Cervical Disease and Neoplasia

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APGO educational topic 52 cervical
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disease and neoplasia globally cervical
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cancer is the second most common cancer
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among women it is the most common cause
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of mortality from gynecologic malignancy
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accounting for 250,000 deaths per year
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in the United States cervical cancer
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incidence and mortality have decreased
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substantially it is now thought of as a
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preventable cancer that is caused by a
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virus called human papilloma virus or
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HPV the objectives of this video are to
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describe the pathogenesis and risk
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factors for cervical cancer list the
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guidelines for cervical cancer screening
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describe the initial management for a
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patient with an abnormal pap smear
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describe the symptoms and physical
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findings of a patient with cervical
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cancer there are over 100 types of HPV
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and 30 affect the anal genital tract 15
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of these 30 are high-risk HPV types and
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the majority of cervical cancers are
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caused by four of these 16 18 31 and 45
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low risk HPV types are not associated
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with cancer and low risk type 6 and 11
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are associated with genital warts HPV
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infection so let’s take a moment now to
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discuss cervical anatomy the cervix is
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covered by both squamous and columnar
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epithelium the squamous columnar
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Junction or scj where these two meet is
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an important landmark where over 90
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percent of lower genital tract cancers
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arise the squamous epithelium is on the
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vaginal side of the scj and the columnar
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epithelium is on the endocervical side
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of the suj during menarche there is an
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estrogen surge and this causes the
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cervix to mushroom and drag the
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glandular or columnar epithelium of the
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Ender cervix onto the vaginal exposed
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portion of the cervix thus the scj at
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menarche will be at or close to the
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vaginal part of the external awesome as
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the woman ages the scj recedes up the
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endocervical canal the transformation
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zone is this area between the old scj
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and the new scj depicted by this area
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with the pink stripes this is the area
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where columnar epithelium is replaced by
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squamous epithelium in a process called
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squamous metaplasia the cells that are
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undergoing metaplasia are vulnerable to
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various carcinogens such as HPV
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colposcopy is how we clinically
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visualize this
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cervical anatomy a copla scope is a
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binocular stereo microscope with
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magnification acetic acid is placed on
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the cervix which dehydrates cells
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causing those with large nuclei to
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appear white these white cells will be
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those undergoing metaplasia or dysplasia
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this Copas Copic photograph shows a
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cervix treated with acetic acid the
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original squamous epithelium is pink and
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smooth and the columnar epithelium is
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red and irregular here is the old scj
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and the transformation zone with
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squamous metaplasia is white let’s now
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focus on some virology and here is our
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character mr HPV most of the time if he
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infects a host the infection will be
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transient and the host immune system
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will be able to eradicate the HPV before
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it causes change certain risk factors
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will increase the likelihood that the
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HPV infection will stay if the host is
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immunocompromised secondary to HIV or is
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on immunosuppression medications and
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there’ll be a higher incidence of
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infection and progression cigarette
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smoking is our second risk factor and
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smokers have a 3.5 times greater rate of
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cervical cancer than non-smokers the
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carcinogens from cigarette smoke are
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found in high concentrations in the
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cervical mucus of smokers other risk
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factors include anything that will
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increase the chance of exposure to HPV
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including early cor turkey multiple
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sexual partners and sexually transmitted
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diseases let’s discuss cervical cancer
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screening the Pap test is inexpensive
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and not invasive and we are now able to
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test for HPV at the time of the Pap test
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adding the HPV testing has allowed us to
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space out the interval between testing
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however it could now be confusing for
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patients and medical students so let’s
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spend a moment to clarify screening
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recommendations the screening
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recommendations differ by age here is
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our young patient screening should start
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at age 21 for women between 21 and 29
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years old Pap test alone should be every
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three years
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HPV testing is not performed in this age
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group for HPV prevalence approaches 20%
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for teens and women in their early 20s
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for older woman age 30 to 60 for Pap
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test and HPV testing every five years is
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preferred or a Pap test alone can be
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tested every three years for women who
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are 65 or older Pap test screening can
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stop if she has adequate negative
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screening and no history of cervical
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dysplasia greater than cin 2 within the
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last twenty
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years it is important to note that more
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than half of patients to develop
