cervical anatomy
the cervix is composed of:
- columnar epithelium: which lines the endocervical canal
-squamous epithelium: which covers the exocervix
🔸
The Squamocolumnar Junction
The SCJ rarely remains restricted to the
the point at which they meet is called the squamocolumnar
junction (SCJ)
🔸
external OS.
Instead, it is a dynamic point that changes in
response to puberty, pregnancy, menopause, and
🔸
hormonal stimulation.
🔸 In neonates, the SCJ is located on the exocervix.
At menarche, the production of estrogen
🔸
causes the vaginal epithelium to fill with glycogen.
Lactobacilli act on the glycogen to lower the
pH, stimulating the subcolumnar reserve cells to
undergo metaplasia .
Cancer cervix Is the most common malignancy
in the world of cases occurred in the developing
countries 80%In USA it is the third common
🔸
malignancy
The incidence of cancer cervix had been declined
due to the introduction of PAP TEST and HPV
HPV 🔸
screening and vaccination
🔸
Classification World Health Organization (WHO)
🔸
the mean age of cancer cervix 52.2
In 1975 classified the CIN into three categories correlating with former
🔸
99.7% OF CANCER CX IS DUE TO HPV grading of dysplasia and CIS.
INFECTIONIT IS NON ENVELOPED DOUBLE DNA
virusIt spread through sexual contact 🔸
Risk factors of cancer cervix
🔸 Exposure to HPV
The grading is done according to the thickness occupied by the
undifferentiated cells.
🔸
🔸
SMOKING
PARITY
- CIN 1: Mild dysplasia
- CIN 2: moderate dysplasia
🔸
🔸
IMMUNE SUPRESSION
Multiple sexual partner
- CIN 3: Severe dysplasia and carcinoma in situ
🔸 Sexual transmitted infection
Early age at first coitus
Low socioeconomic
The 2001 Bethesda System (Abridged)
Epithelial Cell Abnormalities
🔸
Squamous cell
Atypical squamous cells (ASC)
- Of undetermined significance (ASC-US)
🔸
CLINICAL PRESENTATION
🔸 Abnormal uterine bleeding (postcoital, intermenstrual,postmenopausal)
- Cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-
🔸 Serosaginous vaginal discharge foul smell
dysparunia
🔸
H)
Low-grade squamous intraepithelial lesion (LSIL)
- Encompassing human papillomavirus/mild dysplasia/ cervical
Late symptoms:
Hematometra due to occlusion of cervix
Anemia
🔸
intraepithelial neoplasia (CIN) 1
High-grade squamous intraepithelial lesion (HSIL)
- Encompassing moderate and severe dysplasia, carcinoma in situ CIN 2
Pelvic pain
Sciatic and back pain(side wall extention,hydronephrosis) 🔸
Definition ·
Cervical dysplasia is a cytological term used to describe cells
🔸
and CIN3
Squamous cell carcinoma
Bladder and rectal invasion(hematochesia.hematurea
Lower limb swelling (DVT, lymphatic involvement) 🔸
resembling cancer cells
Cervical intraepithelial neoplasia (CIN) refers to histopathological
description in which a part or full thickness of stratified squamous
epithelium is replaced by cells showing varying degrees of 🔸
Glandular cell
Atypical glandular cells (AGC)(specify endocervical, endometrial, or
🔸
DIAGNOSIS:
SPECULUM EXAMINATION:
dysplasia;however the basement membrane is intact.
