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a pictorial guide to a confusing topic presented as as part of obs & gynecology seminar series of 8th semester on 16th march,2011 at IMCH hall
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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