Benign conditions of the cervix

Benign conditions of the cervixBenign conditions of the cervix

Dr. Ahmad S. AlkatheriDr. Ahmad S. AlkatheriMDMD

Important points about cervical cancerImportant points about cervical cancer

• It is rising in young women.It is rising in young women.• There are 450,000 cases of cervical cancer/year.There are 450,000 cases of cervical cancer/year.• There are 300,000 death/year.There are 300,000 death/year.• It is the fourth most common cancer (breast, lung, and It is the fourth most common cancer (breast, lung, and

stomach).stomach).• It is a preventable disease (screening programme-cervical It is a preventable disease (screening programme-cervical

smear).smear).• The surgical treatment is mainly for early stage. The surgical treatment is mainly for early stage.

Cervical Intraepithelial Neoplasia (CIN)Cervical Intraepithelial Neoplasia (CIN)

Definition of CINDefinition of CIN::CIN is a pre-invasive changes of the cervical CIN is a pre-invasive changes of the cervical epithelium where the epithelium thickness is replaced epithelium where the epithelium thickness is replaced by abnormal cells in varying degree without by abnormal cells in varying degree without breaching the cell membrane.breaching the cell membrane. symptomless.symptomless.

Abnormal cytological changes of CIN Abnormal cytological changes of CIN (immature (immature and disorganized cells)and disorganized cells) are are::Increased Nuclear/Cytoplasmic ratio.Increased Nuclear/Cytoplasmic ratio.Prominence of nuclear chromatin.Prominence of nuclear chromatin.Multinucleation.Multinucleation.

Grades of CIN Grades of CIN

CIN is graded according the proportion of epithelium CIN is graded according the proportion of epithelium occupied by the abnormal cells.occupied by the abnormal cells.

• CIN 1 (mild dysplasia):CIN 1 (mild dysplasia):

- One-third or less is occupied by the abnormal cells.- One-third or less is occupied by the abnormal cells.

- P- Progress to (CIS) in 6%.rogress to (CIS) in 6%.

- Regressed or disappeared in 62%, - Regressed or disappeared in 62%,

Grades of CINGrades of CIN

• CIN 2(modrate dysplasia):CIN 2(modrate dysplasia):- Between 1/3-2/3 of the epithelium is occupied by the abnormal - Between 1/3-2/3 of the epithelium is occupied by the abnormal

cells. cells. - Become invasive in 13%.- Become invasive in 13%.• CIN 3 (severe dysplasia):CIN 3 (severe dysplasia):- T- The whole thickness of the squamous epithelium is occupied he whole thickness of the squamous epithelium is occupied

by the abnormal cells.by the abnormal cells.- It is regarded as carcinoma-in-situ (CIS).It is regarded as carcinoma-in-situ (CIS).- It could arise as CIN 3 or progress from CIN 1or CIN 2.- It could arise as CIN 3 or progress from CIN 1or CIN 2.- Become invasive in 29%.- Become invasive in 29%.

Incidence of CINIncidence of CIN

The incidence of CIN: is 4 to 5% of Pap tests.The incidence of CIN: is 4 to 5% of Pap tests. The incidence of CIN vary according to the: (1) The incidence of CIN vary according to the: (1)

population studied, as the peak incidence being population studied, as the peak incidence being between 25 and 29 years of age, (2)socioeconomic between 25 and 29 years of age, (2)socioeconomic factors, and (3) risk-related behaviours. factors, and (3) risk-related behaviours.

The true incidence and prevalence The true incidence and prevalence can only be can only be estimatedestimated, as screening , as screening cytologycytology and and colposcopy colposcopy lack lack complete sensitivity. complete sensitivity.

Risk factors (Epidemiology)Risk factors (Epidemiology)

Demographic risk factorsDemographic risk factors:: • Ethnicity (Latin American countries, U.S. Ethnicity (Latin American countries, U.S.

minorities). minorities). • Low socioeconomic status. Low socioeconomic status. • Older age.Older age.

Medical risk factors:Medical risk factors: • Cervical human papilloma virus infection. Cervical human papilloma virus infection. • Parity. Parity. • ImmunosuppressionImmunosuppression..


Behavioural risk factorsBehavioural risk factors • Infrequent or absent cancer screening Pap tests. Infrequent or absent cancer screening Pap tests. • Early coitus. Early coitus. • Multiple sexual partners. Multiple sexual partners. • Male partner who has had multiple sexual partners. Male partner who has had multiple sexual partners. • Tobacco smoking. Tobacco smoking. • Dietary deficiencies.Dietary deficiencies.


Risk factors for CIN are similar for invasive lesions.Risk factors for CIN are similar for invasive lesions.

The risk is most strongly related to: (1) infection The risk is most strongly related to: (1) infection with a HR HPV type, (2) older age, and (3) most with a HR HPV type, (2) older age, and (3) most importantly, persistence of the HR HPV infection.importantly, persistence of the HR HPV infection.

Older age:Older age: (1) persistent HPV infection (1) persistent HPV infection (2)accumulation of mutations leading to cellular (2)accumulation of mutations leading to cellular malignant transformation (3) less access to cancer malignant transformation (3) less access to cancer prevention programs (decreased needs for prenatal prevention programs (decreased needs for prenatal care and contraception). care and contraception).


Tobacco smokingTobacco smoking : :

- ↑ the risk of cervical cancer among HPV-positive women. - ↑ the risk of cervical cancer among HPV-positive women. - Nicotine and its major metabolite cotinine are found in the Nicotine and its major metabolite cotinine are found in the

cervical mucus of women and in the semen of men who smoke cervical mucus of women and in the semen of men who smoke → suppression of local cervical immunity and promotion of → suppression of local cervical immunity and promotion of HPV-driven cellular transformation and neoplasia.HPV-driven cellular transformation and neoplasia.

