Benign conditions of the cervix

1. Benign conditions of the cervix Dr. Ahmad S. Alkatheri MD

2. Important points about cervical cancer • It is rising in young women. • There are 450,000 cases of cervical cancer/year. • There are 300,000 death/year. • It is the fourth most common cancer (breast, lung, and stomach). • It is a preventable disease (screening programme-cervical smear). • The surgical treatment is mainly for early stage.

3. Cervical Intraepithelial Neoplasia (CIN) • Definition of CIN: • CIN is a pre-invasive changes of the cervical epithelium where the epithelium thickness is replaced by abnormal cells in varying degree without breaching the cell membrane. • symptomless. • Abnormal cytological changes of CIN (immature and disorganized cells) are: • Increased Nuclear/Cytoplasmic ratio. • Prominence of nuclear chromatin. • Multinucleation.

4. Grades of CIN • CIN is graded according the proportion of epithelium occupied by the abnormal cells. • CIN 1 (mild dysplasia): - One-third or less is occupied by the abnormal cells. - Progress to (CIS) in 6%. - Regressed or disappeared in 62%,

5. Grades of CIN • CIN 2(modrate dysplasia): - Between 1/3-2/3 of the epithelium is occupied by the abnormal cells. - Become invasive in 13%. • CIN 3 (severe dysplasia): - The whole thickness of the squamous epithelium is occupied by the abnormal cells. • It is regarded as carcinoma-in-situ (CIS). - It could arise as CIN 3 or progress from CIN 1or CIN 2. - Become invasive in 29%.

6. Incidence of CIN • The incidence of CIN: is 4 to 5% of Pap tests. • The incidence of CIN vary according to the: (1) population studied, as the peak incidence being between 25 and 29 years of age, (2)socioeconomic factors, and (3) risk-related behaviours. • The true incidence and prevalence can only be estimated, as screening cytology and colposcopy lack complete sensitivity.

7. Risk factors (Epidemiology) • Demographic risk factors: • Ethnicity (Latin American countries, U.S. minorities).   • Low socioeconomic status.   • Older age. • Medical risk factors: • Cervical human papilloma virus infection.   • Parity.   • Immunosuppression.

8. Risk factors (Epidemiology) • Behavioural risk factors • Infrequent or absent cancer screening Pap tests.   • Early coitus.   • Multiple sexual partners.   • Male partner who has had multiple sexual partners.   • Tobacco smoking.   • Dietary deficiencies.

9. Risk factors (Epidemiology) • Risk factors for CIN are similar for invasive lesions. • The risk is most strongly related to: (1) infection with a HR HPV type, (2) older age, and (3) most importantly, persistence of the HR HPV infection. • Older age: (1) persistent HPV infection (2)accumulation of mutations leading to cellular malignant transformation (3) less access to cancer prevention programs (decreased needs for prenatal care and contraception).

10. Risk factors (Epidemiology) • Tobacco smoking : - ↑ the risk of cervical cancer among HPV-positive women. • Nicotine and its major metabolite cotinine are found in the cervical mucus of women and in the semen of men who smoke → suppression of local cervical immunity and promotion of HPV-driven cellular transformation and neoplasia. • Dietary deficiencies: - Vitamins such as A, C, E, beta carotene, and folic acid may alter cellular resistance to HPV infection → persistent viral infection and cervical neoplasia.

11. Risk factors (Epidemiology) • Combined Oral Contraception (COC: steroid hormones may affect the HPV genome and increase viral expression of oncoproteins E6 and E7. • Parity > 7 & full term: (1) immunosuppression (cell-mediated arm) (2) hormonal influences on cervical epithelium (3) trauma related to vaginal deliveries.

12. Identification of CIN • Cervical Cytology (The Pap test ): • Initiation of screening: 3 years after onset of vaginal intercourse; no later than age 21. • Screening intervals:(1) age < 30 years: annually, (2) age > 30 years: : every 2 to 3 years after 3 consecutive negative tests. (3) patients with HIV or other immunocompromised state: 2 tests during the first year, then annually. • Discontinuation of screening: Age 65 to 70 in women not at high risk (history of cervical cancer, DES, HPV, HIV, & immunocompromised state).

13. CIN Management A. Abnormal cervical smear: • Due to infection: treat then repeat the smear. • Atrophic smear: give oestrogen then repeat the smear. • Colposcopy. B. Colposcopy: • To view the cervix telescopically at magnification range of 6 to 40 times. • 4% of acetic acid is applied to the cervix which coagulates proteins of the epithelial cells and abnormal epithelium appears white; biopsies should be taken from that area. or

14. CIN Management B. Colposcopy: • Apply Lugol's iodine solution (Schiller test) to the cervix: • Iodine 2 gm, potassium iodide 4 gm and distilled water 300 ml • Malignant cells lack glycogen so they fail to take iodine (stainless). - Normal epithelium (rich in glycogen) stains dark-brown. - Biopsies taken from the non-staining areas. - Squamo-columnar junction should be seen entirely.

15. CIN Management C. Cone biopsies: • indications: - squamo-columnar junction not seen. - negative colposcopic examination with positive repeated cervical smear. • microinvasion or invasion is suspected. • Size: kept to a minimum with normal tissue, tailored & cut with a knife. • D/C is should be done. • Haemostasis: is achieved by using Dexon at 3 & 9 0’clock of the cervix. • Complications: primary & 2nd bleeding & scarring → stenosis → impaired fertility, cryptomenorrhoea, abortion, preterm labour & cervical dystocia.

16. CIN treatment • Knife Cone biopsy. • Total hysterectomy: • Persistent lesion after conization. • Lesion extends to the upper vagina (colposcopy). • Coexisting indication (menorrhagia or prolapse). • Local destruction (ablation): (for young, unmarried or wanting children): • Cryocautery: freezing the tissue. • Electrocautery: burning the transformation zone. • Large loop excision of the transformation zone: using electrodiathermy. • Cold coagulation: destruction of the transformation zone with a probe heated to 100 to 120Ċ.

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