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Dr. Maryam B. MAHMMUD
 The cervix is a tubular structure. It is
  composed of stromal tissue which is lined by
  sequamous epithelium in the vagina
  (ectocervix) and columnar epithelium within
  the cervical canal (endocervix).
 The meeting of the two types of the
  epithelium is called squamocolumnar
  junction SCJ and this is usually at the
  ectocervix.
The position of the SCJ changes throughout the
  reproductive years.
 In children it lies at the ectocervix that is
  just at the external os.
 At puberty and during pregnancy it extends
  outwards as the cervix enlarges and in adult
  life it returns to the ectocervix through the
  process of metaplasia
 isan important area on the cervix which is
  defined as the area where the original SCJ
  was to the current SCJ and it includes areas
  of metaplasia.
 Occasionally, when the mucous columnar
  epithelium is covered by the squamous
  epithelium there is retention of the mucus-
  this is called a nabothian follicle.
 The transformation zone TZ is the site where
  pre-malignancy and
malignancy develop.
 CIN: cervical intraepithelial neoplasia,
 Dysplasia: a histological term describing
  architectural abnormalities within the tissue.
 Dyskaryosis: a cytological term describing
  the nuclear abnormalities- not synonymous
  with dysplasia
 CIN  I: minimal dysplasia.
 CIN II: moderate dysplasia.
 CIN III: sever dysplasia or CIS carcinoma in
  situ ( CIN III, sever dysplasia and CIS are all
  different names for the same thing that is
  early cervical cancer)
 Metaplasia: a physiological process whereby
 columnar epithelium is replaced by squamous
 tissue in response to the acid environment of
 the vagina.



 Squamocolumnar    junction SCJ: where
 squamous and columnar tissue meets, this is
 not fixed, but is affected by metaplasia.
 Paps smear: or cervical smear- cytological
 test described by Papanicolaou.
 CIN is a condition characterized by new
  cellular growth (neoplasia) in a normal tissue
   Once CIN is diagnosed this alarm us that an
  abnormal tissue has been diagnosed in the
  cervix of that lady.
 The most important causative factor is HPV
  which could cause other combined genital
  and anal cancer.
 However,   CIN is much more common than
  the other types of genital neoplasia.
 The tissue changes associated with CIN
  signify presence of premalignant or
  precancerous condition i.e. CIN is essentially
  a precursor to invasive cervical cancer and is
  collectively composed of cells that have
  undergone abnormal individual changes that
  is with abnormal mitotic activity and leads to
  formation of a lesion in the cervix.
 A revised classification has been introduced:
 Low – grade lesion CIN I and HPV associated
  changes with unknown but a likely low
  progressive potential.
 High-grade lesion CIN II and CIN III that is likely
  to behave as cancer precursors.
 Simpler classification is according to Bethesda
  divided to:
 Low grade squamous intraepithelial lesion (LSIL)
  = CIN I.
 High grade squamous intraepithelial lesion (HSIL)
  = CIN II and CIN III
gynaecology.CIN.(dr.mraim)
 Human  papillomavirus HPV infection is the
 essential prerequisite for the development of
 cervical malignancy.
 HPV infection is extremely common with up
 to 80% of sexually active women being HPV
 positive at some point during their lifetime.
 Using the incidence of genital wart as a
 marker, the incidence appears to be raising
 five fold in the female population and eight
 fold in male population with approximately
 15% prevalence of the oncogenic HPV types
 16 and 18.
 However most infections are usually
 transient with 90% of women clearing the
 infection within 2 year and young competent
 women are able to eliminate the infection.
 Smoking  reduces local cervical immunity.
 Multiple sexual partners.
 Having a partner with multiple sexual
  partners or with sexually transmitted
  disease.
 Presence of other sexually transmitted
  disease like HIV and genital herpes.
 Long term use of contraceptive pill.
 Immunosupression or use of anticancer
  drugs.
 Being born to mother used diethylstilbestrol.
 Often it’s a symptomatic and diagnosed
  during routine annual Pap smear,
 non-specific:
 Genital lesion (wart)
 Abnormal lower genital bleeding.
