Cervical Intraepithelial Neoplasm

1
Cervical IntraepithelialNeoplasm

• Speaker Tseng Jen-Yu

2
Introduction

• Cervical cancer was the most common malignancy in
  both incidence and mortality among women prior to
  the 20th century
• Incidence fallen dramatically in developed
  nations due to implementation of population based
  screening, detection, and treatment programs for
  pre-invasive disease

3
Epidemiology and Risk Factor

• 500,000 cases of cervical cancer diagnosed
• 2nd leading cause of cancer death
• Risk factors
• Sexually transmitted disease
• Human papilloma virus
• Multiple sexual partners
• Intercourse at early age
• Poor personal hygine
• Immunocompromise
• Cigarette smoking

4
Pathophysiology

• Transformation zone
• Area where glandular epithelium undergoes
  squamous metaplasia
• Metaplasia
• Occurs during fetal development / adolescence /
  and first pregnancy
• Columnar cells replaced by squamous cells
• Cells undergoing metaplasia are vulnerable to
  carcinogens

5
Bethesda System

• LSIL
• Low grade squamous epithelial lesion
• HSIL
• High grade squamous epithelial lesion
• ASCUS
• Atypical squamous cells of undetermined
  significance
• AGUS
• Atypical glandular cells of undetermined
  significance

6
Terminology and Definition

• CIN I
• Mild dysplasia ( lower 1/3 of epithelium )
• CIN II
• Moderate dysplasia ( 2/3 of epithelium )
• CIN III
• Severe dysplasia ( upper 1/3 of epithelium / CIS
  )
• Dysplasia
• Disorder maturation / Nuclear hyperchromatism
• Increased N/C ratio / Pleomorphism / Mitosis

7
(No Transcript)
8
CIN I

• Disease Profile
• Self limited sexually transmitted HPV infection
• 60 regress spontaneously
• 30 persistent
• 10 15 progress to CIN II / III
• 1 progress to invasive cancer

9
(No Transcript)
10

• Treatment
• Ablation ( cryotherapy / laser )
• Excision ( LEEP / Knife conization )
• Follow up without treatment
• Pregnant women
• Immunosuppressed women
• Adolescents

11
CIN II / III

• Disease Profile
• 43 untreated CIN II spontaneous regression
• 32 untreated CIN III spontanenous regression
• 35 CIN II will persist
• 56 CIN III will persist
• 22 CIN II progress to CIS or invasive cancer
• 14 CIN II progress to CIS or invasive cancer

12
(No Transcript)
13

• Treatment
• Ablation ( cryotherapy / laser )
• Excision ( LEEP / Knife conization )
• Follow up without treatment
• Pregnant women
• Adolescents

14
ASCUS

• Represent reactive / reparative changes secondary
  to inflammation
• 5 of routine Pap smears
• Treatment
• Repeat Pap smear in 4 6 months
• Colposcopy if repeat Pap shows ASCUS

15
AGUS

• Suspected glandular lesion that cant be
  classified as reactive or neoplastic
• Higher risk of neoplasia ( adenocarcinoma )
• 0.5 2.5 of routine Pap smear
• Treatment
• Colposcopy
• Conization ECC

16
Colposcopy

• Acetic acid
• coagulation of nuclear protein preventing light
  to pass through the epithelium
• Higher nuclear density and higher concentration
  of protein gt white intensity increase

17

• Schiller / Lugols Iodine
• Normal, mature squamous epithelium contains
  abundant glycogen
• Produce dark brown stain
• Abnormal epithelium contains relatively little
  or no glycogen
• Remain relative unstained

18
Cryotherapy

• Indication
• Cytology / Colposcopy / ECC gt No microinvasion
• Lesion in ectocervix
• Criteria
• CIN I / II
• Small lesion
• Ectocervix
• ECC negative
• No endocervical gland involvement

19
Conization

• Indication
• Unsatisfactory colposcopy
• Evidence of premalignant or malignant glandular
  epithelium
• Microinvasion on biopsy / colposcopy / Pap smear
• HSIL ( CIN II / CIN III )
• Uncertainty regarding presence of microinvsaion
  or invasion following direct biopsy for CIn
• Inconsistent Pap smear and colposcopy

20
Cold Knife

• Indication
• Lesion extend to endocervical canal and extent
  not possible to confirm
• Extent exceeds capability of LEEP ( 1.5 cm )
• Cytology shows atypical glandular cells
• Colposcopy suggest glandular dysplasia or
  adenocarcinoma
• Abnormal endocervical curretage

21
Thank You for your attention