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cervical cancer have not been screened
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appropriately and among women diagnosed
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with invasive cervical cancer one half
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have never had a Pap test women who are
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at highest risk of being rarely or never
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screened for cervical cancer are
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minority women low socioeconomic status
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foreign-born and women with no usual
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source of health care let’s move now to
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management of an abnormal pap test Pap
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tests give a cytological result and two
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common abnormal cytology ZAR low-grade
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squamous epithelial lesions or LS il and
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high-grade squamous intrepid ileal
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lesions or HSI L a colposcopy is the
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next step and the biopsies from the
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colposcopy will give a histologic
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diagnosis there are two common
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classification systems for describing
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the results of Kulpa scopic directed
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biopsies we’ll start with the bethesda
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system this system describes the
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biopsies obtained at the time of
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colposcopy as cervical intraepithelial
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neoplasia
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or CIN and there are CIN 1 2 & 3 these
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are classified by the extent that
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cervical epithelium is replaced by
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abnormal cells CIN 1 has one third of
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the epithelium involved with abnormal
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cells CIN 2 has 2/3 and CIN 3 has full
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thickness involvement in 2012 the lower
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inner genital squamous terminology with
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the clever acronym last was introduced
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in this terminology system the
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histological biopsy results are
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classified as either LS il or HS il
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mirroring the same terminology that was
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used for the cytology results lesions
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that would have been classified as cin 1
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are now LS il most CIN 3 is classified
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as HS il specimens that were CIN 2 or an
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unclear CIN 3 can now be tested with P
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16 immunostaining that helps diagnostic
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reproducibility specimens that are P 16
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negative are classified as LS il and
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those that are positive are classified
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as HS il to summarize when a pap smear
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is abnormal that alkyl paska P should be
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performed the results of the copis copic
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directed biopsies triage the next step
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of management expectant management can
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be used for cin 1 or LS il because of
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its high rate of regression and low rate
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of progression immediate treatment is
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needed for CIN 2 and CIN 3
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or HS IL because of their higher rates
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of progression of cervical cancer there
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are two approaches to immediate
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treatment ablation for example
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cryotherapy or laser ablation and
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excisional methods called life cone or
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leap procedure the principle difference
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between ablation and excisional methods
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is that ablation provides no diagnostic
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information additional factors to
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consider our future childbearing plans
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and patient compliance both a cone
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biopsy and LEEP procedure excised the
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transformation zone this following video
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courtesy of dr. rich Lieberman shows a
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leak procedure the cervix has been
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treated with luke all solution which
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stains normal tissue with iodine
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dysplastic cells appear non stained or
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white a loop electrode is used to excise
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the transformation zone and then a
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rollerball cautery is used to obtain
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hemostasis let’s move now to cervical
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cancer despite the progress made in
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early detection and treatment there are
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approximately 11,000 new cases of
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cervical cancer diagnosed annually with
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3870 deaths the average age of diagnosis
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is 50 years old the signs and symptoms
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of cervical cancer a variable and
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nonspecific including watery vaginal
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discharge intermittent spotting and post
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coital bleeding the cervix can appear
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normal and appearance or there can be a
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visible cervical lesion large tumors may
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appear to replace the cervix entirely
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the cervical cancer usually arises from
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the transformation zone here is a
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photograph of cervical cancer note the
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irregular friable surface of the
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transformation zone let’s conclude by
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discussing prevention and future
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directions we began this video by
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discussing the high and low risk strains
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of HPV the quadrivalent or Gardasil
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vaccine protects against the low risk
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HPV strains of 6:11 and high risk
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strains 16 and 18
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this quadrivalent HPV vaccine has been
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shown to prevent 91% of new infections
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current HPV vaccines are only indicated
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right now for prophylaxis and women who
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receive the HPV vaccine should still
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follow regular cervical cytology
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screening in January 2015 the American
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Society for colposcopy and cervical
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pathology in the Society for gynecologic
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oncology recommend
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a consideration of primary HPV testing
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for cervical cancer screening stay tuned
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for guidelines and recommendations we’ll
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continue to evolve this concludes the
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aapko video on cervical disease in
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neoplasia we have discussed the
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pathogenesis and risk factors for
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cervical cancer and discuss
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recommendations for screening and
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management of abnormal pap tests