Beruflich Dokumente
Kultur Dokumente
DISEASE OF THE
CERVIX
CERVICAL INTRAEPITHELIAL
NEOPLASIA
cellular immaturity
cellular disorganization
nuclear abnormalities
increased mitotic activity
CERVICAL ANATOMY
columnar epithelium
lines the endocervical
canal
squamous epithelium
covers the exocervix
SquamoColumnar
Junction (SCJ) point
where they meet
SCJ
Transformation
zone metaplasia
occurs in the
original SCJ towards
the external os and
over the columnar
villi
CIN is believed to
originate as a single
focus in the
transformation zone
at the advancing SCJ
Anterior lip - 2x as
likely to develop CIN
progress horizontally
to involve the whole
transformation zone
cervical clefts most
severe CIN lesions
extent of involvement
of cervical glands
significant therapeutic
implications because
the entire gland must
be destroyed to ensure
elimination of the CIN
Normal Transformation
Zone
4 layers:
1. basal layer single
row of immature cells
with large nuclei and a
small amount of
cytoplasm
2. parabasal layer 2-4
rows of immature cells
that have normal mitotic
figures and provide the
replacement cells for the
overlying epithelium
Risk Factors
EPIDEMIOLOGIC CHARACTERISTICS
Early intercourse
Multiple sex partners
Early marriage
Early childbearing
Prostitution
Male factor
Socioeconomic status and race
STDs
Immune status (e.g. HIV)
Risk Factors
OTHER POTENTIAL FACTORS
OCP Use
Smoking
Vitamin C deficiency
Prior Radiation
In utero DES exposure
Lupus Erythematosus
Vitamin A, E and folate deficiency
Risk Factors
VIRAL RELATIONS
Papilloma virus (HPV)
Non-oncogenic (6,11,42,43,44)
Oncogenic
(16,18,31,33,35,39,45,51,52,56,58,59,6
8)
Herpes Virus
CMV
CIN 1 mitoses
immature
cells
present only on
UPPER
3rd
of
epithelium
and
are
the
the
HPV
koilocytosis cytologic
changes of HPV
DIAGNOSIS
PAPANICOLAOU TEST
> reduced incidence of
cervical CA by 79%
> decreased mortality by
70%
> sensitivity in detecting
CIN 2&3 47-62%
> specificity 60-95%
ACS
CTF
IAC
NCI
Start
18,start Start of
of sex
sex
activity activity
18-35
annual
Annual
until 2
negq
3 yrs
annual Annual
if active of
active
After 2
negs
q 3 yrs
36-60
annual
q 3 yr,
After 2 annual
more of neg q
hi risk
5 yr
q 1 to 3
yr
Over 60 annual
q 3 yr,
2 neg annual
more of can
hi risk
stop
2 neg
can
stop
Exceptions:
EXCEPTIONS
specimen adequacy
satisfactory
unsatisfactory >> repeat 2-4 months
satisfactory but limited >> repeat 6-12
months
general categorizations:
Negative for intraepithelial lesions or
malignancy
- trichomonas, candida, bacterial
vaginosis, HSV
- reactive cellular changes,
atrophy
Epithelial cell abnormality
Screening Guidelines
COLPOSCOPY FINDINGS
Acetowhite epithelium
application of acetic acid
coagulates the proteins of the
nucleus and cytoplasm and makes
the proteins opaque and white
- dysplastic cells are mostly
affected
Punctation dilated
capillaries terminating on
the surface appear from the
ends as a collection of dots
Mosaic terminal capillaries
surrounding roughly circular
or polygonal shaped blocks
of acetowhite epithelium
crowded together
- assoc with higher grade
lesions and CIN 2
Atypical vascular patternlooped, branching and
reticular vessels
Ablative therapy
no evidence of microinvasive or
invasive cancer on cytology,
colposcopy, endocervical curettage or
biopsy
lesion located in the ectocervix and
can be seen entirely
no involvement of the endocervix
with high-grade dysplasia as
determined by colposcopy and
endocervical curettage
Cryotherapy
Laser ablation
CONIZATION
in women with HSIL by PAP test with:
1. limits of the lesion cant be visualized by
colposcopy
2. SCJ is not seen by colposcopy
3. ECC histologic findings are positive for CIN 2
or 3
4. substantial lack of correlation between