 Abnormal vaginal discharge.
 Vague lower abdominal pain.
 Metaplasia  is a normal finding but this may
  be disrupted by some factors like HPV,
  smoking or immunosupression and etc.. And
  lead to development of disorder squamous
  epithelium called dysplasia which
  characterized by:
 Lack of normal maturation of cell as they
  move from basal layer to superficial layer.
 Large nuclei more available in size and
  shape.
 High mitotic activity means more rapidly
  dividing cell.
gynaecology.CIN.(dr.mraim)
 Severity  of atypia.
 Thickness of the epithelium involved.
 CIN I means 1/3 of the epithelium from the
  basal layer is involved.
 CIN II means 2/3 of the epithelium from the
  basal layer is involved.
 CIN III means no maturation throughout the
  full thickness.
Regression and progression of CIN may occur. Spontaneous
  regression of low grade disease is common and is likely to
  occur through the patient’s own cell mediated immunity.
 High grade lesion is less likely to regress spontaneously
  and requires treatment as there is risk of progression to
  cancer.
1 year                 Up to 5 years    Up to 20 years

                             Persistent
                             infection        CIN* 2/3
  Initial
  HPV
  infection
                                CIN* 1
                                                         CANCER




           CLEARED HPV INFECTION

*cervical intraepithelial neoplasia
    If left untreated 20% of patients with high grade
    abnormalities may develop cancer of cervix.
    Reasons for this remain unclear but may include
    reduced host immunity, oncogenic HPV and
    smoking.
. Even the most sever CIN III take several many
  years to change to cancer, this mean we can
  apply screening test to do early detection of
  premalignant condition and do appropriate
  treatment and follow up.
  Since 1988, the UK has offered population
  based cervical screening for women. Women
  aged 25 and 64 are tested routinely as
  follow:
 25        first test
 25-49    every 3 years
 50-64    every 5 years
 64+      only screen those who have not
        screened since age 50 or has recent
                  abnormal test
 Originallythe “Pap” smear was introduced
 by Papanicolou, where cell removed from the
 cervix using a wooden spatula and placed on
 glass slide and fixed. This was then examined
 by a cytologist for the immature squamous
 cells sheds from the area of the CIN.
 Now  Pap smear is superseded by liquid based
  cytology where a small brush is used to
  sample cells from the transformation zone
  and the brush head placed in the fixative.
  This is then spun down and read by
  cytologist.
 Normal cervical cell has small nuclei that is
  flattened and pyknotic but abnormal cell has
  large nuclei, cytological atypia and high N/C
 An  abnormal smear can show cells in
  different degree of maturity (dyskaryosis)
  and is divided into:
 Mild dyskaryosis and borderline changes (low
  grade)
 Moderate and sever dyskaryosis (high grade)
 Abnormal smears act as a mean of referring
  the patient to the colposcopic clinic for
  further assessment.
 The  sensitivity of cervical smear in picking
  up women with CIN is around 70 percent,
  however, as there is slow progression for
  most women with CIN to cancer, if a lesion is
  missed then this should be picked up on
  subsequent smear. The specifity is 90%.
 If the test is negative the patient is re-placed
  on routine recall.
 Ifthe smear shows low grade changes the
  patient offered repeated test in next 3-6
  months and managed accordingly and if test
  shows high grade lesion the patient is
  urgently referred to colposcopy.
 Patient   in lithotomy position under good
 light,
 start by inspection (spread labia and look for
 any discharge or abnormal growth and ulcer)
 then
 insert warm vaginal speculum (not too hot),
 do not use any lubricant , Vaseline or K-Y
 jelly. The blades of speculum is kept closed
 until is fully inserted.
    Identify the SCJ that is the junction of pink
    cervical skin and red endocervical canal then
    use Ayres spatula is used to sample the
    cervix

 the concave end is used to fit the cervix and
  should be rotated 360 degree
 do not use too much force as it may cause
  bleeding and pain
 or too little force as it may lead to in
  adequate sample).
 The smear should be as thin as possible,
 properly labeled,
 allow fully drying before packaging and
  spraying with fixative within 10-15 seconds.
