Immature metaplasia

layers

 Basal

 Para basal

 Intermediate

 Superficial
CIN /Pre invasive cervical cancer
stage 0

Part or full thickness of stratified squamous

epithelium replaced by dysplastic cells

Basement membrane intact

DYSPLASIA-Loss in uniformity & architectural

orientation 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 SCHEME 1 SCHEME 2 SCHEME3
SYSTEM WHO RUCHART BETHESDA

CLASS 1 NEG NEG WNL

CLASS 2 INFL ATYPIA ASCUS

KOILOCYTES

CLASS 3 MILD CIN 1 LSIL

DYSPLASIA

CLASS 4 MODERATE CIN 2 HSIL

SEVERE
DYSPLASIA CIN 3
(CIS)
CLASS 5 INVASIVE INVASIVE INVASIVE
CANCER CANCER 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

others

 Cone biopsy - diagnostic & therapeutic

 AgNOR- silver as molecular marker for

nuclear organizer regions… more dots seen
with advancing dysplasia
 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 Local Radical
destructive excision excision

Cryo
surgery
Conisation
with knife,
Electro laser,
coagulation LLETZ,
LEEP,
NETZ
Laser
ablation
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