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how long is the cervix?
what attaches the cervix to the pelvis?
- laterally: cardinal ligaments
- posteriorly: uterosacral ligaments
what type of epithelium lines the endocervix?
what type of epithelium lines the ectocervix? and what is the name of the part where the 2 meet?
- squamous epithelium
- squamocolumnar junction
what happens during puberty and pregnancy to the cervix?
what process produces the transformation zone?
lower pH of the vagina causes the exposed area of columnar epithelium to undergo metaplasia to squamous epithelium, producing a transformation zone at the squamocolumnar junction
why is the transformation vulnerable to cervical carcinoma?
due to the cells undergoing metaplasia which are vulnerable to agents that induce neoplastic change
what is the blood supply of the cervix?
- upper vaginal branches (vaginal artery is branch of internal iliac artery)
- uterine artery (branch of anterior part of internal iliac artery)
what is the lymph drainage of cervix?
- internal and external iliac
- so to the common iliac and para aortic nodes
where does cervical carcinoma spread to?
- direct invasion into uterus, bladder, vagina, rectum
what is cervical ectropion?
- previously called erosion
- columnar epithelium of the endocervix is visible as a read area around the OS on the surface of the cervix
why does it happen?
who is it found in?
- young women
- pregnant or taking pill
what are the symptoms of cervical ectropion? (3)
- normally asymptomatic
- vaginal discharge
- post coital bleeding
what is the treatment of cervical ectropion? what has to be done first?
- cryotherapy without anaesthetic
- ONLY AFTER A SMEAR, and colposcopy has excluded carcinoma
what is the risk of ectropion?
exposed columnar epithelium is also prone to infection
what causes acute cervicitis?
what are features of acute cervicitis?
ulceration and infection
which disorder can predispose to cervicitis?
what is chronic cervicitis?
chronic inflame or infection often of an ectropion
what is symptom of chronic cervicitis?
what is treatment of chronic cervicitis?
- +/- antibiotics depending on bacterial culture
what are cervical polyps?
benign tumours of endocervical epithelium
what age group does cervical polyps occur and what size max?
what are symptoms of cervical polyps?
- intermenstrual bleeding
- or post coital bleeding
what is treatment of small polyp?
- avulsed without anaesthetic
- examined histologically
- must still Ix bleeding abnormlity
what are nabothian follicles?
- where sq epi has formed by metaplasia over endocervical cells
- so the columnar cell secretions are trapped and form RETENTION CYSTS
- which appear as white or opaque swellings on the ectocervix
what is treatment of nabothian follicles?
not needed unless symptomatic which is rare
what is CIN?
- presence of atypical cells within the squamous epithelium
- cells are dyskaryotic: have larger nuclei with frequent mitoses
what is CIN1?
mild dysplasia: atypical cells are found only in the lower third of the epithelium
what is CIN2?
moderate dysplasia: atypical cells found in lower 2/3
what is CIN3?
- severe dysplasia: atypical cells occupy the full thickness of the epithelium
- this is carcinoma in situ: cells are similar appearance to those in malignant lesions, but there is NO INVASION through basement membrane
what happens to CIN2/3 if untreated?
1/3 will develop cervical cancer over next 10 years if untreated
what is the natural hx of CIN1?
- has LEAST malignant potential
- it can progress to CIN2 but commonly regresses SPONTANEOUSLY
what is the main cause of CIN?
HPV strains 16, 18, 31, 33
what is the main risk factor for CIN?
multiple sexual contacts as HPV is an STD
what are 2 other RF for CIN?
how does HPV cause cancer?
- the virus incorporates its DNA into cell DNA at the transformation zone.
- viral proteins inactivate key cell tumour suppressor gene products and push the cell into a cell cycle
- mutations accumulate and can lead to carcinoma
- viruses also cause changes to hide the infected cell from the immune system
what is done to make the diagnosis of cervical cancer?
- cervical smear: cellular abnormality
- colposcopy: histological abnormality - architecture
what is it called when sometimes abnormal columnar cells are visible?
CGIN: cervical glandular intrapethilial neoplasia
What is the presentation of most CIN?
How are most CIN detected?
Cervical screening – papaliconaou smear tes
What % of high grade CIN will progress to cervical cancer in the next 10 years?
What does a pt with CIN need to be told about CIN? 4 things
- 1. CIN is harmless but if high grade 30% progress to cancer in 10 years
- 2. CIN will not change rapidly
- 3. CIN will not spread down the vagina
- 4. CIN cannot be passed to her partner – but she can transfer the high risk of HPV
Why is screening for cervical cancer so important?
Because cervical cancer is asymptomatic
What investigation is used to confirm the diagnosis and why?
- Includes all layers – including basement membrane so can see if it is breached in invasive disease
- Smear only tells us about single layer of surface cells
What things does the patient who presents with an abnormal PAP smear showing CIN 3 need to be told?
- 1. significance of the diagnosis and the
- 2. likelihood of progression to invasive disease.
- 3. The patient needs to understand that the abnormal PAP smear says nothing about her sexual history and,
- 4. whilst the CIN is in itself harmless, progression can, of course, be
- 5. extremely serious.
When should CIN1 be seen in colposcopy?
Repeat smear in 6 months and if that is abnormal then go to colposcopy clinic
When should CIN2 or CIN3 on smear be seen in colposcopy clinic?
What is used to visualise the cervix?
Which part of the cervix is visualised?
What is done in colposcopy clinic?
- 1. PAP smear repeated & pt tested for high risk HPV using PCR
- 2. 5% acetic acid applied to transformation zone causing protein condensation.