 Colposcopy  is the outpatient examination of
 the magnified cervix using a light source. It
 is used for both diagnosis and treatment.
 After inserting a speculum the cervix is
 examined using Binocular operative
 microscope under magnification (5-20 time).
 5% acetic acid is applied, as it causes
 nucleoproteins within the cells to coagulate.
 Therefore areas of increased cell turnover,
 for example CIN will appear white.
 Schiller’stest: by application of iodine,
 areas of CIN lack the presence of
 intracellular glycogen and therefore are stain
 yellow as opposed to normal which stain
 brown when iodine is applied.
 Abnormal   vascular pattern like punctuate or
  mosiasim.
 Biopsy is taken from the most abnormal site.
 Colposcopy is deemed unsatisfactory if TZ is
  not viewed adequately.
 AsHPV is the main causative factor of CIN
 and cervical cancer, recently detection of
 HPV DNA in serum has been introduced to
 screening program but this is still used under
 research.
 The aim of treatment is to make the post-
 treatment test negative while minimizing
 harm to the patient.
 Low grade lesion will regress spontaneously
 in over 60% of cases and usually they require
 no treatment but careful follow up by with
 colposcopy and cytology in next six month
 after initial diagnosis.
 If CIN is not resolve on follow up tests or
 progress to high grade then treatment is
 needed to avoid development of active
 disease.
Could be out patient or in patient
Excisional methods like:
 Loop electrosurgical excision (LEEP) and
  large loop excision of TZ (LLETZ)
 Laser TZ excision
 Knife, laser or loop cone biopsy.
 Hysterectomy.
Ablative methods:
 Cryocautery.
 Electrodiathermy
 Coagulation
 Laser.
 Thefavored method is LLETZ which is done
 as outpatient under local anesthesia and
 take 15 minutes and should go 10 mm deep
 down cervical stroma,
 theadvantage is that its effective (95% test
 negative post treatment), cost-effective and
 provide specimen for histology. The
 disadvantage may lead to poor obstetric
 outcome as it may weaken the cervix
 Cone  biopsy or conization is both treatment
  and diagnosis and done under anesthesia.
 If hysterectomy is performed (usually after
  completion of family), annual vault smears
  should be performed.
 Closefollow up after initial treatment by
 regular cervical smear is needed after six
 month then yearly for ten year, as the risk of
 recurrence and cancer is remains.
gynaecology.CIN.(dr.mraim)

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gynaecology.CIN.(dr.mraim)

  • 1. Dr. Maryam B. MAHMMUD
  • 2.  The cervix is a tubular structure. It is composed of stromal tissue which is lined by sequamous epithelium in the vagina (ectocervix) and columnar epithelium within the cervical canal (endocervix).  The meeting of the two types of the epithelium is called squamocolumnar junction SCJ and this is usually at the ectocervix.
  • 3. The position of the SCJ changes throughout the reproductive years.  In children it lies at the ectocervix that is just at the external os.  At puberty and during pregnancy it extends outwards as the cervix enlarges and in adult life it returns to the ectocervix through the process of metaplasia
  • 4.  isan important area on the cervix which is defined as the area where the original SCJ was to the current SCJ and it includes areas of metaplasia.  Occasionally, when the mucous columnar epithelium is covered by the squamous epithelium there is retention of the mucus- this is called a nabothian follicle.  The transformation zone TZ is the site where pre-malignancy and malignancy develop.
  • 5.  CIN: cervical intraepithelial neoplasia,  Dysplasia: a histological term describing architectural abnormalities within the tissue.  Dyskaryosis: a cytological term describing the nuclear abnormalities- not synonymous with dysplasia
  • 6.  CIN I: minimal dysplasia.  CIN II: moderate dysplasia.  CIN III: sever dysplasia or CIS carcinoma in situ ( CIN III, sever dysplasia and CIS are all different names for the same thing that is early cervical cancer)
  • 7.  Metaplasia: a physiological process whereby columnar epithelium is replaced by squamous tissue in response to the acid environment of the vagina.  Squamocolumnar junction SCJ: where squamous and columnar tissue meets, this is not fixed, but is affected by metaplasia.
