYTES

ASCUS

CLASS 3 MILD DYSPLASIA

CIN 1 LSIL

CLASS 4 MODERATE SEVERE

DYSPLASIA(CIS)

CIN 2

CIN 3

HSIL

CLASS 5 INVASIVE CANCER

INVASIVE CANCER

INVASIVE CANCER

MILD DYSPLASIA (CIN 1/LSIL)

Dysplasia in lower third

Pap- N/C ratio less than half

Can occur with trichomonas , HPV infection & are reversible with or without treatment

Persists after 1 year despite treatment, called persistent LSIL

0.5 % progress to frank invasive carcinoma

LSIL on VIA - ‘dull white plaque with faint borders’

MODERATE DYPLASIA CIN 2

up to basal 2/3rd

PAP- nucleus half to two thirds

5% risk of invasive carcinoma

SEVERE DYSPLASIA CIN 3

Entire thickness dysplastic with loss of stratification

Abrupt oblique lined cut off from adjacent normal area

Pap smear- mostly para basal cells with high N/C ratio

10% risk of invasive cancer

HSIL in VIA- ‘Thick plaques with sharp borders’

KOILOCYTE ASCUS

TADPOLE CELLS- invasive ca

SYMPTOMS

Unusual- most detected by screening

Post coital bleeding

Inspection- cervix normal/ cervicitis/ erosions

SCREENING

Pap smear +/- HPV

VISUALISATION OF ABNORMAL AREA WITH CHEMICALS

1. Acetowhite

2. Schillers test

VISUALISATION OF ABNORMAL AREA BY LUMINOMETRIC

1. Speculoscopy

2. spectroscopy

Definitive diagnosis

Unaided or colposcopy guided biopsy

PAP SMEAR- CYTOLOGIC SCREENING

All women above 21 who have been sexually active for more than 3 years

Annually for 3 years followed by once in 3-5 years till 50 years

In mild dysplasia, treat inflammatory pathology & repeat pap

REDUCE FALSE NEGATIVES

Endocervical scrape cytology

HPV testing by hybridization or PCR

LIQUID BASED CYTOLOGY

DNA STUDY

ANEUPLOIDY- - malignant

DIPLOIDY/POLYPLOIDY- benign

LIQUID BASED CYTOLOGY

plastic spatula placed in liquid fixative (buffered methanol) containing hemolytic & mucolytic agents

Suspended cells sucked onto filter membrane

Membrane pressed onto slide to form monolayer

Can also use for HPV testing

Cost effective, better sensitivity & specificity

Visual inspection of acetowhite areas (VIA)

If pap smear unavailable

5% acetic acid (down staging) precipitate abnormal areas with inc nuclear material & protein

High sensitivity, low specificity

Cost effective, treatment may be done in the same sitting

VILI- visual inspection with lugols iodine – schillers test

Glycogen containing normal areas stained mahogany brown

SPECULOSCOPY

Blue white chemiluminescent light

SPECTROSCOPY

Cervical impedance/ fluorescent spectroscopy

Identify tissue morphology & biochemical composition instantaneously

COLPOSCOPY

COLPOSCOPY

Study cervix if pap smear is abnormal

Take biopsy from abnormal areas

Conservative surgery

Follow up

COLPOSCOPY

6-16 times magnification

Reduce false positive

Satisfactory examination - SCJ, columnar, transformation zone

Abnormal areas– acetowhite, mosaics, punctuation, abnormal vessels

mosaic & punctuations

Abnormal vessels

cervicography

Photo sent to colposcopist

Cone biopsy - diagnostic & therapeutic

AgNOR- silver as molecular marker for nuclear organizer regions… more dots seen with advancing dysplasia

others

TREATMENT

MILD DYSPLASIA

Usually due to infection

Treat infection & repeat cytology

Colposcopy advised if

1. Persistent LSIL over 1 year

2. Poor compliance

CIN 2 & 3

Local destructive

Cryo surgery

Electro

coagulation

Laser ablation

Local excision

Conisation with knife,

laser, LLETZ, LEEP, NETZ

Radical excision

Criteria for conservative method

Entire lesion visible

No invasion in biopsy

No Endocervical component

Young women desirous of childbirth

cryosurgery

Crystallization of IC fluid

OPD procedure without analgesia, cheap

Freon, CO2, liquid nitrogen used

Abstain intercourse for 4 weeks

Profuse discharge

Electrocoagulation

Painful: GA

COMPLICN: recurrence, bleeding, sepsis, stenosis

Laser ablation

Steams , explodes cells

Minimal bleeding, infection, scar

OPD procedure Under LA

Expensive

Cause no in drawing– repeat procedure possible

Large loop excision of transformation zone (LLETZ)

Low voltage diathermy

Fast, cheap under LA/GA

Loop electrosurgical excision procedure (LEEP)

SIMILAR PROCEDURE

NEEDLE EXCISION OF TRANSFORMATION ZONE (NETZ)

ALL excisional treatment have risk of cervical stenosis

conization

Remove entire outer margin & endo cervix short of internal os

Can be diagnostic & therapeutic

Smaller cone in young to avoid preterm labour, abortion

Other Compli-- bleeding, sepsis, stenosis

HYSTERECTOMY

Old multiparous

Cant comply with follow up

If other uterine pathology

Micro invasion

Recurrence/ persistence