What is the significance of using acetic acid?
- Causes protein condensation
- Cells with a larger nuclei (dyskaryotic) have large nuclei and little cytoplasm and so will experience more condensation and appear WHITER than surrounding tissue
- So CIN looks whiter
What does CIN look like on speculum examination?
- White when apply acetic acid
- Abnormal vascular pattern: mosaic and punctuation (only if in acteowhite areas)
What is done at colposcopy that determines treatment?
Biopsy to check basement membrane is not breeched and it is pre-invasive lesion which can be treated locally
What is the treatment of CIN1?
Watch and wait
What is the treatment of CIN II, III? What are 2 techniques?
- Completely removing the abnormal epithelium
- 2 techniques:
- 1. Ablative/destructive
- 2. Excisional
How deep can CIN extend? And so how much needs to be removed?
- 5 mm into stroma of cervix
- Remove 10mm for best results
What are the different ablative techniques?
- Cold coagulation
- Laser vaporisation
What are the advantages of ablative techniques?
What is the main disadvantage of ablative technique?
- No histology for review
- Sometimes patient may have remaining or worse disease than expected and will only present later when symptomatic
What is the main technique for excision? What does it use?
- LLETZ: large loop excision of the transformation zone
- Use diathermy generator
What are other techniques for excision?
- NETZ: diathermy wire
- Knife cone biopsy
Name one advantage and one disadvantage of LLETZ?
- Adv: quick, easy to perform
- Disadv: not easy to tailor the excision to the exact area of the abnormality so high rate of incomplete excision
Name one advantage and one disadvantage of laser cone biopsy?
- Adv: accurate excision with good visibility
- Disadv: more difficult techniques and take longer
What are 2 disadv of knife cone biopsy?
- 1. Need GA
- 2. More bleeding
What do women need to be warned about after local Rx for CIN?
- 1. Sanitary towels not tampons
- 2. No intercourse for 3-4 weeks
- 3. May get vaginal discharge but if foul smelling then come to Dr
- 4. If bleeding come to Dr
Once cured from CIN, how often to ladies need a PAP smear test?
What needs to be done after local Rx of CIN?
six months after treatment and PAP test and HPV typic swab taken.
Where is the transformation zone in older patients (40+)?
- Extends within endocervical canal because metaplasia has occurred
- across the ectocervical part of the transformation zone in the preceding
- years, and now any ongoing metaplasia is occurring within the
- endocervix. It is therefore common to identify both metaplasia and
- dysplasia occurring within the endocervix in the older age group
where is CIN commonly found in older age group? And what implications does this have for investigations?
- As colposcopy only sees ectocervix, it may miss parts some abnormalities so treatment must include endocervix to be sure that CIN has been removed
What treatment do older pts with CIN need?
- Cone biopsy where both the ectocervical and endocervical dysplastic area are
What needs to be done to guarantee cure in CIN when cone biopsy is done?
- The cone specimen is then examined by the pathologist and, if
- the margins are clear, cure can be virtually guaranteed, since skip
- lesions do not occur in CIN
why is it lucky that mainly older patients need cone biopsy?
Cone biopsy can compromise the structure and the function of the cervix as it relates to conception and pregnancy
How can cone biopsies affect labour?
- Healing after a cone biopsy can produce cervical fibrosis, interfering
- with dilatation during labour.
How can cone biopsy affect pregnancy?
cone biopsy might make the cervix incompetent, allowing the pregnancy to miscarry during the mid trimester.
How can cone biopsy affect conception?
Response by the endocervix to ovulation and the increasing oestrogen levels is an important augmenting factor aiding conception.
If a cervix appears obviously inflamed and there is pus exuding form the glandular epithelium what may it be? Cause and symptoms?
- Cervical erosion: infection with HPV
- Symptoms: PCB, vaginal discharge
In cervical erosion why may a smear test be difficult to interpret?
Because squamous cells are obscured by inflammatory debris
If cervical erosions are found, what is the subsequent management?
- 1. Treat infection
- 2. Repeat smear test
Once the infection of cervical erosion has been treated what should happen?
the symptoms of post-coital bleeding and discharge will disappear, and it will be then possible to provide an adequate cytological sample, to allow accurate diagnosis.
How may patients with larger lesions present?
- Profuse offensive vaginal discharge – may be blood stained
- Pain uncommon till very late
Which type of CANCER of the cervix has been more common and why?
- As screening does not detect this as it affects the endocervix
- So levels of squamous carcinoma have gone down
What is the treatment up to stage 1a?
- Complete local excision – colposcopically by LLETZ
- As long as depth is < 3mm
- If over 3mm then radical treatment may be needed as cancer can spread to LN
What is treatment of stage 1b to 4?
If disease confined to cervix what are 2 Rx options?
If spread beyond cervix what is treatment?
What is the standard surgical procedure for carcinoma of cervix?
- Wertheim hysterectomy
- Remove uterus, paracervical tissues surrounding cervix and upper vagina
- Pelvic LN: external, internal iliac, obturator, presacral nodes
What is the main complication of this procedure? Why?
- Difficulty complete emptying of bladder
- As parasymp nerves to bladder is divided as it runs in uterosacral ligament
What is dyskaryosis?
- Cellular abnormality seen on smear test
- Remember CIN cannot be diagnosed just suggested from smear test
What are the 2 comlpications of LLETZ?
- Post op haemorrhage
- Risk of subsequent preterm delivery
What are the 2 peaks of cervical cancer in age?
30s and 80s
Which type of cervical cancer has worse prognosis?
What can accelerate the process of invasion from CIN?
Immunosuppression: HIV or steroids