  • 8.  Paps smear: or cervical smear- cytological test described by Papanicolaou.
  • 9.  CIN is a condition characterized by new cellular growth (neoplasia) in a normal tissue Once CIN is diagnosed this alarm us that an abnormal tissue has been diagnosed in the cervix of that lady.  The most important causative factor is HPV which could cause other combined genital and anal cancer.
  • 10.  However, CIN is much more common than the other types of genital neoplasia.  The tissue changes associated with CIN signify presence of premalignant or precancerous condition i.e. CIN is essentially a precursor to invasive cervical cancer and is collectively composed of cells that have undergone abnormal individual changes that is with abnormal mitotic activity and leads to formation of a lesion in the cervix.
  • 11.  A revised classification has been introduced:  Low – grade lesion CIN I and HPV associated changes with unknown but a likely low progressive potential.  High-grade lesion CIN II and CIN III that is likely to behave as cancer precursors.  Simpler classification is according to Bethesda divided to:  Low grade squamous intraepithelial lesion (LSIL) = CIN I.  High grade squamous intraepithelial lesion (HSIL) = CIN II and CIN III
  • 13.  Human papillomavirus HPV infection is the essential prerequisite for the development of cervical malignancy.  HPV infection is extremely common with up to 80% of sexually active women being HPV positive at some point during their lifetime.
  • 14.  Using the incidence of genital wart as a marker, the incidence appears to be raising five fold in the female population and eight fold in male population with approximately 15% prevalence of the oncogenic HPV types 16 and 18.  However most infections are usually transient with 90% of women clearing the infection within 2 year and young competent women are able to eliminate the infection.
  • 15.  Smoking reduces local cervical immunity.  Multiple sexual partners.  Having a partner with multiple sexual partners or with sexually transmitted disease.  Presence of other sexually transmitted disease like HIV and genital herpes.
  • 16.  Long term use of contraceptive pill.  Immunosupression or use of anticancer drugs.  Being born to mother used diethylstilbestrol.
  • 17.  Often it’s a symptomatic and diagnosed during routine annual Pap smear,  non-specific:  Genital lesion (wart)  Abnormal lower genital bleeding.  Abnormal vaginal discharge.  Vague lower abdominal pain.
  • 18.  Metaplasia is a normal finding but this may be disrupted by some factors like HPV, smoking or immunosupression and etc.. And lead to development of disorder squamous epithelium called dysplasia which characterized by:  Lack of normal maturation of cell as they move from basal layer to superficial layer.  Large nuclei more available in size and shape.  High mitotic activity means more rapidly dividing cell.
  • 20.  Severity of atypia.  Thickness of the epithelium involved.  CIN I means 1/3 of the epithelium from the basal layer is involved.  CIN II means 2/3 of the epithelium from the basal layer is involved.  CIN III means no maturation throughout the full thickness.
  • 21. Regression and progression of CIN may occur. Spontaneous regression of low grade disease is common and is likely to occur through the patient’s own cell mediated immunity.  High grade lesion is less likely to regress spontaneously and requires treatment as there is risk of progression to cancer.
  • 22. 1 year Up to 5 years Up to 20 years Persistent infection CIN* 2/3 Initial HPV infection CIN* 1 CANCER CLEARED HPV INFECTION *cervical intraepithelial neoplasia
  • 23. If left untreated 20% of patients with high grade abnormalities may develop cancer of cervix. Reasons for this remain unclear but may include reduced host immunity, oncogenic HPV and smoking.
  • 24. . Even the most sever CIN III take several many years to change to cancer, this mean we can apply screening test to do early detection of premalignant condition and do appropriate treatment and follow up.
  • 25.  Since 1988, the UK has offered population based cervical screening for women. Women aged 25 and 64 are tested routinely as follow:  25 first test  25-49 every 3 years  50-64 every 5 years  64+ only screen those who have not screened since age 50 or has recent abnormal test
  • 26.  Originallythe “Pap” smear was introduced by Papanicolou, where cell removed from the cervix using a wooden spatula and placed on glass slide and fixed. This was then examined by a cytologist for the immature squamous cells sheds from the area of the CIN.
