Benign and Malignant conditions of cervix and its management

1. Management of diseases of
Cervix
Dr. Basit Ali
Nishtar Medical University Multan, Pakistan

2. Anatomy of Cervix

3. Disorders of Cervix
Benign diseases of the cervix
• Cervical Ectropion
• Nabothian follicles
• Cervical polyps
• Cervical stenosis
• Cervical incompetence
Premalignant disease of the cervix
Malignant disease of the cervix

4. Cervical Ectropion

5. Cont.
• Influence of 3 P’s : puberty, pill & pregnancy
• Asymptomatic/ large may lead to IMB & PCB/ clear mucus-type discharge
Management
• Guidelines: All cases should be subjected to cytological examination from
the cervical smear to exclude dysplasia or malignancy.
• Detected during pregnancy the treatment should be withheld for at least
12 weeks postpartum. In pill users, the ‘pill’ should be stopped and barrier
method is advised
• Surgical ablation —(i) thermal cauterization (ii) cryosurgery and (iii) laser
vaporization

6. Nabothian follicles
• Mucus filled cysts on ectocervix
Management
• No treatment
• If large – drainage using large
bore needle

7. Cervical polyps
• Smooth, reddish, fingerlike
projections from the cervical canal
• Cause
• Multiparous older women
• Asymptomatic/ vaginal discharge/
IMB/ PCB
Management – avulsion with polyp
forceps & electrical cauterization of
polyp’s base. Antibiotics

8. Cervical stenosis
• Iatrogenic phenomenon caused
by surgical event
• Haematometra - cyclical
dysmenorrhoe with no
menstrual bleeding
Management – Surgical dilation
under USG or hysteroscopic
dilation

9. Premalignant disease of the cervix / Cervical
Intraepithelial neoplasia (CIN)
Etiology
• Persistent high risk HPV infection
(16,18,31,33 & 45)
• Risk factors – early age of
intercourse, multiple sexual
partners, cigarette smoking &
immunosuppression.
• Natural history of CIN – 65%
regress, 20% static & 15%
progress to invasive cancer over
8-10 years

10. • TZ is the site for cervical
dysplasia
• Integration of HPV DNA into the
basal epithelial cells leads to
immortalization and rapid cell
turnover. This disordered
immaturity within epithelium is
called CIN.

11. Screening System
• Best screening test for
premalignant lesions is cytology
by using Pap smear test.
• How is it performed? – 2
specimens. Ectocervical sample
by scraping TZ with Ayres
spatula & Endocervical sample
with cytobrush in non-pregnant
while with cotton-tip applicator
in a pregnant woman

12. Cytologic screening methods
• Conventional Method
• Thin-layer, liquid based cytology
(HPV-DNA typing)

13. Start at which age?
• Age 21 or 3 years after first intercourse - Start Pap test with cytology alone without HPV
testing; the recommendation is the same whether HPV vaccinated or not
Frequency of Pap smear?
• Age 21–29: repeat Pap every 3 years with cytology alone; do not perform HPV testing in
this age group
• Age 30–65: repeat Pap every 3 years with cytology but no HPV testing OR repeat Pap
every 5 years if both cytology and HPV testing (the recommended option in this age
group)
When should be discontinued?
• After age 65 : if negative cytology and/or HPV tests for past 10 years AND no history of
CIN 2, CIN 3 or cervical carcinoma
• Any age : if total hysterectomy AND no history of cervical neoplasia

14. Pap smear Classification
Bethesda system
• Negative : for intraepithelial lesion or
malignancy
• ASC-US : changes suggestive of but
not adequate to label LSIL
• LSIL (low-grade squamous
intraepithelial lesion)
• ASC-H : changes suggestive of but not
adequate to label HSIL
• HSIL (high-grade squamous
intraepithelial lesion)
• Squamous cell carcinoma
Cervical cytology shows squamous cells
at different stages of maturity
(dyskarosis)
• Disproportionate nuclear enlargement
• Irregularity of the nuclear outline
• Abnormalities of the nucleus—in
number, size and shape
• Hyperchromasia
• Condensation of chromatin material
• Multinucleation.

