Screening of cervical cancer

1. Screening of cervical
cancer

2. introduction
 Cancer of the uterine cervix is the third most common gynecologic cancer
diagnosis and cause of death among gynecologic cancers in the United
States
 There are two main types of cervical cancer: squamous cell carcinoma and
adenocarcinoma.
 Squamous cell carcinoma of the cervix is more prevalent than
adenocarcinoma

3.  Infection with high-risk strains of HPV and persistence of HPV infection
are the most important determinants of progression to cervical cancer
High risk HPV(HR-HPV) subtypes include: 16,18,31,33,45,56,58……
 Factors that increase the risk of acquiring HPV infection increase the risk
for cervical cancer (early onset sexual activity, multiple or high-risk sexual
partners) or impaired ability to clear HPV infection (immunosuppression)
 Type 16, 18 are responsible for 70% of cervical cancer

4. Risk factors
 Oral contraceptives.
 Cigarette Smoking (for squamous cell cancer).
 Nonadherance to screening.
 Cervical cancer is less common in sexual partners of circumcised males
 Early age at first birth (younger than 20 years old) and increasing parity (3
or more full term births) are also associated with an increased risk of
cervical cancer, these are also likely due to exposure to HPV through
sexual intercourse.
 Low socioeconomic status is associated with an increased risk of cervical
cancer.

5. Prevention
 Screening program
 Vaccination
Cervarix@ HPV 16 &18
Gardasil@ HPV 6,11,16,18 (reduced anogenital warts by 88% )
(Gardasil 9)@ HPV 6,11,18,16,31,33,45,56,58 (launched in 2016)

6.  Screening for ovarian cancer for asymptomatic pap smear or LBC (liquid
base cytology ) for cytological evidence of malignancy or CIN and
presence of HPV ; the most common risk factor for cervical tumors
 Starts from the age of 25 and ends by the age of 64 .
 If all normal , its done every 2-3 years

7.  A screening method (CYTOLOGY NOT HISTOPATHOLOGY )
 Cells exfoliated from the cervix can be examinedunder the microscope
 By pap smear using wooden spatula and fixed on glass slide to be seen under
microscope
 Recently using brush with LBC , taking cells from the TZ
 Results of abnormal cells shows : borderline dyskaryosis , mild, moderate ,
sever dyskaryosis (CIN1 ,2 , 3 ) , carcinoma in situ and malignant tumor
Cervical cytology

10. Colposcopy
 Diagnostic method, by examination of the magnified cervix using a light
source
 The application of acetic acid and iodine solutions highlights abnormal
areas of the cervix that can be biopsied
 Abnormal areas that show aceto acetic whiteness , and doesn’t stain by
iodine

11.  Colposcopy is to be done after abnormal pap smear like high grade
dyskaryosis
 If low grade is diagnosed (CIN 1 or borderline ) : repaeat cytology and
colposcopy after 6 months
 If high grade diagnosed , biopsy should be taken and treatment maybe
done in the same setting
 If malignancy is suspected : biopsy should be taken

12. Some Indications for colposcopy
 CIN 2, 3 on cytology
 Persistent CIN 1
 Suspicious looking cervix (gross abnormality )
 Persistent unsatisfactory cytology
 Glandular (rather than epithelial ) lesions

13. Cervical biopsy

14. Managing premalignant lesions
CIN I :
60 % spontaneous regression , close follow-up with colposcopy and cytology 6 months after
initial diagnosis
CIN 2,3 :
Ablative : Cryocautary, cold coagulation , Carbon dioxide ablation
Excisional : preferred if invasive cancer is suspected or glandular pathology , with the advantage
of getting histopathology ,
includes : (large loop excision of transformation zone, LLETZ) cold knife conization , laser
conization , simple vaginal hysterectomy