Cervical disease and neoplasms
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Cervical Disease and Neoplasms. Maria Horvat, MD, FACOG. Cervical Disease – Risk factors. HPV Smoking – 2 fold increase Young age at 1 st coitus Multiple sexual partners A partner with multiple sexual partners High parity Lower socioeconomic status Young age at 1 st pregnancy.

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Cervical Disease and Neoplasms

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Cervical disease and neoplasms

Cervical Diseaseand Neoplasms

Maria Horvat, MD, FACOG

Cervical disease risk factors

Cervical Disease – Risk factors

  • HPV

  • Smoking – 2 fold increase

  • Young age at 1st coitus

  • Multiple sexual partners

  • A partner with multiple sexual partners

  • High parity

  • Lower socioeconomic status

  • Young age at 1st pregnancy

Hpv in the united states

HPV in the United States

Cervical disease

Cervical Disease

  • HPV associated with 99.7% of all cervical cancer

  • HPV types associated with higher oncogenic risk:

    • 16, 18

    • 31, 33, 35

    • 45

    • 51, 56

Hpv high risk types

HPV – high risk types

Cervical disease and neoplasms


  • Obligatory intra-nuclear virus

  • Most remit spontaneously

  • 5% of infected women have persistent infection

Pap test

PAP test

  • Only a screening test

  • Goal:

    • To prevent cervical cancer

Histology of sil squamous intraepithelial lesions

Histology of (SIL) squamous intraepithelial lesions.

Grade 1 = CIN 1; Grade 2 = CIN 2; Grade 3 = CIN 3

Cervical neoplasia

Cervical Neoplasia

Potential co factors in cervical carcinogenesis

Potential Co-Factors in Cervical Carcinogenesis

  • Other infectious agents

    • Herpes

    • Chlamydia

    • HIV and other immunosuppression

  • Diet

  • Smoking

  • Hormonal contraceptives

    • Weak immunomodulatory effect

    • Eversion of columnar epithelium

    • Decrease in blood folate levels

    • Progesterone effect on HPV

Management of adolescent women 18 yrs with histological diagnosis of cin grade 1

Management of Adolescent Women (<18 yrs) with histological diagnosis of CIN – Grade 1

< 18 yrs old with CIN 1

Repeat Cytology at 12 mos


Repeat Cytology at 12 mos

Negative > ASC Colposcopy

Routine Screening

Management of adolescent women 18 yrs with histological diagnosis of cin grade 2 3

Management of Adolescent women (<18 yrs) with histological diagnosis of CIN – grade 2,3

<18 yrs old with CIN 2,3

Either treatment or observation is acceptable, provided colposcopy is satisfactory.

When CIN 2 is specified, observation is preferred. When CIN 3 is specified, or colposcopy is unsatisfactory, treatment is recommended.

Observation OR Treatment

With colposcopy and cytology with excision or

at 6 mos intervals for 24 mos ablation of T-zone

2x negative cytology colposcopy worsens or

And normal colpo. High-grade cytology or

colpo. Persists for 1 yr.

Routine Screening Repeat Biopsy CIN 3, or CIN 2 that persists

Recommended for 24 mos since initial dx

Management of women with atypical squamous cells cannot exclude high grade sil asc h

Management of Women with Atypical Squamous Cells: Cannot exclude high grade SIL (ASC – H)

>20 yrs old with ASC-H

Coloposcopic Examination

Management of women with atypical squamous cells of undetermined significance asc us

Management of Women with Atypical Squamous cells of undetermined significance - ASC-US

>20 yrs old with ASC-US

Repeat Cytology HPV DNA testing

@ 4-6 mos

Negative >ASC Positive Negative

(for high risk type)


@ 4-6 mos Colposcopy Repeat cytol.

@ 12 mos



Cervical intraepithelial neoplasia

Cervical Intraepithelial Neoplasia

Colposcopic grading

Colposcopic Grading

Summary for the non gynecologist

Summary for the non-gynecologist


Negative HPV type Positive

Repeat Pap Refer for

in 6 mos coloposcopy

Cin 1 mild dysplasia

CIN 1 – mild dysplasia

< 18 yrs old >18 yrs old

Repeat Pap Colposcopy

Cin 2 3

CIN 2,3


Confirmed cin 2 3

Confirmed CIN 2,3


(adolescents may perform colposcopy q 6 mos up to 24 mos)

Interventional techniques excisional

Interventional Techniques - Excisional

  • Conization

    • Cone of tissue is excised for further examination and/or to remove a lesion

    • Tissue is usually stained with iodine to demarcate the area of resection

    • Cold knife

    • Laser

  • LEEP

    • Loop electrosurgical excision procedure

    • May be complicated by burn artifacts

  • Ablative

    • Cryotherapy

      • Use of a probe containing carbon dioxide or nitrous oxide to freeze the entire transformation zone and area or the lesion

    • Laser vaporization therapy

Atypical glandular cells

Atypical Glandular Cells




Endometrial Sample, women >35 yrs

What is colposcopy

What is colposcopy?

