Benign Conditions Of The Cervix

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Benign Conditions Of The Cervix

• Dr. Abdalla H. Elsadig
• MD

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Important points about cervical cancer

• It is rising in young women.
• There are 450,000 cases of cervical cancer/year.
• There are 300,000 death/year.
• It is the fourth most common cancer (breast,
  lung, and stomach).
• It is a preventable disease (screening
  programme-cervical smear).
• The surgical treatment is mainly for early stage.
  

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Cervical Intraepithelial Neoplasia (CIN)

• Definition of CIN
• CIN is a pre-invasive changes of the cervical
  epithelium where the epithelium thickness is
  replaced by abnormal cells in varying degree
  without breaching the cell membrane.
• symptomless.
• Abnormal cytological changes of CIN (immature and
  disorganized cells) are
• Increased Nuclear/Cytoplasmic ratio.
• Prominence of nuclear chromatin.
• Multinucleation.

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Grades of CIN

• CIN is graded according the proportion of
  epithelium occupied by the abnormal cells.
• CIN 1 (mild dysplasia)
• - One-third or less is occupied by the
  abnormal cells.
• - Progress to (CIS) in 6.
• - Regressed or disappeared in 62,

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Grades of CIN

• CIN 2(modrate dysplasia)
• - Between 1/3-2/3 of the epithelium is occupied
  by the abnormal cells.
• - Become invasive in 13.
• CIN 3 (severe dysplasia)
• - The whole thickness of the squamous
  epithelium is occupied by the abnormal cells.
• It is regarded as carcinoma-in-situ (CIS).
• - It could arise as CIN 3 or progress from CIN
  1or CIN 2.
• - Become invasive in 29.

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Incidence of CIN

• The incidence of CIN is 4 to 5 of Pap tests.
• The incidence of CIN vary according to the (1)
  population studied, as the peak incidence being
  between 25 and 29 years of age, (2)socioeconomic
  factors, and (3) risk-related behaviours.
• The true incidence and prevalence can only be
  estimated, as screening cytology and colposcopy
  lack complete sensitivity.

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Risk factors (Epidemiology)

• Demographic risk factors 
• Ethnicity (Latin American countries, U.S.
  minorities).  
• Low socioeconomic status.  
• Older age.
• Medical risk factors  
• Cervical human papilloma virus infection.  
• Parity.  
• Immunosuppression.

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Risk factors (Epidemiology)

• Behavioural risk factors  
• Infrequent or absent cancer screening Pap
  tests.  
• Early coitus.  
• Multiple sexual partners.  
• Male partner who has had multiple sexual
  partners.  
• Tobacco smoking.  
• Dietary deficiencies.

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Risk factors (Epidemiology)

• Risk factors for CIN are similar for invasive
  lesions.
• The risk is most strongly related to (1)
  infection with a HR HPV type, (2) older age, and
  (3) most importantly, persistence of the HR HPV
  infection.
• Older age (1) persistent HPV infection
  (2)accumulation of mutations leading to cellular
  malignant transformation (3) less access to
  cancer prevention programs (decreased needs for
  prenatal care and contraception).

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Risk factors (Epidemiology)

• Tobacco smoking
• - ? the risk of cervical cancer among
  HPV-positive women.
• Nicotine and its major metabolite cotinine are
  found in the cervical mucus of women and in the
  semen of men who smoke ? suppression of local
  cervical immunity and promotion of HPV-driven
  cellular transformation and neoplasia.
• Dietary deficiencies
• - Vitamins such as A, C, E, beta carotene, and
  folic acid may alter cellular resistance to HPV
  infection ? persistent viral infection and
  cervical neoplasia.

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Risk factors (Epidemiology)

• Combined Oral Contraception (COC steroid
  hormones may affect the HPV genome and increase
  viral expression of oncoproteins E6 and E7.
• Parity gt 7 full term (1) immunosuppression
  (cell-mediated arm) (2) hormonal influences on
  cervical epithelium (3) trauma related to vaginal
  deliveries.

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Identification of CIN

• Cervical Cytology (The Pap test )
• Initiation of screening 3 years after onset of
  vaginal intercourse no later than age 21.
• Screening intervals (1) age lt 30 years
  annually, (2) age gt 30 years every 2 to 3
  years after 3 consecutive negative tests. (3)
  patients with HIV or other immunocompromised
  state 2 tests during the first year, then
  annually.
• Discontinuation of screening Age 65 to 70 in
  women not at high risk (history of cervical
  cancer, DES, HPV, HIV, immunocompromised state).

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CIN Management

• A. Abnormal cervical smear
• Due to infection treat then repeat the smear.
• Atrophic smear give oestrogen then repeat the
  smear.
• Colposcopy.
• B. Colposcopy
• To view the cervix telescopically at
  magnification range of 6 to 40 times.
• 4 of acetic acid is applied to the cervix which
  coagulates proteins of the epithelial cells and
  abnormal epithelium appears white biopsies
  should be taken from that area. or

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CIN Management

• B. Colposcopy
• Apply Lugol's iodine solution (Schiller test) to
  the cervix
• Iodine 2 gm, potassium iodide 4 gm and distilled
  water 300 ml
• Malignant cells lack glycogen so they fail to
  take iodine (stainless).
• - Normal epithelium (rich in glycogen) stains
  dark-brown.
• - Biopsies taken from the non-staining areas.
• - Squamo-columnar junction should be seen
  entirely.

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CIN Management

• C. Cone biopsies
• indications
• - squamo-columnar junction not seen.
• - negative colposcopic examination with
  positive repeated cervical smear.
• microinvasion or invasion is suspected.
• Size kept to a minimum with normal tissue,
  tailored cut with a knife.
• D/C is should be done.
• Haemostasis is achieved by using Dexon at 3 9
  0clock of the cervix.
• Complications primary 2nd bleeding scarring
  ? stenosis ? impaired fertility,
  cryptomenorrhoea, abortion, preterm labour
  cervical dystocia.

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CIN treatment

• Knife Cone biopsy.
• Total hysterectomy
• Persistent lesion after conization.
• Lesion extends to the upper vagina (colposcopy).
• Coexisting indication (menorrhagia or prolapse).
• Local destruction (ablation) (for young,
  unmarried or wanting children)
• Cryocautery freezing the tissue.
• Electrocautery burning the transformation zone.
• Large loop excision of the transformation zone
  using electrodiathermy.
• Cold coagulation destruction of the
  transformation zone with a probe heated to 100 to
  120C.

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