  • 27.  Now Pap smear is superseded by liquid based cytology where a small brush is used to sample cells from the transformation zone and the brush head placed in the fixative. This is then spun down and read by cytologist.  Normal cervical cell has small nuclei that is flattened and pyknotic but abnormal cell has large nuclei, cytological atypia and high N/C
  • 28.  An abnormal smear can show cells in different degree of maturity (dyskaryosis) and is divided into:  Mild dyskaryosis and borderline changes (low grade)  Moderate and sever dyskaryosis (high grade)  Abnormal smears act as a mean of referring the patient to the colposcopic clinic for further assessment.
  • 29.  The sensitivity of cervical smear in picking up women with CIN is around 70 percent, however, as there is slow progression for most women with CIN to cancer, if a lesion is missed then this should be picked up on subsequent smear. The specifity is 90%.  If the test is negative the patient is re-placed on routine recall.
  • 30.  Ifthe smear shows low grade changes the patient offered repeated test in next 3-6 months and managed accordingly and if test shows high grade lesion the patient is urgently referred to colposcopy.
  • 31.  Patient in lithotomy position under good light,  start by inspection (spread labia and look for any discharge or abnormal growth and ulcer) then  insert warm vaginal speculum (not too hot), do not use any lubricant , Vaseline or K-Y jelly. The blades of speculum is kept closed until is fully inserted.
  • 32. Identify the SCJ that is the junction of pink cervical skin and red endocervical canal then use Ayres spatula is used to sample the cervix 
  • 33.  the concave end is used to fit the cervix and should be rotated 360 degree  do not use too much force as it may cause bleeding and pain  or too little force as it may lead to in adequate sample).  The smear should be as thin as possible,  properly labeled,  allow fully drying before packaging and spraying with fixative within 10-15 seconds.
  • 34.  Colposcopy is the outpatient examination of the magnified cervix using a light source. It is used for both diagnosis and treatment. After inserting a speculum the cervix is examined using Binocular operative microscope under magnification (5-20 time).
  • 35.  5% acetic acid is applied, as it causes nucleoproteins within the cells to coagulate. Therefore areas of increased cell turnover, for example CIN will appear white.
  • 36.  Schiller’stest: by application of iodine, areas of CIN lack the presence of intracellular glycogen and therefore are stain yellow as opposed to normal which stain brown when iodine is applied.
  • 37.  Abnormal vascular pattern like punctuate or mosiasim.  Biopsy is taken from the most abnormal site.  Colposcopy is deemed unsatisfactory if TZ is not viewed adequately.
  • 38.  AsHPV is the main causative factor of CIN and cervical cancer, recently detection of HPV DNA in serum has been introduced to screening program but this is still used under research.
  • 39.  The aim of treatment is to make the post- treatment test negative while minimizing harm to the patient.  Low grade lesion will regress spontaneously in over 60% of cases and usually they require no treatment but careful follow up by with colposcopy and cytology in next six month after initial diagnosis.  If CIN is not resolve on follow up tests or progress to high grade then treatment is needed to avoid development of active disease.
  • 40. Could be out patient or in patient Excisional methods like:  Loop electrosurgical excision (LEEP) and large loop excision of TZ (LLETZ)  Laser TZ excision  Knife, laser or loop cone biopsy.  Hysterectomy.
  • 41. Ablative methods:  Cryocautery.  Electrodiathermy  Coagulation  Laser.
  • 42.  Thefavored method is LLETZ which is done as outpatient under local anesthesia and take 15 minutes and should go 10 mm deep down cervical stroma,
  • 43.  theadvantage is that its effective (95% test negative post treatment), cost-effective and provide specimen for histology. The disadvantage may lead to poor obstetric outcome as it may weaken the cervix
  • 44.  Cone biopsy or conization is both treatment and diagnosis and done under anesthesia.  If hysterectomy is performed (usually after completion of family), annual vault smears should be performed.
  • 45.  Closefollow up after initial treatment by regular cervical smear is needed after six month then yearly for ten year, as the risk of recurrence and cancer is remains.