cervix.txt

2-3cm

• laterally: cardinal ligaments
• posteriorly: uterosacral ligaments

glandular

• squamous epithelium
• squamocolumnar junction

partial eversion

lower pH of the vagina causes the exposed area of columnar epithelium to undergo metaplasia to squamous epithelium, producing a transformation zone at the squamocolumnar junction

due to the cells undergoing metaplasia which are vulnerable to agents that induce neoplastic change

• upper vaginal branches (vaginal artery is branch of internal iliac artery)
• uterine artery (branch of anterior part of internal iliac artery)

• obturator
• internal and external iliac
• so to the common iliac and para aortic nodes

• lymph
• direct invasion into uterus, bladder, vagina, rectum

• previously called erosion
• columnar epithelium of the endocervix is visible as a read area around the OS on the surface of the cervix

eversion

• young women
• pregnant or taking pill

• normally asymptomatic
• vaginal discharge
• post coital bleeding

• cryotherapy without anaesthetic
• ONLY AFTER A SMEAR, and colposcopy has excluded carcinoma

exposed columnar epithelium is also prone to infection

STD

ulceration and infection

• prolapse
• pessary

chronic inflame or infection often of an ectropion

vaginal discharge

• cryotherapy
• +/- antibiotics depending on bacterial culture

benign tumours of endocervical epithelium

• above 40 years
• 1cm max

• intermenstrual bleeding
• or post coital bleeding

• avulsed without anaesthetic
• examined histologically
• must still Ix bleeding abnormlity

• where sq epi has formed by metaplasia over endocervical cells
• so the columnar cell secretions are trapped and form RETENTION CYSTS
• which appear as white or opaque swellings on the ectocervix

not needed unless symptomatic which is rare

• presence of atypical cells within the squamous epithelium
• cells are dyskaryotic: have larger nuclei with frequent mitoses

mild dysplasia: atypical cells are found only in the lower third of the epithelium

moderate dysplasia: atypical cells found in lower 2/3

• severe dysplasia: atypical cells occupy the full thickness of the epithelium
• this is carcinoma in situ: cells are similar appearance to those in malignant lesions, but there is NO INVASION through basement membrane

1/3 will develop cervical cancer over next 10 years if untreated

• has LEAST malignant potential
• it can progress to CIN2 but commonly regresses SPONTANEOUSLY

HPV strains 16, 18, 31, 33

multiple sexual contacts as HPV is an STD

• OCP
• smoking

• the virus incorporates its DNA into cell DNA at the transformation zone.
• viral proteins inactivate key cell tumour suppressor gene products and push the cell into a cell cycle
• mutations accumulate and can lead to carcinoma
• viruses also cause changes to hide the infected cell from the immune system

• cervical smear: cellular abnormality
• colposcopy: histological abnormality - architecture

CGIN: cervical glandular intrapethilial neoplasia

Asymptomatic

Cervical screening – papaliconaou smear tes

30%

• 1. CIN is harmless but if high grade 30% progress to cancer in 10 years
• 2. CIN will not change rapidly
• 3. CIN will not spread down the vagina
• 4. CIN cannot be passed to her partner – but she can transfer the high risk of HPV

Because cervical cancer is asymptomatic

• Biopsy
• Includes all layers – including basement membrane so can see if it is breached in invasive disease
• Smear only tells us about single layer of surface cells

• 1. significance of the diagnosis and the
• 2. likelihood of progression to invasive disease.
• 3. The patient needs to understand that the abnormal PAP smear says nothing about her sexual history and,
• 4. whilst the CIN is in itself harmless, progression can, of course, be
• 5. extremely serious.

Repeat smear in 6 months and if that is abnormal then go to colposcopy clinic

Straight away

Cusco’s speculum

Transformation zone

• 1. PAP smear repeated & pt tested for high risk HPV using PCR
• 2. 5% acetic acid applied to transformation zone causing protein condensation.

