Dr. Lubna maghur MRCOG Benign and premalignant disease of the cervix.
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Transcript of Dr. Lubna maghur MRCOG Benign and premalignant disease of the cervix.
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Dr. Lubna maghur MRCOG
Benign and premalignant disease of the cervix
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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.
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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
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Epithelium of the cervix
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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.
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Benign diseases of the cervix1) Cervical ectropion.2) Nabothian follicle.3) Genital warts.
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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.
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Nabothian follicleEndocervical glands in the transformational
zone become covered with squamous cells and forms mucus filled cysts.
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Premalignant disease of the cervix
Cervicalcancer
Normal cervix
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HPV infectionDNA virus.Over 100 different types and subtypes of this
virus.Common infection effecting epithelial surface.Genital HPV is divided intoLow 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.
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Factors that increase risk of transmission:
Smoking.Increasing parity.Early age of intercourse.Oral contraceptive pills.Immunity.
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Cervical intraepithelial neoplasiaMetaplasia: 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
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Classification of CIN
CIN1 Normal
CIN 1(condylom
a)
CIN 1(mild
dysplasia)
CIN 2 (moderate dysplasia)
CIN 3(severe dysplasia/CIS)
Invasive cancer
Histology of squamous cervical epithelium1
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Bethesda systemLow grade squamous intraepithelial lesion
(LSIL); HPV infection, CIN I.High grade squamous intraepithelial lesion
(HSIL); CIN II, CIN III.
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Outcome of CINSpontaneous regression.Progression to invasive cancer.Progression from one stage to another
takes years.Detection and treatment of CIN prevents
cancer cervix.
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Screening for CINcervical smearScreening 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.
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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 <6% 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 monthsOr 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
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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.
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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 Lugol’s iodine stains the normal cervix brown.
Colposcopy gives a clinical diagnosis.Punch biopsy from the abnormal area gives a
histopathological diagnosis.
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Management of abnormal colposcopyCIN 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
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Adenocarcinoma insituLess 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.
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Human papilloma virus vaccineThe first vaccine that intends to prevent
cancer.2 forms of vaccine are availableBivalent 16, 18Quadrevalent 6, 11, 16, 18.Now licensed in a number of countries.
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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.