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Objectives

Objectives. Review cervical histology Outline Bethesda 2001 terminology Review management of abnormal cervical cytology. Cervical Epithelium. Original squamous epithelium Vagina and outer ectocervix Columnar epithelium Upper and middle endocervical canal Squamous metaplasia

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Objectives

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  1. Objectives • Review cervical histology • Outline Bethesda 2001 terminology • Review management of abnormal cervical cytology

  2. Cervical Epithelium • Original squamous epithelium • Vagina and outer ectocervix • Columnar epithelium • Upper and middle endocervical canal • Squamous metaplasia • Central ectocervix and lower endocervical canal

  3. Original Squamous Epithelium • Histology • 4 layers • Well glycogenated (unless atrophic) • Colposcopic features • Smooth and featureless • Shades of pink • No change with acetic acid • Stains mahogany with Lugol’s solution

  4. Columnar Epithelium • Histology • Single layer of columnar cells arranged in folds • Mucin producing (not true glands) • Vascular loops • Colposcopic features • Dark red before acetic acid • Grape-like villi and clefts • Rounded papillae after acetic acid • Non-staining with Lugol’s solution

  5. Squamous Metaplasia • Replacement of columnar epithelium by squamous epithelium • Progressive • Stimulated by • Acidic environment with onset of puberty • Estrogen surges causing eversion of endocervix

  6. Squamous Metaplasia • Production of multi-layered undifferentiated, immature squamous metaplastic cells • Obliteration of original columnar cells • Subsequent maturation of immature squamous metaplastic cells to well-differentiated, glycogenated squamous epithelium

  7. Squamous Metaplasia • Colposcopic features • Loss of translucency at tips of villi • Individual villi indistinct • Coalescence of papillae • Columnar cells remain until 3-5 layers of metaplastic squamous cells develop • Continued maturation until formation of fully differentiated squamous epithelium

  8. Mature Squamous Metaplasia • Colposcopic features • Smooth, shiny pink • May be lighter than original squamous cells • Branching subcapillary vessels • Nabothian cysts • Translucent pink/white with acetic acid • Over time will stain with Lugol’s solution

  9. Transformation Zone • Zone between original squamocolumnar junction and the “new” squamocolumnar junction • Colposcopic features • Mature and immature squamous metaplasia • “Gland” openings • Islands of “glands” • Nabothian cysts

  10. Original Squamocolumnar Junction • Placement determined between 18-20 weeks gestation • Most often found on ectocervix • Can be found in vagina or vaginal fornices in DES exposed women • Less apparent over time with maturation of epithelium

  11. “New” Squamocolumnar Junction • Border between squamous epithelium and columnar epithelium • Found on ectocervix or endocervical canal • Majority of cervical cancers and precursor lesions arise in immature squamous metaplasia, i.e. the leading edge of the SCJ • Adequate colposcopy requires visualization of the entiresquamocolumnar junction

  12. Summary • Squamous metaplasia is a progressive, permanent transformation of columnar to squamous epithelium • Immature squamous metaplastic cells are the “fertile ground” of cervical cancer • Adequate colposcopy requires visualization of the entire squamocolumnar junction

  13. Bethesda 2001Negative for Intraepithelial Lesion or Malignancy • Other non-neoplastic findings • Reactive cellular changes associated with inflammation IUD, or radiation • Glandular cells status post hysterectomy • Atrophy • Other • Endometrial cells (women  40 yrs)

  14. Bethesda 2001Epithelial Cell Abnormalities • Squamous cells • Atypical squamous cells • ASC-US: undetermined significance • ASC-H: cannot exclude HSIL • LSIL: low grade (CIN 1) • HSIL: high grade (CIN 2 - 3) • Squamous cell carcinoma

  15. SIL and CIN

  16. Bethesda 2001Epithelial Cell Abnormalities • Glandular cells • Atypical endocervical, endometrial or glandular cells (NOS) • Atypical endocervical or glandular - favor neoplastic • Endocervical adenocarcinoma in situ • Adenocarcinoma: endocervical, endometrial or extrauterine

  17. Management of ASC-USPost-menopausal Women • If atrophy then three management options • Intravaginal estrogen or • 0.5 gm intravaginal estrogen 3x/week for 2 weeks then repeat pap smear 1 week later • If pap negative then repeat pap 4-6 mos •  ASC then colposcopy • Colposcopy or • HPV testing

  18. Management of ASC-H • Colposcopy • Biopsy-confirmed CIN • Pap or LEEP • No lesion seen - review pap smear and colposcopy • No change in interpretation then pap at 6 and 12 mos or HPV testing at 12 mos • Change in interpretation then manage per guidelines

  19. Management of LSIL • Colposcopy - satisfactory • No CIN or cancer • Pap at 6 and 12 mos or HPV testing at 12 mos •  ASC or HPV + then repeat colposcopy • Negative paps or HPV then routine screening • CIN or cancer • Manage per guidelines

  20. Management of HSIL • Colposcopy - satisfactory • No CIN or only CIN 1 • Review pap smear, colposcopy and biopsy material • No change in interpretation then diagnostic excisional procedure • Change in interpretation then manage per guidelines • CIN 2 or 3 • Manage per guidelines (LEEP)

  21. Management of HSIL • Colposcopy unsatisfactory • No lesion identified • Review pap smear, colposcopy and biopsy material • No change in interpretation or only CIN 1 on bx then diagnostic excisional procedure • Change in interpretation then manage per guidelines • Biopsy confirmed CIN (any grade) • Manage per guidelines

  22. Management of Abnormal Paps: Summary • It is essential to correlate cytology, histology and colposcopic findings • Algorithms are flexible and can be tailored to patient population and clinic resources

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