1. Dr. Sourav Chowdhury MBBS DGO &
Dr. Debraj Mondal MBBS MS
Senior Resident
IQ City Medical College, Durgapur
.
2. Cervical Histology:
Squamocolumnar Junction (SCJ):
The cervix is composed of columnar epithelium,
which lines the endocervical canal, and squamous
epithelium, which covers the exocervix. The point at
which they meet is called the squamocolumnar
junction.
3. Transformation Zone:
Transformation zone also called ectropion, an
area between original SC junction and new SC
junction due to regenerative metaplastic response.
6. Formation of TZ:
SCJ is a dynamic point and it works in response to
puberty, pregnancy, Menopause and hormones.
Neonates SCJ located at exocervix.
In menarche, SCJ moves inwards and towards external
os resulting Transformation Zone.
As metaplastic epi. Matures in TZ it resembles to
original squamous epithelium.
8. Columnar Epithelium:
Columnar epithelium has a single layer of columnar cells
with mucus at the top and a round nucleus at the base.
The glandular epithelium is composed of numerous ridges,
clefts, and infoldings and when covered by squamous,
metaplasia, leads to the appearance of gland openings.
Technically, the endocervix is not a gland, but the term
gland opening often is used.
9. Metaplastic Epithelium
Metaplasia originates at SCJ esp. at subcolumnar cells
Begins at tip of columnar villi exposed to acidic pH
Metaplastic cells replace columnar epithelium
Deeper clefts, however, may not be completely
replaced, leaving them trapped below.
Gland openings and nabothian cysts mark the original
SCJ
10. Satisfactory Colpscopy:
1. Adequate visualisation
2. Entire squamocolumnar junction to be visualized
3. Proximal and distal end of lesion
Jennifer E. Frank, MD (2008) The colposcopic examination, Available
12. Cervical Intraepithelial Neoplasia:
CIN I – Abnormal cells confined to lower third of sq. epi.
CIN II – Extending to middle third of sq. epi.
CIN III- Into upper third as severe dysplasia
CIS – Full thickness involvement
In contrast being only one cell thick, columnar cells
does not demonstrate similar analogous neoplastic
disease spectrum, histologic abnormalities limited to
AIS or Adenocarcinoma.
13. Why screen for cervical cancer?
1) It’s a highly prevalent condition in Indian population,
2) It has a long latent phase,
3) Its natural history of disease is well understood,
4) There are suitable test for screening,
5) These tests are easily available, cost-effective & well acceptable,
6) Treatment of screen positive patients will stop the disese
progression
17. ACOG or ACS-
AGE Recommendations
Before 21 yr No screening (Irrespective of sexual
activity).
21 to 29 yrs Screen every 2 years with
conventional PAP smear or LBC
30 to 65 yr If 3 consecutive tests in last 10 yr are
negative then
Screen every 3 yrly with PAP/ LBC
Or
Every 5 yrly with CO-TESTING
(HPV-DNA + Cytology)
*ACOG has no upper age limit
18. ACOG & ACS
After 65 yr* If 3 consecutive tests in last 10 yr are negative
AND
There is no h/o CIN2+ in last 20 yr
Then
DISCONTINUE screening (even if the women report having
a new partner)
Post-
hysterectomised
If Cervix is removed
AND
Hysterectomy was done for benign indication
AND
There is no h/o CIN2+ in last 20 yr
Then
DISCONTINUE screening
*ACOG has no upper age limit
19. ACOG & ACS-
HPV vaccinated women:
Women who have been vaccinated should continue to
be screened.
Screening practices should not change on the basis
of HPV vaccination status.
*ACOG has no upper age limit
20. More frequent screening
1. History of CIN 2 or greater (screen annually for 20 yr)
2. HIV (Twice in 1st yr then annually after) or immune-
suppressed
3. Diethylstilbesterol(DES) daughters.
21. WHO-
AGE Recommendations
Before 30 yr New programmes should start
screening women aged 30 years or more
Before 25 yr Existing programmes should not
include women < 25 years of age
25−49 years Screen every 3 yrly with Cytology
>50 years Screen every 5 yrly with Cytology
>65 years Screening NOT necessary
provided the last two smears were
negative.
22. Methods of screening-
Down staging screening Recommended methods
Under The National Cancer
Control Program, Govt. of India
VIA based screening & with
Lugol’s Iodine (VILI)
Use of Magnascope
Single visit approach
Cryosurgery for VIA +ve
women
Self collected samples for
cytology and (HPV)-DNA
testing
1. Cytology
Conventional PAP smear
Liquid Based Cytology
2. HPV DNA
3. Visual approach
VILI, VIA.
24. Sample collection
CONVENTIONAL LBC
Ayre’s spatula-
predominantly samples the
ectocervix,
The endocervical brush-
samples the endocervical
canal and is used in
combination with a spatula
Samples are collected in
Koplik jar.
The broom- samples both
endo and ectocervical
epithelia simultaneously.
Samples are then collected in
a jar containing special
preservative solution.
26. HPV DNA testing The Hybrid Capture 2, HC2, test is the most widely
used HPV-DNA test
Has a very high negative predictive value (approx 99%)
Currently tests for 13 high risk HPV types, It screens
for the presence of HPV 16, 18, 31, 33, 35, 39, 45, 51, 52,
56, 58, 59 and 68.