• Causes protein condensation
• Cells with a larger nuclei (dyskaryotic) have large nuclei and little cytoplasm and so will experience more condensation and appear WHITER than surrounding tissue
• So CIN looks whiter

• White when apply acetic acid
• Abnormal vascular pattern: mosaic and punctuation (only if in acteowhite areas)

Biopsy to check basement membrane is not breeched and it is pre-invasive lesion which can be treated locally

Watch and wait

• Completely removing the abnormal epithelium
• 2 techniques:
• 1. Ablative/destructive
• 2. Excisional

• 5 mm into stroma of cervix
• Remove 10mm for best results

• Cold coagulation
• Cryotherapy
• Laser vaporisation

• Quick
• Cheap
• Easy to learn

• No histology for review
• Sometimes patient may have remaining or worse disease than expected and will only present later when symptomatic

• LLETZ: large loop excision of the transformation zone
• Use diathermy generator

• Laser
• NETZ: diathermy wire
• Scalpel
• Knife cone biopsy

• Adv: quick, easy to perform
• Disadv: not easy to tailor the excision to the exact area of the abnormality so high rate of incomplete excision

• Adv: accurate excision with good visibility
• Disadv: more difficult techniques and take longer

• 1. Need GA
• 2. More bleeding

• 1. Sanitary towels not tampons
• 2. No intercourse for 3-4 weeks
• 3. May get vaginal discharge but if foul smelling then come to Dr
• 4. If bleeding come to Dr

yearly

six months after treatment and PAP test and HPV typic swab taken.

• Extends within endocervical canal because metaplasia has occurred
• across the ectocervical part of the transformation zone in the preceding
• years, and now any ongoing metaplasia is occurring within the
• endocervix. It is therefore common to identify both metaplasia and
• dysplasia occurring within the endocervix in the older age group

• Endocervix
• As colposcopy only sees ectocervix, it may miss parts some abnormalities so treatment must include endocervix to be sure that CIN has been removed

• Cone biopsy where both the ectocervical and endocervical dysplastic area are
• excised.

• The cone specimen is then examined by the pathologist and, if
• the margins are clear, cure can be virtually guaranteed, since skip
• lesions do not occur in CIN

Cone biopsy can compromise the structure and the function of the cervix as it relates to conception and pregnancy

• Healing after a cone biopsy can produce cervical fibrosis, interfering
• with dilatation during labour.

cone biopsy might make the cervix incompetent, allowing the pregnancy to miscarry during the mid trimester.

Response by the endocervix to ovulation and the increasing oestrogen levels is an important augmenting factor aiding conception.

• Cervical erosion: infection with HPV
• Symptoms: PCB, vaginal discharge

Because squamous cells are obscured by inflammatory debris

• 1. Treat infection
• 2. Repeat smear test

the symptoms of post-coital bleeding and discharge will disappear, and it will be then possible to provide an adequate cytological sample, to allow accurate diagnosis.

• PCB
• IMB
• PMB
• Profuse offensive vaginal discharge – may be blood stained
• Pain uncommon till very late

• Adenocarcinoma
• As screening does not detect this as it affects the endocervix
• So levels of squamous carcinoma have gone down

• Complete local excision – colposcopically by LLETZ
• As long as depth is < 3mm
• If over 3mm then radical treatment may be needed as cancer can spread to LN

• Surgery
• Radio
• Chemo

• Surgery
• Chemoradiotherapy

Chemoradiothearpy

• Wertheim hysterectomy
• Remove uterus, paracervical tissues surrounding cervix and upper vagina
• Pelvic LN: external, internal iliac, obturator, presacral nodes

• Difficulty complete emptying of bladder
• As parasymp nerves to bladder is divided as it runs in uterosacral ligament

• Cellular abnormality seen on smear test
• Remember CIN cannot be diagnosed just suggested from smear test

• Post op haemorrhage
• Risk of subsequent preterm delivery

30s and 80s

Adenocarcinoma

Immunosuppression: HIV or steroids