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Premalignant lesions of the cervix
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Applied anatomy
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Cervical intraepithelial neoplasia

• It is a continuum from atypia to HSIL
• Confined to epithelium
• Thus non-invasive
• Thus a precursor of cervical cancer
• Pathologically described as CIN 1-3
• Of CIN1 most will regress. Of CIN 2 about a
  third will regress. Of CIN 3 ALL WILL PROGRESS
  TO CaCx

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Epidemiology

• Disease of sexually active women
• Caused by high risk types of HPV namely 16, 18
  and also 31,33,48, 52 and some other types
• Epidemiological risk factors early age of first
  coitus, multiple partners, smoking, immune
  suppression
• Concerns long term use of OC, multiple
  pregnancies, poor nutritional status

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Prevalence

• USA data up to 80 of college graduates are HPV
• By age 30 rate down to 30 HPV
• About 15 of women will have abnormal cytology
• Every year in SA gt20 new cases of CaCx per 100
  000 women
• As common as (or more common than) breast cancer

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Pathogenesis

• Pubertal developments E leads to outgrowth of
  columnar epithelium Exposed SCJ leads to
  METAPLASIA
• If HPV present DYSPLASIA
• Typically HPV -gt atypia -gt LSIL -gt HSIL
• Majority will regress but not all and not much
  from HSIL
• Transmission time varies and can be years

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Clinically

• Mean age 30 (SA screening policy will miss many
  ? Role of HIV)
• Mainly asymptomatic, may have PCB
• Cx may appear normal or have a red lesion
• COLPOSCOPY with acetic acid allows detection of
  abnormal area (acetowhite) -gt biopsy (diagnosis
  made histologically)

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Management of patient with abnormal smears

• See flow diagram (is in GEP and textbook)
• Preferred option is one step management where
  patients with abnormal smears are referred for
  colposcopy and also LLETZ at the same visit
• This may be excessive for LSIL unless repeated or
  have follow-up problems

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Treatment methods

• Local destruction cryotherapy, laser
• Local excision LLETZ, cone biopsy
• Surgical options hysterectomy (uncommonly)
• LLETZ is current first choice management with
  gt95 effectiveness and very few complications and
  side effects
• Bi-to annual cytology for follow-up

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Outcomes

• If left untreated
• HPV, LSIL most will regress
• HSIL all will probably develop CaCx over time
• If HSIL is treated lt5 risk for recurrence (and
  then esp. when HIV)
• If treated and followed ltlt1 risk for later CaCx

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Counselling issues

• Very hard to trace original source of HPV not
  worth the trouble
• Normal PAP smear result is good but follow-up
  screening should be performed
• Male partner most will have HPV but few will
  develop visible lesions (and then usually warts)