15. Diagnostic Approach to Abnormal Pap Smear
Accelerated repeat Pap : Preferred option for ASC-US and LSIL in
patients ages 21-24. Repeat the Pap in 12 months.
• If repeat cytology is negative, repeat Pap in another 12 months.
• If repeat cytology is anything other than negative, proceed to
colposcopy and biopsies.
HPV DNA testing : Preferred option for ASC-US in patients age ≥25.
• Perform colposcopy only if high-risk HPV DNA is identified

16. Colposcopy : This is indicated for evaluation of LSIL in patients age ≥25,
and all patients with ASC-H and HSIL. Colposcopy is a magnification of
the cervix (10–12x); it is aided by acetic acid.
• – Satisfactory or adequate colposcopy is diagnosed if the entire T-
zone is visualized and no lesions disappear into the endocervical
canal.
• – Unsatisfactory or inadequate colposcopy is diagnosed if the
entire T-zone cannot be fully visualized.

19. Abnormal Colposcopy findings
• White lesions
• Mosaicism
• Punctation
• Atypical / abnormal blood vessels

20. White Lesion Mosaicism

21. Punctation Atypical blood vessels

22. Unsatisfactory or inadequate
colposcopy :
• Endocervical curettage (ECC)- to
rule out endocervical lesion

23. Abnormal colposcopic findings :
• Ectocervical biopsy – sent for
histology
• Compare Pap smear and biopsy

24. Histology – Normal epithelium

25. CIN 1 : <1/3 of the thickness of the epithelium

26. CIN 2 : <2/3 of the thickness of the epithelium

27. CIN 3: slightly less than the entire thickness of
the thickness of the epithelium

28. Carcinoma in situ

29. Invasive carcinoma

31. Pap smear is worse than
histology :
• Cone biopsy – other indications
Unsatisfactory colposcopy
Abnormal ECC histology
Ectocervical biopsy showing
microinvasive carcinoma

32. Management According to histology

33. • Observation & follow up :
repeat Pap in 6 and 12 months;
colposcopy and repeat Pap in 12
months; or HPV DNA testing in
12 months
• LEEP/LLETZ : local anaesthesia ,
atleast 7mm deep
• Patients who have received
treatment for CIN undergo
undergo a test of cure 6 months
later

34. LEEP

35. Cryotheraoy Cold knife cone

36. Prevention by HPV vaccination
• Vaccine protection against 4 HPV (6,11,16 & 18)
• 3 doses – initial, then 2 months later, then 6 months later
Recommendations
• Administer to all females age 9–26, with a target age of 11–12
• Testing for HPV is not recommended before vaccination
• Continue regular Pap smears according to current guidelines
• Sexually active women and women with previous abnormal cervical
cytology can receive vaccine but less effective
• Vaccine is not recommended for pregnant, lactating, or immunosuppressed
women

37. Invasive Cervical carcinoma
• Cervical neoplasia that has penetrated through the basement
membrane.
• IMB, PCB…mean age 45 years
Diagnostic Tests
• Cervical biopsy
• Metastatic workup – includes pelvic examination, CXR, IV pyelogram,
cystoscopy & sigmoidoscopy
• Imaging studies – abdominal pelvic CT or MRI

38. Staging of invasive cervical carcinoma
Clinically staged
Stage 0: Carcinoma in-situ (CIS). The basement membrane is intact.
Stage I: Spread limited to the cervix. This is the most common stage at diagnosis.
Ia1 : Invasion is ≤3 mm deep (minimally invasive)
Ia2 : Invasion is >3 but ≤5 mm deep (microinvasion)
IB :Invasion is >5 mm deep (frank invasion)
Stage II: Spread adjacent to the cervix
IIa. Involves upper two thirds of vagina
IIb. Invasion of the parametria
Stage III: Spread further from the cervix
IIIA. Involves lower one third of vagina
IIIB. Extends to pelvic side wall or hydronephrosis
Stage IV: Spread furthest from the cervix
IVA. Involves bladder or rectum or beyond true pelvis
IVB. Distant metastasis

39. Management of stage 1

40. Management of other stages
• Stage 2 A : Radical hysterectomy with pelvic and paraaortic
lymphadenectomy (premenopausal) or pelvic radiation
(postmenopausal)
• Stage 2b,3 or 4 : Radiation therapy and chemotherapy
Follow-up: All patients with invasive cervical cancer should be followed
up with Pap smear every 3 months for 2 years after treatment, and
then every 6 months for the subsequent 3 years