🔸
not otherwise specified)
Atypical glandular cells, favor neoplastic (specify endocervical or not
Exophytic lesion bleeds to conact
Some times inside cervical canal and the cervix looks normal externally 🔸
otherwise specified)
🔸Endocervical adenocarcinoma in situ (AIS)
🔸
((barrel shaped cervix))
Bimanual examination:
Adenocarcinoma
🔸
firm indurated cervix
Rectal examination:
🔸to exclude uterosacral ligament involvement
General examination:
Pleural effusion
Ascitis
Lower limb edema
Supraclavicular lymph node enlargement
spread
🔸 Direct extention to parametrial through cardinal ligamentVaginal spread in 50% extention
🔸
Bladder and rectal
🔸Lymphatit spread Obturator,ext.illiac,hypogastric,parametrial ,presacral…common illiac
Hematogenous spread:rare occure late
Clinical staging rather than surgical
🔸
Screening
🔸
prevention:
🔸
🔸
No tumor marker use of condoms
Screening for cervical cancer differs from
Pelvic examinationI:
BIOPSY
other
cancer screening because there is a well
🔸
🔸
Dietary changes
Behaviour changes
CONIZATION defined premalignant stage of disease which
🔸Human Papilloma Virus Vaccine
Because HPV infection is a necessary factor in the development of
🔸
HYSTEROSCOPY can be easily treated.
COLPOSCOPY cervical neoplasia, an important step in primary prevention was the
CERVICAL Cervical screening was first introduced in
development of a prophylactic vaccine to protect against HPV infection.
🔸
DENDOCERVICAL CURRETTAGE British Columbia and Finland.
CYSTOSCOPY INTRAEPITHELIAL It is now one of the most successful cancer
- Bivalent vaccine
- Quadrivalent Vaccine
PROCTOSCOPY prevention programmes.
NEOPLASIA -Nonavalent vaccine
🔸 maging technique:
cervical lesions
🔥
MRI Diagnosis of cervical intraepithelial neoplasia
🔸
CT SCAN shiller or Acetic acid Test for Neoplasia:
-Because a pelvic exam is usually normal in women with cervical intraepithelial neoplasia, a Pap test is necessary to diagnose the
LYMPHANGIOGRAM Although colposcopyis more accurate, the Schilleror Acetic acid test
LAPARASCOPY condition.
can be performed when cancer or precancerous changes of the cervix
Cancer cervix -Although a Pap test alone can identify mild, moderate, or severe cervical intraepithelial neoplasia, further tests are often required to
🔸
LAPARATOMY… or vaginal mucosa are suspected
determine appropriate follow-up and treatment. "The suspect area is paintedwith Lugols(strong iodine)solution or
🔸
These include:
🔸 Repeat Pap tests
Acetic acid, interacts and maks the glycogen-rich epithelial cells of the
cervix Any portion of the epithelium that does not accept the dye is
🔸 Colposcopy, a magnified exam of the cervix to detect abnormal cells so that biopsies can be taken abnormal because of the presence of scartissue, neoplasia
Endocervical curettage, a procedure to check for abnormal cells in the cervical canal
🔸
and precursos, and columnar epithelium.
"Biopsyofsamples taken fom this area shoudbe perfomedifthere is any
suspicion of cancer
🔸
colposcopy
stages
🔸 Colposcopes are expensive, specialized pieces of equipment. 🔸Colposcopy is resource intensive; it requires provider training,
Colposcopy can be used to guide a biopsy of an abnormal area.
🔶
🔸 🔸
specialized equipment and pathology services.
🔸ItIf should
Stage 1 ((confined to the cervix)) not be used as a screening method.
🔸
🔸
1a1less than 3mm in depth and 7mm in width
1a2more than 3 mm depth and less than 7mm width
the procedure is not readily available, this can create bottlenecks in the system,leading to patients being lost to follow-up.
🔸1B1 confined to the cervix less than 4cm
1B2more th 4 cm VIA (1 of 2): Background:
🔶 Stage 2 🔸
🔸
Beyond cervix but not reach pevic side wall or lower vagina
🔸
HISTOLOGICAL TYPES OF CANCER CERVIX 🔸
🔸
visual Inspection with Acetic Acid (VIA) is a technique for the detection of pre-cancerous or cancerous lesions in the cervix.
The application of dilute aceticacid on such lesions triggers whitening of these regions.
🔸2a2b with out parametrial invasion
with parametrial invasion 1-INVASIVE SQUAMOUS CELL CANCER
🔸 VIA is a relatively simple, low-cost method presenting immediate results.