Dietary deficienciesDietary deficiencies: :

- Vitamins such as A, C, E, beta carotene, and folic acid may - Vitamins such as A, C, E, beta carotene, and folic acid may alter cellular resistance to HPV infection → persistent viral alter cellular resistance to HPV infection → persistent viral

infection and cervical neoplasiainfection and cervical neoplasia..


Combined Oral Contraception (COCCombined Oral Contraception (COC: steroid hormones may : steroid hormones may affect the HPV genome and increase viral expression of affect the HPV genome and increase viral expression of oncoproteins E6 and E7. oncoproteins E6 and E7.

Parity Parity > 7 & full term> 7 & full term: (1) immunosuppression (cell-mediated : (1) immunosuppression (cell-mediated arm) (2) hormonal influences on cervical epithelium (3) arm) (2) hormonal influences on cervical epithelium (3) trauma related to vaginal deliveries. trauma related to vaginal deliveries.

Identification of CINIdentification of CIN

Cervical Cytology (The Pap test ):Cervical Cytology (The Pap test ):

• Initiation of screeningInitiation of screening: 3 years after onset of vaginal : 3 years after onset of vaginal intercourse; no later than age 21.intercourse; no later than age 21.

• Screening intervalsScreening intervals:: (1) age (1) age < 30 years: annually, (2) age > < 30 years: annually, (2) age >

30 years: 30 years: : : every 2 to 3 years after 3 consecutive negative every 2 to 3 years after 3 consecutive negative tests. (3) patients with HIV or other immunocompromised tests. (3) patients with HIV or other immunocompromised state: 2 tests during the first year, then annually. state: 2 tests during the first year, then annually.

• Discontinuation of screeningDiscontinuation of screening: Age 65 to 70 in women not at : Age 65 to 70 in women not at high risk (history of cervical cancer, DES, HPV, HIV, & high risk (history of cervical cancer, DES, HPV, HIV, & immunocompromised state)immunocompromised state)..

CIN ManagementCIN Management

A. A. Abnormal cervical smearAbnormal cervical smear::• Due to infection: treat then repeat the smear.Due to infection: treat then repeat the smear.• Atrophic smear: give oestrogen then repeat the smear.Atrophic smear: give oestrogen then repeat the smear.• Colposcopy.Colposcopy.

B. B. Colposcopy:Colposcopy:• To view the cervix telescopically at magnification range of To view the cervix telescopically at magnification range of

6 to 40 times.6 to 40 times.• 4% of acetic acid is applied to the cervix which coagulates 4% of acetic acid is applied to the cervix which coagulates

proteins of the epithelial cells and abnormal epithelium proteins of the epithelial cells and abnormal epithelium appears white; biopsies should be taken from that area. appears white; biopsies should be taken from that area. oror


B. B. Colposcopy:Colposcopy:• Apply Apply Lugol's iodine solution (Schiller test)Lugol's iodine solution (Schiller test) to the to the

cervix: cervix: - Iodine 2 gm, potassium iodide 4 gm and distilled Iodine 2 gm, potassium iodide 4 gm and distilled

water 300 mlwater 300 ml- Malignant cells lack glycogen so they fail to take Malignant cells lack glycogen so they fail to take

iodine (stainless).iodine (stainless).- Normal epithelium (rich in glycogen) stains dark-- Normal epithelium (rich in glycogen) stains dark-

brown.brown.- Biopsies taken from the non-staining areas.- Biopsies taken from the non-staining areas.- Squamo-columnar junction should be seen entirely.- Squamo-columnar junction should be seen entirely.


C. C. Cone biopsies: Cone biopsies: indicationsindications::- squamo-columnar junction not seen.- squamo-columnar junction not seen.- negative colposcopic examination with positive repeated - negative colposcopic examination with positive repeated

cervical smear.cervical smear.- microinvasion or invasion is suspected.microinvasion or invasion is suspected. Size: kept to a minimum with normal tissue, tailored & cut Size: kept to a minimum with normal tissue, tailored & cut

with a knife.with a knife. D/C is should be done. D/C is should be done. Haemostasis: is achieved by using Dexon at 3 & 9 0’clock of Haemostasis: is achieved by using Dexon at 3 & 9 0’clock of

the cervix.the cervix. Complications: primary & 2Complications: primary & 2ndnd bleeding & scarring → stenosis bleeding & scarring → stenosis

→ impaired fertility, cryptomenorrhoea, abortion, preterm → impaired fertility, cryptomenorrhoea, abortion, preterm labour & cervical dystocia.labour & cervical dystocia.

CIN treatmentCIN treatment

Knife Knife Cone biopsyCone biopsy..Total hysterectomyTotal hysterectomy::

• Persistent lesion after conization.Persistent lesion after conization.• Lesion extends to the upper vagina (colposcopy).Lesion extends to the upper vagina (colposcopy).• Coexisting indication (menorrhagia or prolapse). Coexisting indication (menorrhagia or prolapse).

Local destruction (ablation): Local destruction (ablation): (for young, unmarried or wanting children):(for young, unmarried or wanting children):• Cryocautery: freezing the tissue.Cryocautery: freezing the tissue.• Electrocautery: burning the transformation zone.Electrocautery: burning the transformation zone.• Large loop excision of the transformation zone: using electrodiathermy.Large loop excision of the transformation zone: using electrodiathermy.• Cold coagulation: destruction of the transformation zone with a probe Cold coagulation: destruction of the transformation zone with a probe

heated to 100 to 120Ċ.heated to 100 to 120Ċ.

Documents

Benign conditions of the cervix