Cervical Carcinoma and Precancer

1. Teaching Hospital of the Medical University Graz Pathology Cervical Carcinoma and Precancer Sigurd F. Lax Department of Pathology, General Hospital Graz West, Graz, Austria

2. Global Incidence of cervical carcinoma (WHO, 2000)

3. Epidemiology of cervical carcinoma • HPV • Socio-economic status • Dramatic decrease of the incidence by cervical cytology screening

4. Cervical carcinoma and precursor CIN AIS HPV Squamous cell carcinoma Adenocarcinoma

5. Statistik Austria: Incidence &mortality of cervical carcinoma 83-01

6. WHO: Incidence & mortality of cervical carcinoma in Finland

7. Risk factors for cervical carcinoma • HPV infection • Cigarette smoking • Multiparity • Oral contraceptivs • Other STD (Chlamydia trachomatis) • Poor nutritional status

8. HPV Infection versus Persistence/ Malignant Transformation

9. High risk HPV and Age-specific Incidence of Cervical Carcinoma in the Netherlands Bosch et al. J Clin Pathol 2002

10. HPV and Cervix • Almost all cervical neoplasias HPV-related (99.7% of all cervical carcinomas world wide) • HPV-positivity strongest independent rik factor for the development of cervical carcinoma • HPV Prevalence among 30-40 year-old: US10-20%; NL 5% • Depending on sensitivity of the used method • In USA newly diagnosed 13000 invasive cervical carcinomas and 1 000 000 SIL per anno

11. Fundus Corpus Endometrial stroma Cavum Endometrium Glandular epithelium Perimetrium Isthmus Reserve cells Endocervix Mucinous epithelium Cervix Portio Squamous epithelium Uterus Modified acc. to Lax et al: Böcker, 4th ed., 2008

12. Anatomy of the uterine cervix • Ectocervix: squamous epithelium (non-keratinizing, glycogen-rich) • Endocervix: glandular epithelium, „glands“ (clefts) • Transformation zone: squamous metaplasia

13. Transformation zone • Changes during life (Epithelial transformation, moving of the squamo-columnar junction) • Proliferation of reserve cells (undermine squamous epithelium): „labile epithelium“ • Predominant site of most pathological changes, in particular intraepithelial neoplasia

14. Fertile period of life Before puberty Squamous metaplasia Endocervical mucosa Ectopy (Eversion) New squamo-columnar junction Squamous epithelium Modified acc. to Lax et al: Böcker, 4th ed., 2008

15. Pathology of the uterine cervix • Reactive changes • inflammation • Neoplastic changes • Non-invasive (precursor lesions; “precancer”) • Invasive (cancer) Central and crucial role of HPV!

16. Uterine cervix: Pathology and clinic • Early changes (CIN): cytology and colposcopy • Clinical tumours: contact bleeding, hemorrhagic discharge

17. Precancers of the uterine cervix • Squamous epithelium: • Cervical intraepithelial neoplasia (CIN 1-3) • Squamous intraepithelial lesion: low / high grade • Columnar epithelium: • (glandular dysplasia) • Adenocarcinoma in situ (AIS) • Association with HPV (up to 100%)!

18. Terminology of non-invasive squamous lesions

19. CIN and Prognosis

20. Flat condyloma • Considered among CIN 1 • No distinction by cervical cytology from CIN 1

21. Dysplasia / Intraepithelial Neoplasia • Architectural and cytological abnormalities (atypia)

22. HPV and cervical neoplasia • Almost all cervical neoplasia HPV-associated (99.7% of all cervical carcinomas world-wide) • HPV-positivity strongest independent risk factor for development of cervical carcinoma • HPV prevalence among 30-40 year old: US10-20%; NL 5% • Depends on sensitivity of used method

23. HPV Structure Episomal HPV Genome E6 URR E7 L1 E1 integrated HPV Genome L2 cellular L1 E7 E1 E2/4/5 L2 URR E6 cellular E2 E4 E5

24. Molecular mechanisms of HPV on the host cell DNA damage Apoptosis HPV E6 p53 Cyclin / cdk-complexes p21 Telomerase HPV E7 E2F pRB cdk4 Cyclin E p16 G1- cell cycle arrest DNA sythesis

25. HPV 16 Infection Invasive Carcinoma Intraepithelial Neoplasia Normal basal cell polyclonal monoclonal different subclones diploid aneuploid deregulated cell cycle (high proliferation rate) Regulated cell cycle Increasing losses and gains of alleles Episomal Viral DNA Integrated Viral DNA regulated episomal E6/E7 expression constitutive E6/E7 expression 3q amplification Modified after Crum C et al. Mod Pathol 2000

26. Cellular effects of HPV: LSIL • Infection of the basal- (reserve-) cells • Suprabasal expression of E-proteins • Further differentiation: Induction of all viral genes, viral DNA synthesis, viral replication • Nuclear enlargement, hyperchromasia: direct consequence of E6/E7 mediated activation of host DNA-synthesis (ineffective, because excessive) • Koilocytes: Expression of keratin-binding protein E4