🔶 Stage 3 🔸
80%Endometriod,mucinous,adensquamous
🔸2-ADENOCARCINOMA15% 🔸AVIApositive result can be followed by immediate treatment(i.e. single-visit approach).
is subjective and depends on the skills and experience of the provider.
🔸
extend to pelvic side wall and lower vagina with hydronephrosis 3-SMALL CELL CARCINOMA((RAPID SPREAD))
🔸3a3b lower vaginawithout side wall invasion
lateral pelvic side wall with renal involvement HISTOLOGICAL GRADES
🔶
POOR DIFFERENTAITED
🔸 Stage 4 MODERATELY DIFFERENTIATED --->play role in survival rate
🔸4b extent to distant metastasis
4a extend to bladder and rectum WELL DIFFERENTIATED
PROGNOSIS:
🔸
5 years survivor rate
🔸 90-100% in stage 1
🔸
🔸
60-80% in stage 2
Stage 3 40%
STAGE 4 20%
treatmant
Surgical management Imited to stage 1 and 2a only
Stage 1 cone biopsy
Stage 2 simple hysterictomy
Stages beynond this chemotherapy and radiotherapy
Radical trachelectomy:
is considered to be the optimal treatment for women of age =40 years with
a desire to preserve fertility and stage IA2 or mild stage IB1 disease;
by fatema okoff
TREATMENT:
🔶
treatment options:
🔸 excisional:
🔸
🔶
LEEP
conization cold knife cone
🔸
🔸
ablation:
cryotherapy
carbon dioxide laser 7mm depth burn
🔸
Thermal ablation
The equipment is simple & relatively inexpensive. External gas is not required.
🔸
Electricity is not necessarily required; can function off of portable batteries power-supply.
In the context of a screen & treat approach, a screen-positive result can be followed
by an offer of treatment at the same visit, maximizing treatment coverage and reducing
🔸This treatment method does not produce a specimen for pathological examination.
loss to follow-up.
the cervix is composed of:
- columnar epithelium: which lines the endocervical canal
-squamous epithelium: which covers the exocervix
🔸
The Squamocolumnar Junction
The SCJ rarely remains restricted to the
the point at which they meet is called the squamocolumnar
junction (SCJ)
🔸
external OS.
Instead, it is a dynamic point that changes in
response to puberty, pregnancy, menopause, and
🔸
hormonal stimulation.
🔸 In neonates, the SCJ is located on the exocervix.
At menarche, the production of estrogen
🔸
causes the vaginal epithelium to fill with glycogen.
Lactobacilli act on the glycogen to lower the
pH, stimulating the subcolumnar reserve cells to
undergo metaplasia .
Cancer cervix Is the most common malignancy
in the world of cases occurred in the developing
countries 80%In USA it is the third common
🔸
malignancy
The incidence of cancer cervix had been declined
due to the introduction of PAP TEST and HPV
HPV 🔸
screening and vaccination
🔸
Classification World Health Organization (WHO)
🔸
the mean age of cancer cervix 52.2
In 1975 classified the CIN into three categories correlating with former
🔸
99.7% OF CANCER CX IS DUE TO HPV grading of dysplasia and CIS.
INFECTIONIT IS NON ENVELOPED DOUBLE DNA
virusIt spread through sexual contact 🔸
Risk factors of cancer cervix
🔸 Exposure to HPV
The grading is done according to the thickness occupied by the
undifferentiated cells.
