cervical intaepithelial neoplasia
DESCRIPTION
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 hallTRANSCRIPT
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Immature metaplasia
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layers
Basal
Para basal
Intermediate
Superficial
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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
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Dysplasia
Increased N/C ratio
Hyperchromatism
Peripheral condensation
Mitotic figures
Loss of polarity
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CIN
Arises by atypical metaplasia of reserve cells
Exposure to high risk HPV
Aneuploidy characteristic
Variably progresses to invasive cervical cancer
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RISK FACTORS
Average age 35-45 years. Precancerous lesions 10-15 years earlier
Early coitus
Multiple sexual partners
Early delivery
Multiparity, poor birth spacing
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Poor personal hygeine
Poor socioeconomic status
Coexistence of STD
Immunosuppression
OCP, DES, Smoking, alcohol
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HPV
High risk types
16, 18,31, 33
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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
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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
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LSIL on VIA - ‘dull white plaque with faint borders’
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MODERATE DYPLASIA CIN 2
up to basal 2/3rd
PAP- nucleus half to two thirds
5% risk of invasive carcinoma
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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
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HSIL in VIA- ‘Thick plaques with sharp borders’
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KOILOCYTE ASCUS
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TADPOLE CELLS- invasive ca
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SYMPTOMS
Unusual- most detected by screening
Post coital bleeding
Inspection- cervix normal/ cervicitis/ erosions
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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
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Definitive diagnosis
Unaided or colposcopy guided biopsy
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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
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REDUCE FALSE NEGATIVES
Endocervical scrape cytology
HPV testing by hybridization or PCR
LIQUID BASED CYTOLOGY
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DNA STUDY
ANEUPLOIDY- - malignant
DIPLOIDY/POLYPLOIDY- benign
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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
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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
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VILI- visual inspection with lugols iodine – schillers test
Glycogen containing normal areas stained mahogany brown
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SPECULOSCOPY
Blue white chemiluminescent light
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SPECTROSCOPY
Cervical impedance/ fluorescent spectroscopy
Identify tissue morphology & biochemical composition instantaneously
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COLPOSCOPY
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COLPOSCOPY
Study cervix if pap smear is abnormal
Take biopsy from abnormal areas
Conservative surgery
Follow up
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COLPOSCOPY
6-16 times magnification
Reduce false positive
Satisfactory examination - SCJ, columnar, transformation zone
Abnormal areas– acetowhite, mosaics, punctuation, abnormal vessels
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mosaic & punctuations
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Abnormal vessels
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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
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TREATMENT
MILD DYSPLASIA
Usually due to infection
Treat infection & repeat cytology
Colposcopy advised if
1. Persistent LSIL over 1 year
2. Poor compliance
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CIN 2 & 3
Local destructive
Cryo surgery
Electro
coagulation
Laser ablation
Local excision
Conisation with knife,
laser, LLETZ, LEEP, NETZ
Radical excision
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Criteria for conservative method
Entire lesion visible
No invasion in biopsy
No Endocervical component
Young women desirous of childbirth
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cryosurgery
Crystallization of IC fluid
OPD procedure without analgesia, cheap
Freon, CO2, liquid nitrogen used
Abstain intercourse for 4 weeks
Profuse discharge
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Electrocoagulation
Painful: GA
COMPLICN: recurrence, bleeding, sepsis, stenosis
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Laser ablation
Steams , explodes cells
Minimal bleeding, infection, scar
OPD procedure Under LA
Expensive
Cause no in drawing– repeat procedure possible
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Large loop excision of transformation zone (LLETZ)
Low voltage diathermy
Fast, cheap under LA/GA
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Loop electrosurgical excision procedure (LEEP)
SIMILAR PROCEDURE
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NEEDLE EXCISION OF TRANSFORMATION ZONE (NETZ)
ALL excisional treatment have risk of cervical stenosis
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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
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HYSTERECTOMY
Old multiparous
Cant comply with follow up
If other uterine pathology
Micro invasion
Recurrence/ persistence
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