Cervical cancer staging review

Cervical Cancer – staging review

  • Stage 0: CIS, CIN grade III

  • Stage 1: carcinoma strictly confined to the cervix

  • Stage 2: cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina

  • Stage 3: carcinoma has extended to the pelvic wall. On rectal exam there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower 1/3 of the vagina. All cases with hydronephrosis or non-functioning kidney unless known to be due to other causes.

  • Stage 4: Carcinoma has extended beyond the true pelvis, or has involved the mucosa of the bladder or rectum.

Cervical cancer staging

Cervical Cancer Staging

  • Stage 0: The cancer cells are very superficial (only affecting the surface) are found only in the layer of cells lining the cervix, and they have not grown into (invaded) deeper tissues of the cervix. This stage is also called carcinoma in situ (CIS) or cervical intraepithelial neoplasis (CIN) grade III.

Cervical cancer staging1

Cervical Cancer Staging

  • Stage I: In this stage the cancer has invaded the cervix, but it has not spread anywhere else.

  • Stage IA: This is the earliest form of stage I. There is a very small amount of cancer, and it can be seen only under a microscope.

  • Stage IA1: The area of invasion is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide.

  • Stage IA2: The area of invasion is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide.

  • Stage IB: This stage includes Stage I cancers that can be seen without a microscope. This stage also includes cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm.

  • Stage IB1: The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches).

  • Stage IB2: The cancer can be seen and is larger than 4 cm

Cervical cancer staging2

Cervical Cancer Staging

  • Stage II: In this stage, the cancer has grown beyond the cervix and uterus, but hasn't spread to the walls of the pelvis or the lower part of the vagina.

  • Stage IIA: The cancer has not spread into the tissues next to the cervix (called the parametria). The cancer may have grown into the upper part of the vagina.

  • Stage IIB: The cancer has spread into the tissues next to the cervix

Cervical cancer staging3

Cervical Cancer Staging

  • Stage III: The cancer has spread to the lower part of the vagina or the pelvic wall. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder).

  • Stage IIIA: The cancer has spread to the lower third of the vagina but not to the pelvic wall.

  • Stage IIIB: The cancer has grown into the pelvic wall. If the tumor has blocked the ureters (a condition called hydronephrosis) it is also a stage IIIB.

Cervical cancer staging4

Cervical Cancer Staging

  • Stage IV: This is the most advanced stage of cervical cancer. The cancer has spread to nearby organs or other parts of the body.

  • Stage IVA: The cancer has spread to the bladder or rectum, which are organs close to the cervix.

  • Stage IVB: The cancer has spread to distant organs beyond the pelvic area, such as the lungs.

Question 1

Question #1.

  • What if HGSIL pap and normal colposcopy?

Answer 1

Answer #1.

  • LEEP or cone biopsy.

Question 2

Question #2.

  • Biopsy on face cervix is normal and ECC is positive, what is the next step?

Answer 2

Answer #2.

  • LEEP or cone biopsy.

There is hope

There is hope!

  • Gardisil immunization guards against types 6, 11, 16, and 18.

  • Administer at 0, 2, and 6 months for females 9 years or older.

Hpv vaccine trials

HPV Vaccine Trials

Phase 2 trial of quadrivalent hpv vaccine conclusions

Phase 2 Trial of Quadrivalent HPV Vaccine: Conclusions

  • The vaccine was highly effective in reducing incidence of persistent HPV infection

  • Efficacy with regard to clinical disease associated with HPV types 6,11,16,18, was 100%

  • The vaccine was highly immunogenic, inducing high antibody titers to each HPV type

  • The vaccine was generally well tolerated

Do condoms help prevent

Do condoms help prevent?

  • YES!

  • 60% decrease in transmission

  • Does not eliminate risk.

Pap smear schedules

Pap smear schedules:

  • Many different recommendations

  • ACOG

  • APGO

  • ACS

Pap smear recommendations

Pap smear recommendations

  • 1st pap by age 21 or within 3 years of 1st coitus

  • Annually until the age of 30

  • Pap with HPV at age 30, then can perform every few years.

Pap smear recommendations1

Pap smear recommendations:

  • Post Menopausal

    • Some guidelines: No Pap

    • ACOG: q 3-5 years

  • Hysterectomized female:

    • If hysterectomy for benign reasons, then pap q 3-5 years

      • Yearly if:

        • Cervix present

        • History of abnormal paps

        • History of gyne cancer

        • History of DES exposure

        • History of cervical cancer

        • Smoking (increases chance of vaginal cancer)



  • APGO Educational Series on Women’s Health Issues: Advances in the Screening, Diagnosis, and Treatment of Cervical Disease

  • Review in Obstetrics and Gynecology, Vol. 1 No. 1 2008

  • American Society for Colposcopy and Cervical Pathology

  • Crosstalk; Preventing Cervical Cancer and Other Human Papillomavirus-related diseases

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