🔸
🔸
SMOKING
PARITY
- CIN 1: Mild dysplasia
- CIN 2: moderate dysplasia
🔸
🔸
IMMUNE SUPRESSION
Multiple sexual partner
- CIN 3: Severe dysplasia and carcinoma in situ
🔸 Sexual transmitted infection
Early age at first coitus
Low socioeconomic
The 2001 Bethesda System (Abridged)
Epithelial Cell Abnormalities
🔸
Squamous cell
Atypical squamous cells (ASC)
- Of undetermined significance (ASC-US)
🔸
CLINICAL PRESENTATION
🔸 Abnormal uterine bleeding (postcoital, intermenstrual,postmenopausal)
- Cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-
🔸 Serosaginous vaginal discharge foul smell
dysparunia
🔸
H)
Low-grade squamous intraepithelial lesion (LSIL)
- Encompassing human papillomavirus/mild dysplasia/ cervical
Late symptoms:
Hematometra due to occlusion of cervix
Anemia
🔸
intraepithelial neoplasia (CIN) 1
High-grade squamous intraepithelial lesion (HSIL)
- Encompassing moderate and severe dysplasia, carcinoma in situ CIN 2
Pelvic pain
Sciatic and back pain(side wall extention,hydronephrosis) 🔸
Definition ·
Cervical dysplasia is a cytological term used to describe cells
🔸
and CIN3
Squamous cell carcinoma
Bladder and rectal invasion(hematochesia.hematurea
Lower limb swelling (DVT, lymphatic involvement) 🔸
resembling cancer cells
Cervical intraepithelial neoplasia (CIN) refers to histopathological
description in which a part or full thickness of stratified squamous
epithelium is replaced by cells showing varying degrees of 🔸
Glandular cell
Atypical glandular cells (AGC)(specify endocervical, endometrial, or
🔸
DIAGNOSIS:
SPECULUM EXAMINATION:
dysplasia;however the basement membrane is intact.
🔸
not otherwise specified)
Atypical glandular cells, favor neoplastic (specify endocervical or not
Exophytic lesion bleeds to conact
Some times inside cervical canal and the cervix looks normal externally 🔸
otherwise specified)
🔸Endocervical adenocarcinoma in situ (AIS)
🔸
((barrel shaped cervix))
Bimanual examination:
Adenocarcinoma
🔸
firm indurated cervix
Rectal examination:
🔸to exclude uterosacral ligament involvement
General examination:
Pleural effusion
Ascitis
Lower limb edema
Supraclavicular lymph node enlargement
spread
🔸 Direct extention to parametrial through cardinal ligamentVaginal spread in 50% extention
🔸
Bladder and rectal
🔸Lymphatit spread Obturator,ext.illiac,hypogastric,parametrial ,presacral…common illiac
Hematogenous spread:rare occure late
Clinical staging rather than surgical
🔸
Screening
🔸
prevention:
🔸
🔸
No tumor marker use of condoms
Screening for cervical cancer differs from
Pelvic examinationI:
BIOPSY
other
cancer screening because there is a well
🔸
🔸
Dietary changes
Behaviour changes
CONIZATION defined premalignant stage of disease which
🔸Human Papilloma Virus Vaccine
Because HPV infection is a necessary factor in the development of
🔸
HYSTEROSCOPY can be easily treated.
COLPOSCOPY cervical neoplasia, an important step in primary prevention was the
CERVICAL Cervical screening was first introduced in
development of a prophylactic vaccine to protect against HPV infection.
🔸
DENDOCERVICAL CURRETTAGE British Columbia and Finland.
CYSTOSCOPY INTRAEPITHELIAL It is now one of the most successful cancer
- Bivalent vaccine
- Quadrivalent Vaccine
PROCTOSCOPY prevention programmes.
NEOPLASIA -Nonavalent vaccine
🔸 maging technique:
cervical lesions
🔥
MRI Diagnosis of cervical intraepithelial neoplasia
🔸
CT SCAN shiller or Acetic acid Test for Neoplasia:
-Because a pelvic exam is usually normal in women with cervical intraepithelial neoplasia, a Pap test is necessary to diagnose the
LYMPHANGIOGRAM Although colposcopyis more accurate, the Schilleror Acetic acid test
LAPARASCOPY condition.
