Cervical Biopsy - Obstetrics & Gynaecology

Principles, indications, methods, steps, advantages and disadvantages of cervical biopsy.
OBSTETRICS and GYNAECOLOGY

1. Cervical Biopsy Apoorva Kottary

2. Contents Anatomy Cervical Biopsy Types Punch Biopsy Wedge Biopsy Ring Biopsy Cone Biopsy Complications

3. Basic Anatomy It is lowermost part of the uterus. Cylindrical in shape and measures about 2.5 cm It lies between the histological internal os and the vagina. Mainly composed of fibrous connective tissue. With average of 10-15 % smooth muscle fibers.

4. Transitional zone - also known as squamo -columnar junction or tranformation zone , where the squamous epithlium of the vagina merges with the columnar epithelium of the endocervix and is around 1-10 mm. I t is not static and changes with hormone level of oestrogen .

5. Squamo -Columnar Junction The constant cellular activity of the cells makes the cell highly sensitive to irritants mutagens and viral agents such as papilloma virus 16,18 These nuclear changes eventually lead to dysplasia and carcinoma cervix.

6. Cervical Biopsy Removal of a small sample of tissue of the cervix for examination under a microscope; used for the diagnosis and treatment of cervical cancer and precancerous conditions .

7. Types of Cervical Biopsy Punch Biopsy Wedge Biopsy Ring Biopsy Cone Biopsy – Conization Surface Biopsy – Pap Smear for cytology

8. Punch Biopsy An out patient procedure without anesthesia Using Cusco’s Bivalve Speculum biopsy is taken from the suspected area or a 4-quadrant using Punch Biopsy forceps. It can be also Colposcopic directed or stained with Schiller’s iodine or Acetic acid

9. Iodine staining revealing saffron-colored abnormal area. Acetowhite lesion after washing with acetic acid.

10. A : Graves or Pederson speculum, B: Endocervical curette, C: Tischler punch biopsy forceps, D: Fixative for histology (formalin), E: Cytobrush , F: Proto swabs/“ pom-pom” vaginal swabs, G: Monsel’s solution (ferrous subsulfate ), H: Silver nitrate sticks, I: Lugol’s iodine solution , J: 3% acetic acid, K: Cervical speculum.

11. Wedge Biopsy It is done when definite growth is visible An area near the edge is the ideal site Steps: Posterior vaginal speculum is introduced. Anterior and the posterior lip of the cervix is held by Alley’s forceps. With a scalpel, a wedge of tissues is cut from the edge of the lesion including the healthy tissue for comparative histological study.

12. Ring Biopsy Whole of squamo -columnar junction area of the cervix is excised with a special knife. The tissue is subjected to serial section to detect cervical intraepithelial neoplasia (CIN) or early invasive carcinoma.

13. Cone Biopsy - Conization Both diagnostic and therapeutic purpose Removal of cone of the cervix which includes entire Squamocolumnar junction, stroma with glands and endocervical mucous membrane. Methods: Cold knife, CO₂ laser, Laser diathermy loop

14. Indication: Unsatisfactory Colposcopic findings Inconsistent findings - Colposcopic , Cytology and directed biopsy Positive endocervical curettage for CIN II and III When biopsy cannot rule out invasive cancer from carcinoma in-situ Biopsy shows microinvasion – to exclude gross invasive carcinoma

15. Steps in Cold Knife Under general anesthesia Blood loss is minimized with prior haemostatic sutures at 3 o'clock and 9 o'clock positions on the cervix by ligating the descending cervical branches. The cone is cut so as to keep the apex below the internal os . After the cone is removed, a margin suture is placed at 12 o'clock for identification of the cone.

16. Routine endocervical curette above the apex of the cone is performed and uterine curettage is done if indicated Cone margins are repaired by haemostatic sutures. The excised cervical tissue is sent for histological examination (serial section – minimum 6) If the margins of the cone are involved in neoplasia , hysterectomy should be considered either before 48 hours or before 6 weeks to prevent infection.

17. Advantages of Laser over Cold Knife Done in the out patient under local anesthesia Less tissue damage and less blood loss Less post operative pain and morbidity All types of CIN can be treated Fertility and pregnancy outcomes are not affected adversely

18. Complications Secondary Hemorrhage Cervical stenosis leading to Haematometra Infertility Diminished cervical mucus Cervical incompetence leading to recurrent miscarriage

19. Bibliography Howkins & Bourne Shaw’s Textbook of Gynaecology – 16 th edition D. C. Dutta’s Textbook of Gynaecology – Hiralal Konar – 8 th edition

20. Thank you