Introduction:
1964 cervical screening programme introduced in UK.
1988 NIIS cervical screening programme national co-ordinated network.
Cervical cancer is the 8th most common cancer in women (and the most common
cancer in women under the age of 35 years).Histopathology:
The cervix consists of the colunmar epithelium of the endocervix and the stratified squamous epithelium of the ectocervix. The point where the 2 types of epithelium meet is called the squamo-columnar junction. This is the area where the exposed columnar epithelium undergoes metaplasia to squamous epithelium. A smear is taken from the squamo-columnar junction as this is the active region where carcinoma first develops.
The cytologist looks at the size of nuclei and the nuclear/cytoplasmic ratio of cells on the smear slide. Normal cells develop a small nucleus as they migrate up from the basal layer. In malignant transformation epithelial turnover increases and causes immature cells with larger nuclei to reach the surface (these are called dyskaryotic cells). Dyskaryosis is therefore used to describe the cytological appearance of abnormal smears. Dysplasia, as distinct from dyskaryosis is used to describe The histological appearances of abnormal cervical tissue taken at biopsy. The link between dvskaryosis/dysplasia and CIN (cervical intraepithelial neoplasia) is shown in table 12.6.
Natural history:
Possible phases of progression to invasive carcinoma of the cervix:
Normal cervix >>> Mild dysplasia >>> Moderate/severe dysplasia >>> Carcinoma in situ >>> Invasive carcinoma
It is thought that progression from cervical dysplasia to carcinoma in situ normally takes over 10 years. However progression may be more rapid.Risk factors:
1) Sexual behavior; an increased no. of sexual partners increases risk (and so does by inference young age at first intercourse and young age at first pregnancy).
2) Sexually transmitted factors: HPV (Human Papilloma Virus — particularly types 16 and 18).
3) Method of contraception: COCP (controversial); barrier methods may be protective.
4) Lower social class: probably due to earlier marriage, more pregnancies and more partners.
5) Smoking.So what advise would you give to patients to decrease their risk factors for developing carcinoma of the cervix?
Screening guidelines:
The present UK guidelines are that all women aged 20 —64 who are or have ever been sexually active should be screened. It is suggested that screening should stop at age 65 if a woman has had regular negative smears. A smear should be taken at least every 5 years. Many screening programmes adopt a 3 year recall policy, whilst in other areas it varies with age. Women who have never been sexually active do not need to be screened. There is a national call and recall system.
Taking a smear:
Aylesbury spatula (+/- cytobrush).
Best time = days 10-20 of a 28 day cycle.
Results, their interpretation and management:
Tables 12.6 and 12.7
Colposcopy:
The colposcope is a low-powered microscope for viewing the cervix. During the investigation the patient lies on her back with her legs up in stirrups. The cervix is exposed with a bivalve speculum. The colposcope remains 1-l5cms away from the peritoneum and the cervix is magnified x 10. The cervix is wiped with normal saline. Abnormal epitheliuin may appear a deeper pink than the normal pale pink squamous epithelium. Next the cervix is painted with 5% acetic acid which is a protein coagulant that stains abnormal immature epithelium white (because immature cells have less glycogen and more cytoplasmic protein). The degree of’whiteness of the demarcated area and the coarseness of the vascular pattern visible allows an estimate of the degree of CIN present. A punch biopsy is taken and local destructive therapy applied then or later after histology results are known. (Methods of treatment = diathermy, cold coagulation, laser, cryocautery, laser cone biopsy, LLETZ, cold knife). Arrange appropriate follow up.
Inadequate.
Insufficient cellular material. Inadequate fixation. Smear consisting mainly of blood or inflammatory cell exudates.Little or no material to suggest that the transformation zone has been sampled
Repeat smear
Negative.
Normal. Includes simple inflammatory changes including a mild polymorph exudates. Routine recall
Borderline changes, with or without HPV change. Cellular appearance that cannot be described as normal. Smears in which there is doubt as to whether the nuclear changes are inflammatory or dyskaryosis. Repeat smear at 6 months. Consider for colposcopy if changes persist Mild dyskaryosis with or without HPV change Cellular appearances consistent with origin from GIN I (mild dysplasia Repeat smear at 6 months. Consider for colposcopy if changes persist Moderate dyskaryosis with or without HPV change Cellular appearances consistent with origin from GIN II (moderate dysplasia) Refer for colposcopy
Severe dyskaryosis with or without HPV change Cellular appearances consistent with origin from GIN III (severe dysplasialcarcinoma in situ) Refer for colposcopy
Severe dyskaryosis/? invasive carcinoma Cellular appearances consistent with origin from GIN III, but with additional features which suggest the possibility of invasive cancer Refer for colposcopy
Glandular neoplasia for suspicion of glandular neoplasia Cellular appearances suggesting pre-cancer or cancer in the cervical canal or the endometrium. Refer for colposcopy
Note: The use of the term atypical ceNt is no longer recommended in the result Codes and its use should be discontinued. The preferred term is Borderline changes (atypia may still be used, but the degree of atypia should be clarified in the Resuk Code)
Sources: BSCC (1989); I. Duncan (1991); Austoker and McPherson (1992); Austoker and Davey (In press)
Specific infections Trichomonas, Candida, and cell changes associated with herpes simplex can be identified Trichomonas — treat Candida — treat if symptoms Herpes — no treatment — to discuss with patient Actinomyces Organisms associated with IUD No consensus. Alternatives (1) do nothing unless other symptoms, e.g. pain or discharge; (2) change coil and the Actinomyces organisms will disappear Endocervical cells Cells from the glandular epithelium of the cervical canal. During its formation the transformation zone will include similar epithelium No action needed Metaplastic cells (metaplasia/squamous metaplasia) Normal cells from the transformation zone that are ideally contained in a smear No action needed Cytolysis Normal process of cell disintegration No action needed Endometrial cells Cells derived from the endometrial lining of the uterine cavity. Shed during menstruation and in some other circumstances If TUD present — probably normal finding. If 1—12 day of 28-day cycle — normal finding. Otherwise discuss with laboratory or local gynecologist Inflammatory changes Cellular appearance present in some degree in many smears and not evidence of CIN No consensus. Alternatives (1) do nothing; (2) take high vaginal swabs for culture and sensitivity and take chlamydial swabs. Then treat as necessary Atrophic smear Common in post-menopausal smears, i.e. when oestrogen and progesterone levels are low. Similar changes are seen in postnatal smears. No action needed
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