can be performed when cancer or precancerous changes of the cervix
Cancer cervix -Although a Pap test alone can identify mild, moderate, or severe cervical intraepithelial neoplasia, further tests are often required to
🔸
LAPARATOMY… or vaginal mucosa are suspected
determine appropriate follow-up and treatment. "The suspect area is paintedwith Lugols(strong iodine)solution or
🔸
These include:
🔸 Repeat Pap tests
Acetic acid, interacts and maks the glycogen-rich epithelial cells of the
cervix Any portion of the epithelium that does not accept the dye is
🔸 Colposcopy, a magnified exam of the cervix to detect abnormal cells so that biopsies can be taken abnormal because of the presence of scartissue, neoplasia
Endocervical curettage, a procedure to check for abnormal cells in the cervical canal
🔸
and precursos, and columnar epithelium.
"Biopsyofsamples taken fom this area shoudbe perfomedifthere is any
suspicion of cancer
🔸
colposcopy
stages
🔸 Colposcopes are expensive, specialized pieces of equipment. 🔸Colposcopy is resource intensive; it requires provider training,
Colposcopy can be used to guide a biopsy of an abnormal area.
🔶
🔸 🔸
specialized equipment and pathology services.
🔸ItIf should
Stage 1 ((confined to the cervix)) not be used as a screening method.
🔸
🔸
1a1less than 3mm in depth and 7mm in width
1a2more than 3 mm depth and less than 7mm width
the procedure is not readily available, this can create bottlenecks in the system,leading to patients being lost to follow-up.
🔸1B1 confined to the cervix less than 4cm
1B2more th 4 cm VIA (1 of 2): Background:
🔶 Stage 2 🔸
🔸
Beyond cervix but not reach pevic side wall or lower vagina
🔸
HISTOLOGICAL TYPES OF CANCER CERVIX 🔸
🔸
visual Inspection with Acetic Acid (VIA) is a technique for the detection of pre-cancerous or cancerous lesions in the cervix.
The application of dilute aceticacid on such lesions triggers whitening of these regions.
🔸2a2b with out parametrial invasion
with parametrial invasion 1-INVASIVE SQUAMOUS CELL CANCER
🔸 VIA is a relatively simple, low-cost method presenting immediate results.
🔶 Stage 3 🔸
80%Endometriod,mucinous,adensquamous
🔸2-ADENOCARCINOMA15% 🔸AVIApositive result can be followed by immediate treatment(i.e. single-visit approach).
is subjective and depends on the skills and experience of the provider.
🔸
extend to pelvic side wall and lower vagina with hydronephrosis 3-SMALL CELL CARCINOMA((RAPID SPREAD))
🔸3a3b lower vaginawithout side wall invasion
lateral pelvic side wall with renal involvement HISTOLOGICAL GRADES
🔶
POOR DIFFERENTAITED
🔸 Stage 4 MODERATELY DIFFERENTIATED --->play role in survival rate
🔸4b extent to distant metastasis
4a extend to bladder and rectum WELL DIFFERENTIATED
PROGNOSIS:
🔸
5 years survivor rate
🔸 90-100% in stage 1
🔸
🔸
60-80% in stage 2
Stage 3 40%
STAGE 4 20%
treatmant
Surgical management Imited to stage 1 and 2a only
Stage 1 cone biopsy
Stage 2 simple hysterictomy
Stages beynond this chemotherapy and radiotherapy
Radical trachelectomy:
is considered to be the optimal treatment for women of age =40 years with
a desire to preserve fertility and stage IA2 or mild stage IB1 disease;
by fatema okoff
TREATMENT:
🔶
treatment options:
🔸 excisional:
🔸
🔶
LEEP
conization cold knife cone
🔸
🔸
ablation:
cryotherapy
carbon dioxide laser 7mm depth burn
🔸
Thermal ablation
The equipment is simple & relatively inexpensive. External gas is not required.
🔸
Electricity is not necessarily required; can function off of portable batteries power-supply.
In the context of a screen & treat approach, a screen-positive result can be followed
by an offer of treatment at the same visit, maximizing treatment coverage and reducing
🔸This treatment method does not produce a specimen for pathological examination.
loss to follow-up.