cytology, biopsy, and colposcopy
results
5. microinvasion is suspected based on biopsy,
colposcopy or biopsy result
6. Colposcopist unable to rule out invasive cancer
Complications of Excision
Cervical Stenosis
Infertility
Premature Birth (Cervical
Incompetence)
HYSTERECTOMY
microinvasion
CIN 3 at limits of conization
specimen in selected patients
poor compliance with follow up
other gynecologic problems
requiring hysterectomy like fibroids,
prolapse, endometriosis and PID
Cervical Cancer
Clinical Presentation
Histologic Types
Histologic Types
Adenocarcinomas 10-15%
Endocervical/typical
Endometrioid
Clear cell
Adenoid cystic
Adenoma malignum
* prognosis-stage, size, grade, depth of
invasion
Histologic Types
Mixed
Adenosquamous
Glassy Cell
IA2
IB1
IB2
Stage II
IIA
IIB
Stage III
IIIA
IIIB
Stage IV
IVA
IVB
IA1
IA2
IB
IB1
IB2
Stage II
IIA
IIA1
IIA2
IIB
Stage III
IIIA
IIIB
Stage IV
IVA
IVB
Management Guidelines
Management Guidelines
Primary Prevention
Monogamy
Delay in onset of sexual activity
Barrier contraception
Prompt and adequate tx of STDs
Hematogenous Spread
Lung
Liver
Bone
Follow Up
CERVICAL CA IN
PREGNANCY
Diagnosis
Radiationinduces abortion
CLINICAL PRACTICE
GUIDELINES
FOR THE
OBSTETRICIANGYNECOLOGIST
2010
LEVEL
DEFINITION
II-1
II-2
II-3
III
GRADE
DEFINITION
GPP
CERVICAL CANCER
Risk Factors/
Co-factors
Statement 2:
(Level II-2,
Grade A)
High parity
Parity of 7 or more
increases the risk for cervical
cancer.
Muoz N, Franceschi S, Bosetti C, et al. Role of parity and
human papillomavirus in cervical cancer: the IARC
multicentric case-control study. Lancet 2002 Mar
30;359(9312):1093-101.
International Collaboration of Epidemiological Studies of
Cervical Cancer. Cervical carcinoma and reproductive
factors: Collaborative reanalysis of individual data on
16,563 women with cervical carcinoma and 33,542 women
without cervical carcinoma from 25 epidemiological
studies. Int J. Cancer 2006;119:1108-1124
Statement 7:
(Level II-2,
Grade A)
Early coitus
Statement 8:
(Level II-2,
Lifetime partners (6 vs 1)
Grade B)
(RR 2.27; 95% CI 1.98 2.61)
Six or more
lifetime
sexual
partners
6 partners; C vs NC
(OR 0.42; 95% CI 0.23 0.79)
Statement 11:
(Level II-2,
Grade A)
No prior
screening
Low socioeconomic
status
Primary Prevention
Statement 1:
(Level II-2,
Grade A)
Abstinence
from sexual
activity
Statement 2:
(Level II-2,
Grade A)
Mutual
Monogamy
Statement 4:
(Level I,
Grade A)
HPV
Vaccination
Vaccination against
HPV 16/18 is efficacious
against persistent HPV
infection and CIN 2+.
Munoz N, Manalastas R Jr., Pitisuttithum. Safety, immunogenicity,
and efficacy of quadrivalent human papillomavirus (types 6, 11,
16, 18) recombinant vaccine in women aged 24-45 years: a
randomised, double-blind trial. Lancet 2009 Jun 6;373(9679):194957.
Paavonen J, Naud P, Salmeron J, et al. Efficacy of human
papillomavirus (HPV) 16/18 AS04-adjuvanted vaccine against
cervical infection and precancer caused by oncogenic HPV types
(PATRICIA): final analysis of a double-blind, randomised study in
young women. Lancet 2009 Jul 25;374(9686):301-14
Secondary
Prevention
Statement 3:
(Level I,
Grade A)
Visual
Inspection
with Acetic
Acid
Statement 4:
(Level II-2,
Grade A)
When to
start
screening
Statement 6:
(Level I to II2, Grade A)
Screening
interval
Statement 12:
(Level III,
Grade C)
Annual
gynaecologic
examination
Annual gynecologic
examination is recommended
regardless of the frequency of
screening.
American College of Obstetricians and
Gynecologists. ACOG Practice Bulletin number
109, December 2009: cervical cytology
screening. Obstet Gynecol 2009;114:1409-1420.
Statement 14:
(Level III,
Grade C)
Pap test in
patients with
HIV infection