27. Cellular effects of HPV: HSIL • Coordination between cellular differentiation and expression of viral E- proteins lost; Causes unclear • Virus integration or mutation in E2? (subsequently E2- controlled regulation of E6/E7 expression) • Cell proliferation predominates differentiation • Supported by cofactors? (other viruses, smoking, spontaneous mutations etc.) • Occurs less frequent than LSIL

28. Cell transformation in squamous intraepithelial lesions Terminally differentiated cells Committed cells Basal and stem cells Transformed terminally differentiated cells LSIL / CIN 1 Committed cells Basal and stem cells Lack of terminal differentiation HSIL / CIN 2&3 Transformed basal/stem and committed cells

29. “Molecular markers” for CIN diagnosis • HPV • p16 • “Proliferationsmarker” (Ki-67, PCNA) • pRb • Cytokeratine 13 und 14 • p63 • Telomerase • CEA

30. HPV in situ Hybridisation • HPV in situ Hybridisation helpful for the differential diagnosis between HPV associated cytopathic changes (e.g. koilocytes) and reactive/ metaplastic changes • Disadvantage: method more laborious and more expensive, but full automatisation available

31. Ki-67 (Mib 1) • Expression during the cell cycle • In normal epithelium expression only in suprabasal and a few basal cells (hormone dependence) • HPV infection leads to activation of the cell cycle • LSIL: positive cells in the superficial third of the epithelium (not found in reactive changes) • HSIL: multple positive cells throughout the epithelium • Assist in the distinction of SIL from reactive changes !

32. p16INK4 • Overexpression in CIN, AIS and most carcinomas; • Association with HPV: RB Inactivation ?! • Good correlation with SIL/CIN • Detection of dysplastic cells in Pap smears (Klaes et al. Int J Cancer 2001)

33. p16 and CIN Klaes et al., AJSP 2002, Branca et al., IJGP 2004, Tringler et al. Hum Pathol 2004 • Diffuse positive p16 immunoreactivity only in invasive carcinomas, CIN2/3 and CIN1 associated with high risk HPV • Part of CIN 1-3 negative for p16 • No predictive value for high risk HPV clearance after conisation, no prognostic value for carcinomas • Positivity also in reactive and metaplastic epithelium

34. p63Quade et al. Gynecol Oncol 2001; Ince et al. AJP, 2002 • Homologous to p53 • Expression in immature squamous epithelium and reserve cells • Marker for maturation and differentiation • Important role for the development of the urogenital tract • Inactivation of p63 leads to malformations

35. P63 and precursors • Normal squamous epithelium: Expression in basal and parabasal cells • CIN 1: basal and parabasal cells • CIN 2&3: in upper levels of the epithelium • Atrophy: Expression in the whole epithelium • AIS: no Expression

36. p63 and Ki-67 • Correlation between maturation and proliferation • Normal squamous epithelium: Ki67 suprabasal • CIN1: Koilocytes Ki-67 positive, p63 negative • CIN2&3: Ki-67 and p63 also in the superficial layers • Atrophy: no Ki-67 positivity

37. The Technique of in situ Hybridisation From: Böcker et al., 4th ed., 2008

38. Adenocarcinoma in situ (AIS/ACIS) • Normal glandular or surface epithelium replaced by neoplastic epithelium • No invasion • Concomitant CIN in ca. 50% • Atypical Pap Smear only in 50%

39. Malignant Tumours • Carcinoma • Squamous cell carcinoma (Keratinizing or non-keratinizing) • Adenocarcinoma • Rare types (adenosquamous, small cell carcinoma) • Malignant lymphoma

40. Invasive cervical carcinoma • Any age; peak incidence at 40-45 years • Cervix enlarged, ton-like, ulcerated tumor • Spread: to parametrium, vagina, rectum, bladder • Metastases to pelvic and para-aortal lymph nodes, lungs, liver, bone • Prognosis depends on stage: 95%-85%-75%-<50% (IA-IB-II-III and>)

41. Microinvasive squamous cell carcinoma • No palpable or visible tumour • Diagnosed on cone or punch biopsy • Pathological cytology (Pap IV/HSIL) • Horizontal extension: 7 mm maximum • Depth of infiltration: 3 and 5 mm, respectively • Therapy: cone biopsy or vaginal hysterectomy (+/- lymphadenectomy) • Lymph node metastases rare (<5% even at stage IA2) • Prognosis excellent

42. Prognostic Faktors of Squamous Cell Microcarcinoma Raspagliesi et al. Int J Gynecol Cancer 2005 • 67 Microcarcinoma pT1a • Therapy with conisation • Lymph vascular invasion • Distance to the endocervical margin > 10 mm

43. Adenocarcinoma • Less frequent compared to SCC (10-20% of cervical carcinomas) • Association with HPV Typ 18 • Same spread and behavior as squamous cell carcinoma • Adenosquamous carcinoma: origin from stem cells? Poor behavior • Microinvasive adenocarcinoma • Rare tumour • Excellent prognosis

44. Therapy of invasive cervical carcinoma • Depends from stage • Stage (FIGO) determined before therapy by clinical examination (remains unchanged after therapy)