Objectives

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Objectives

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

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Cervical Epithelium

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

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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 Lugols 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 Lugols solution

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Squamous Metaplasia

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

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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

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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

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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 Lugols solution

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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

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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

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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
  entire squamocolumnar junction

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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

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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)

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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

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SIL and CIN
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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

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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

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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

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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

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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)

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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

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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