27. HPV DNA testing
Almost 80% women <30 yr show +ve
HPV HC-2.
Most women clears of the infection
within 10 yr.
Due to high prevalence of this
temporary infection this test has no
diagnostic value <30 yr.
so it should not be done <30 yr.
28. TRIAGE Screening It is done to reduce the load on the colposcopy centers.
If PAP smear shows atypical cells
HPV DNA testing by HC-2 method
Positive
Go for colposcopy
Negative
Repeat smear after 1 year
29. Management of CIN I preceeded by ASC-US or
LSIL-
Follow-up without treatment
Colposcopy
Routine
Screening
•Lesser abnormalities include ASC-US or LSIL
cytology. HPV16 or 18 +ve persistent HPV
•Management options would vary if pregnant
or age less than 21-24yrs
•Cytology if less than 30yrs and cotestinf if
age≥30yrs
Either ablative or excisional
Excisional if colposcopy inadequate or CIN II
Manage According
to ASCCP
30. Management of CIN I preceded by HSIL or
ASC-H -
Cotesting at 12 & 24 months
Diagnostic
Excisional
Procedure
Review of Cytological or
Histological or Colposcopic
findings
Colposcopy •Provided colposcopy is Adequate and EndoCx sampling is –ve
•Except in special population/pregnant women/age 21-24yrs
•Cytology if less than 30yrs, Cotesting if age ≥30yrs
31. Management of CIN I in Special Population
*
Cytology at
12 months
Repeat Cytology at
12months
32. Management of Women
with Biopsy confirmed CIN II or III
Adequate Colposcopy
Inadequate Colposcopy or Recurrent
CIN 2/3 EndoCx sampling CIN 2/3
Excision or Ablation of
the TZ
Diagnostic Excisional
Procedure
Cotesting at 12-24months
Any test Abnormal
Colposcopy
Two consequtive –ve
results
Repeat Cotesting at
3yrs
Routine Screening
33. Management of a Women with Biopsy-confirmed CIN
2or3 in special circumstances -
A young women with CIN 2 or 3
Observation-Cytology & Colposcopy
6month interval for 12months
Treatment using Excision
or Ablation
2x Cytology _ve &
Normal Colposcopy
Cotest in 1yr
Both tests -ve
Cotest in 3yrs
Colposcopy worsens or High-
grade Cytology or colposcopy
persists for 1yr
Repeat Biopsy or
colposcopy
If CIN 2 or 3
persists for
≥ 24months
Treatment
Required
37. Cryotherapy-
Criteria
CIN I persisted for 2yrs or CIN II
Lesion in EctoCx
Negative EndoCx sampling
Small lesion
No EndoCx gland involvement
Effective Temperature -20˚to -30˚C
Iceball of 5mm from edge of probe=Effective
Failure Rate
Size
EndoCx sample +ve
EndoCx Gland +ve
*1
38. CO₂ Laser Vapourization :
Outline of lesion are demarcated
Vapourization to the depth 6-7mm.
Advantages-
Precise
Spare unnecessary damage
Ability to destroy coexisting lesions
Disadvantage-
Increase preocedure time
Very expensive
Complications
Minor discomfort
Uterine cramps
39. Long Loop Excision of Transformation
Zone(LLETZ)-
Tissue effects depends on
Size of wire 0.5mm
Power (watts) 35-55W
Water content of tissue
Steam envelope at tissue-wire interface =cutting
Zone of 4-5mm beyond the affected area
Advantage
Specimen for Histopathological diagnosis
Less expensive
Complications
Operative/post-operative haemorrhage
Cervical stenosis
40. Conization
Conization diagnostic/therapeutic
Provides tissue for further evaluation
Indications-
Microinvasive Carcinoma present in EndoCx currettings
Cytolopgy not consistent with tissue diagnosis
Entire TZ not visualized
Microinvasive Ca diagnosis by biopsy
Cytology/Biopsy evidence of Premalignant or Malignant
glandular epithelium.
Lesions with +ve margins more likely to recur
41. Hysterectomy-
Indications:
Microinvasion
CIN III at the EndoCx limits of conization specimens in
selected patients
Poor compliance with follow-up
Other gynaecologic problems requiring Hysterectomy
Histologically confirmed recurrent high-grade CIN
43. Referrence
1. Jennifer E. Frank, MD (2008) The colposcopic examination,Available
at: http://www.medscape.com/viewarticle/579947_4(Accessed: 21st july 2014).
2. berek jonathan s., abaid s. lisa, anderson r. jean, aubuchon mira, baker l.
valerie, baram a. david, et el. Berek and Novak's Gynecology, 15th ed. united
states of america: wolters kluwers / lippincott william wilkins; 2011.
3. Connor P. Joseph, Hartenbach M. Ellen. Treatment of Cervical Intraepithelial
Neoplasia.
http://www.glowm.com/section_view/heading/Treatment%20of%20Cervical%2
0Intraepithelial%20Neoplasia/item/228#9151 (accessed 24th july 2014).
4. Massad Stewart L.,Einstein H. Mark, Huh k. Warner, Katki A. Hormuzd,
Kinney K. Walter, Schiffman Mark, et el. 2012 Updated Consensus Guidelines for
the Management of Abnormal Cervical Cancer Screening Tests and Cancer
Precursors. http://www.omniaeducation.com/images/hpv_resource2.pdf
(accessed 20th July 2014).