Premalignant and malignant conditions of the cervix

lecture for medical students

1. Dr.Tarig Mahmoud Ahmed MD SUDAN HAIL UNIVERSITY KSA Premalignant and malignant conditions of the cervix

2. Dysplasia is abnormal growth and development of the cervical epithelium Carcinoma-in-situ --- abnormal change in cells but not invading the deeper tissues Incidence of CIN – 1.2 – 12% Usually discovered by the Pap smear[cervical screening] Peak incidence between 25-35 years age

3. Dysplasia can be grading to:

4. Etiology Exact cause is unknown Predisposing factors: Human papilloma virus infection 16 & 18. Multiple partners. High risk sexual partners. Coitus at an early age. Sexually transmitted diseases. Cigarette smoking. immunodeficiency. multiparty.

5. transformation zone The transformation zone is an important area on the cervix which is defined as the area where the original squamocolumnar junction (SCJ) was to the current SCJ ; and it includes areas of metaplasia. The transformation zone (TZ) is the site where premalignancy and malignancy develop.

6. Transformation zone

7. Normal cervix with transformation zone.

8. Diagnosis

9. Pelvic examination : Vagina and adjacent organs are examined visually and bimanually (using both hands). Pap smear : Involves using a small spatula to obtain a sample of the cells from the cervix and any abnormal areas by scraping gently from the cervix. The cells are spread onto a glass slide. The sample is sent to a laboratory to be examined under a microscope.

10. A speculum is inserted into the vagina in order to get a good view of the cervix -you will use a thin wooden stick called a spatula and a soft cervical brush called a cytobrush to remove cells from the cervix. Papanicolaou test…

11. Technic 11 Spatula and cytobrush

12. Colposcopy : If the smear test is abnormal, patient may be referred for a colposcopy in order for a biopsy to be taken. A colposcope is like a small microscope with a light. Abnormal lesions on the cervix are examined using a magnifying device. A small sample of cells (a biopsy) is then taken .

13. Colposcopy 13 Is the examination of the uterine cervix and lower genital tract epithelium under magnification

14. Management of CIN Destructive method: Cryotherapy ( cervix is frozen with liquid nitrogen) Cold coagulation( placing a hot probe on the cervix in outpatients under local anaesthetic.) Electro-diathermy

15. cryotherapy

16. cryotherapy

17. Excisional method : Large loop excision of transformation zone (LLETZ ) : Often used to remove the area of the cervix that contains the abnormal cells. It uses a thin wire to cut away the affected area . Knife cone biopsy: A larger, cone-shaped sample of cervical tissue is removed and examined for cancer cells. Hysterectomy.

18. large loop excision of transformation zone (LLETZ)

19. Knife cone biopsy

20. Cervical cancer is one of the most common cancers, accounting for 6% of all malignancies in women. Worldwide, cervical cancer is second to breast cancer in incidence and mortality. 80% of the new cases occur in developing countries.

21. 2% women above the age of 40 yrs will develop this cancer Average age 45yrs range 40 – 60 years Etiology same as for CIN Pathology: lesion starts at the squamo -columnar junction as an ulcer or fungating mass. Histology: 70% squamous cell cancer, 30% adenocarcinomas and mixed cancer.

22. Clinical Presentation

23. Clinical presentation In all stages Post-coital bleeding Intermenstrual bleeding Post-menopausal bleeding Blood stained vaginal discharge

24. Clinical presentation Pelvic and speculum examination: Cervical mass which bleeds on contact and if advanced disease, a hardness and fixity of the tissues . A biopsy in the outpatient should be taken .

25. Clinical presentation In advanced disease (stages 3-4): Pain (malignant infiltration of the spinal cord). Incontinence (due to vesicovaginal fistulae). Anemia (from chronic vaginal bleeding) . Renal failure (from ureteric blockage)

26. Normal cervix Smooth, pink . Clear mucoid secretion. Central hole-'external os' Nulliparours-round Multiparous-slit or cr u ciate . Cervix in postmenopausal women is atrophic .

27. Ca cervix

28. Cervical Cancer Staging

29. Treatment Stage 1a Surgical treatment- cone excision - infertility to be preserved . Hysterectomy is not necessary Stage 1b Radical hysterectomy- and pelvic nodes dissection should be considered( Wertheim's hysterectomy) . Stages 2 – 4 Radiotherapy ± chemotherapy

30. Radiotherapy Tow types: External radiotherapy ( Teletherapy) Internal radiotherapy (brachytherapy )

31. Cervical cancer is a preventable disease Primary prevention: Education to reduce high risk sexual behaviour Measures to reduce/avoid exposure to HPV and other STIs HPV vaccines Secondary prevention: Treatment of precancerous lesions before they progress to cervical cancer (implies practical screening test).

32. Thank you