2.Cervical benign & premalignant diseases (1).pptx

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1. By Dr.Bekana Fekecha (Asst Prof)

2. Benign diseases of the cervix are common and are unusually asymptomatic or cause minor symptoms but must be differentiated from malignancy. Cervical cancer is the second commonest cancer in women. It is proceeded by a premalignant form years before its invasion. Screening for premalignant disease of the cervix markedly reduces the deaths from cervical cancer.

3. Transformational zone : The area of cervix between the old and new squamo- columnar junction. It is the area of risk of developing premalignant and malignant disease of the cervix.

4. Cervical ectopy (erosion) Cervical eversion (ectropion) Cervical tears Cervical cyst Endocervical polyp. Inflammatory conditions of cervix

5.  CLINICAL FEATURES Symptoms -Vaginal discharge -Contact bleeding -Associated cervicitis may produce backache, pelvic pain Signs p/s bright red area extending beyond external os. Neither tender nor bleeds on touch. Outer edge clearly demarcated The feel is soft, granular and gives rise to grating sensation aetiology

6.  DIAGNOSIS It can be confused with -ectropion -early carcinoma (indurated, friable and bleeds to touch) -primary chancre (ulcer has a punched out appearance. -tubercular ulcer (indurated with caseation at base)  MANAGEMENT All cases should be subjected to cytological examination to exclude dysplasia and malignancy In symptomatic cases -Pill should be stopped and barrier method is advised. -persistent ectopy with troublesome discharge thermal cautrisation cryosurgery laser vaporisation

7.  In chronic cervicitis there is marked thickening of cervical mucosa with underlying tissue edema. These thickened tissue tend to push out through the ex. Os along direction of least resistance.   More marked if cx already lacerated As a result lips of cx curl upwards and outwards exposing red looking endocervix

8. It frequently occurs during vaginal delivery. One or both sides of cx may be torn, or it may b e irregular ( stellate) /star type If these is no infection the torn surfaces approximate and heal leaving a notch if infection persists it causes eversion. Non obstetric causes include lacerations due to operative procedures of D & C Postmenopausal atrophy or chronic cervicitis also predisposes to tear.

9. These include Nabothian cyst Endometriotic cyst Mesonephric cyst

10. Endocervical glands in the transformational zone become covered with squamous cells and forms mucus filled cysts. As this benign process continues, smooth, clear or yellow glandular elevations are visible during routine examination Nabothian cyst warrants no further therapy..

11. E N D O M E TR I O T I C CYST Situated in portio vaginalis part of cx. It is small reddish and <1cm dia. Implantaion of endometrium due to surgery or during labour occurs giving rise to cyst Symptoms -PCB, intermenstrual bleeding -Dy s m e n orrho ea Treatment Destruction by cauterisation Rarely excision M E S O N E P H R I C CYST Usually situated in outer side of cervical stroma Seldom increase 2.5cm. Lined by cuboidal epithelium. They are asymptomatic . Warrants no further treatment

12. It is one of the most common neoplasms It is a hyperplastic projection of the endocervical folds.  T he se le s io n s a r e c o mm o n l y f o u nd a n d ma y be ass o c i a t ed with leukorrhea and post coital spotting If it has a slender stalk it is removed b y continuous twisting using a ring forceps. Twisting leads to occlusion of supporting vessels and avulsion of mass A thick pedicled polyp needs surgical excision Exci s e d c e r vica l p o l y p s r e q u i r e p at h o l o g i c evaluation to rule out malignancy

13. ACUTE CERVICITIS Usually follows child birth, abortion or any operative procedure on cervix. Responsible organisms aregonococcal, chlamydia, thrichomonal vaginosis, mycoplasma and HPV. Clinical features -Painful vaginal examination -Tender, Oedematous and congested cx -Muco purulent discharge seen at os Prognosis -Resolve completely. -infection spreads to adjacent structures. -becomes chronic Treatment -high vaginal endocervical swab to be taken for bacteriological examination -treat with appropriate antibiotics. CHRONIC CERVICITIS Follows attack of acute cervicitis Endocervix i s a potential reservoir of infection with N. gonorrhoeae, chlamydia, HPV, bacterial vaginosis. Clinical features -asymptomatic -excessive mucoid discharge might be present -h/o contact bleeding might be there On examination -Cx is tender M ucopurulent discharge escaping ex. Os Treatment No role of antimicrobial therapy except in gonococcal Diseased tissue destroyed by electo or diathermy cauterisation or laser cryosurgery.

14. C e r v i c a l cancer Normal cervix

15.  DNA virus. Over 100 different types and subtypes of this virus. Common infection a ffecting epithelial surface. Genital HPV is divided into  Low risk type (HPV 6,11) cause genital warts.  High risk types (HPV 16, 18 , 31, 33, 45, 56).  HPV is a common infection while cervical cancer is a rare disease.

16. Fa c tor s tha t incr e as e r is k o f tr a nsmi s sion :      Smoking. Increasing parity. Early age of intercourse. Oral contraceptive pills. Immunity.

17. Metaplasia: change of epithelium from one cell lining (columnar) to another (squamous). Dysplasia : abnormal epithelial cells that fail to maturate. (hyperchromasia, larger, variable size, mitosis). It may be mild, moderate or severe

18. No r m a l CIN 1 ( c o n d y l oma ) CIN 1 (mild d y s p l as i a ) CIN 2 ( m ode r a te d y s p l as i a ) CIN 3 (severe dysplasia/CIS) Invasive cancer CIN 1 Histolog y of squamo us cervical epitheliu m 1

19. O u tcom e o f C I N Spontaneous regression. Progression to invasive cancer.   Progression from one stage to another takes years. Detection and treatment of CIN prevents cancer of cervix .

20. Screening for dyskariosis (change of appearance in cells) by obtaining cervical cytology. Cervical screening should be carried out every 3-5 years in all sexually active women from 20-60 years of age. There is a 10-15 % chance of false positive or false negative results.

21. Is the inspection of the cervix with a low powered microscope. Magnifies the cervix 4-20 times. The patient is put in lithotomy position. Passing a bivalve speculum gently into the vagina.

22. Inspection of the cervix and its vasculature     Abnormal vascular structure includes punctuation and mosaicism ( state of being composed of cells of two genetically different types) . Acetic acid test : application of 3% acetic acid stained the abnormal area. The degree of staining correlates with severity of the lesion. Schiller test : application of Lugol’s iodine stains the normal cervix brown. Colposcopy gives a clinical diagnosis. Punch biopsy from the abnormal area gives a histopathological diagnosis.

23.  CIN II,CIN III. ?CIN I. Techniques for treatment : Excisional : LEEP (loop electrosurgical excision procedure) CO2 laser cone, knife cone, hysterectomy. Ablative: radical electrodiathermy, cold coagulation, cryocautery, laser.  90-95% cure rate

24. Less common than squamous intraepithelial neoplsia. Has same risk factors. Can not be reliably screened by colposcopy. Does not have particular colposcopic features. Divided into high grade and low grade. Characterized by skip lesions. Treatment by large cone biopsy.

25. The first vaccine that intends to prevent cancer. 2 forms of vaccine are available Bivalent 16, 18 (cervarix) Quadrevalent 6, 11, 16, 18.(gardasil)  Now licensed in a number of countries.

26. Benign diseases of cervix are harmless but malignancy should be excluded. Cervical intraepithelial neoplasia proceedes cancer of cervix by years. (CIN 1 to CIN 3 twenty years) Screening for CIN reduces mortality from cancer of cervix . Those with positive screening test should be referred to colposcopy for diagnosis and treatment.