CERVICAL INTRAEPITHELIAL

NEOPLASIAPROF. M.C. BANSAL

M.B.B.S , M.S. , M.I.C.O.G, F.I.C.O.G.Founder Principal& Controller;

Jhalawar Medical College and Hospital Jhalawar.

Ex. Principal & Controller;

Mahatma Gandhi Medical college And Hospital, Sitapura, Jaipur.

DR. RIDHI KATHURIA

HISTORICAL BACKGROUND

• Mild, moderate, and severe dysplasia were the terms used to describe premalignant squamous cervical cellular changes.

• RUBIN (1910) introduced the term ‘CARCINOMA IN SITU’ as a forerunner term of invasive carcinoma.

• WALTERS & REGAN (1956) introduced the concept of neoplasia.

• RICHART (1967) brought forth the concept of CIN wherein cervical squamous epithelium is replaced by cells with varying degrees of atypia

• WHO in 1975 classified, the CIN into three

categories correlating with former grading of dysplasia – CIN 1,2,3 &

CIS.

• Grading to be done according to the

thickness occupied by the undifferentiated

cells.

• BETHESDA SYSTEM (1988)

classified cytological abnormalities of premalignant lesions into 3 categories

for squamous metaplasia –

a. Atypical Squamous Cells (ASC)

b. Low Grade Squamous Intraepithelial Lesion (LSIL)

c. High Grade Squamous Intraepithelial Lesion (HSIL)

LSIL includes, CIN 1 and the changes of HPV (Koilocytic Atypia)

DYSPLASIA CINLimit of

Histological changes

Bethesda

MILD CIN 1 Basal 1/3rd LSIL

MODERATE CIN 2 Basal ½ to 2/3rd

HSIL

SEVERE CIN 3Whole thickness

except 1 or 2 layers

CIS CIN 3 Whole thickness

There is considerable degree of overlapping regarding the precise

definition of each category of intra-epithelial neoplasia.

RISK FACTORS FOR CIN & CERVICAL CANCER

1) INFECTION – HPV (16, 18, 31, 33), HIV, CHLAMYDIA

2) EARLY FIRST COITUS

3) STD

4) EARLY 1ST PREGNANCY

5) TOO MANY & TOO FREQUENT BIRTHS

6) LOW SOCIOECONOMIC STATUS

7) MULTIPLE PARTNERS

8) IMMUNOSUPRESSION

9) OCP USERS

10)SMOKING

DEMOGRAPHIC RISK

FACTORS• Ethnicit

y• Low Socio-

economic

status• Age

BEHAVIORAL RISK

FACTORS• Infrequent

or absent cancer screening Pap tests.

• Early Coitarche

• Multiple partners

• Tobacco smoking

• Male partner who’s had multiple partners

• Dietary deficiency

MEDICAL RISK

FACTORS• Infectio

n• Immuno

-supression

• Parity

NORMAL CERVICAL TISSUE

CIN 1 - only mild dysplasia, or abnormal cell growth.It is confined to the basal 1/3 of the epithelium. This corresponds to infection with HPV, and typically will be cleared by immune response in a year or so, though can take several years to clear.

CIN 2 - moderate dysplasia confined to the basal 2/3 of the epithelium

CIN 3 - Severe dysplasia that spans more than 2/3 of the epithelium, and may involve the full thickness.

CIN 1

CIN 2

CIN 3

SQUAMO COLUMNAR JUNCTION

Squamo-columnar junction (scj) of the cervix 

refers to a transitional area between

squamous epithelium of the vagina and the

columnar epithelium of the endocervix.

This shifts in location through age from being more external to

internal.

SCJ is thus a dynamic zone, and moves up & down acc to phases of life of the female

TRANSFORMATION

ZONE

Pre-puberty, ectocervix is covered with squamous

epithelium.

Heightened estrogen exposes the columnar epithelium onto

the ectocervix

Replacement of the columnar epithelium by the squamous

epithelium at to form the TZ. New junction is at or slightly

outside the external os during reproductive period.

Following menopause it is drawn back inwards.

1) BASAL LAYER – is a single row of immature cells with large nuclei & small amounts of cytoplasm.

2) PARABASAL LAYER – includes 2 or 4 rows of immature calls that have normal mitotic figures & provide the replacement cells for the overlying epithelium.

3) INTERMEDIATE LAYER – includes 4 to 6 rows of cells with larger amounts of cytoplasm in a polyhedral shape separated by intercellular space.

Intercellular bridges where glycogen production differentiation occurs, can be seen on light microscopy.

4) SUPERFICIAL LAYER – includes 5 to 6 rows of flattened cells with small uniform nuclei & cytoplasm filled with glycogen. Nucleus is pyknotic, & cells undergo exfoliation.

These cells for the basis of Pap Smear Testing.

NORMAL T.Z

The process of carcinogenesis starts at the TZ.

2 mechanisms are involved in this process –

a)Squamous metaplasia of the subcolumnar reserve cells.

b)Squamous epidermidisation by ingrowth of the squamous epithelium of the ectocervix under columnar epithelium.

The metaplastic process is very active at menarche & during and after the 1st pregnancy.

These are periods of high estrogenic activity and low vaginal ph.

In presence of estrogen in the vaginal epithelium, glycogen is accumulated.

The lactobacilli act on glycogen to produce lactic acid, which lowers the ph of the vagina.

The acid ph is an important trigger of metaplastic process.

The metaplastic cells have potential to transform atypically in lieu of infection/trauma.

Prolonged effect of can produce continuous changes in immature cells which may lead to malignant changes.

SQUAMO-COLUMNAR JUNCTION

REPLACEMENT OF COLUMNAR EPITHELIUM

METAPLASIA OF

RESERVE CELLSSQUAMOUS

EPIDERMIDAZATIONIMMATURE UNSTABLE CELLS

PHYSIOLOGIC METAPLASIA (+) CARCINOGEN

HPV INFECTION

ATYPICAL METAPLASIAor

CINorCISor

INVASICE CARCINOMA

HOST IMMUNE DEFEFNSE

WELL DIFFERENTIATED

SQUAMOUS EPITHELIUM

++ ( - )

In most cases, CIN is believed to originate from a single focus in the TZ at the advancing SCJ.

The anterior lip of cervix in twice likely to develop CIN than the posterior lip. Rarely, CIN originates at

the lateral angles.

Once overt, it can progress horizontally to involve the entire TZ, but does not replace the original

squamous epithelium.

Proximally, CIN involves the cervical clefts.

The only way to determine where it all started is to identify the nabothian cysts or cervical cleft

openings, which indicate the presence of columnar epithelium.

After the metaplastic matures, & forms glycogen, it is called, HEALED TRANSFORMATION ZONE, and is

relatively resistant to oncogenic stimuli.

CIN is most likely to develop during menarche or after

pregnancy, when metaplasia is most active.

After menopause, little chances of metaplasia remain, from de

novo HPV.

WHEN IS A FEMALE MOSTLIKELY TO DEVELOP CIN ?

The role of this virus in the genesis of essentially all cervical neoplasia and a

significant portion of vulvar, vaginal, and anal neoplasia is firmly established.

HUMAN PAPILLOMA VIRUS

Human papilloma virus is a non-enveloped DNA virus with a protein

capsid. It infects epithelial cells exclusively

and approximately 30 to 40 HPV types have an affinity for infecting the

lower anogenital tract.

More than 100 HPV types have now been identified.

Clinically, HPV types are classified as high-risk (HR) or low-risk (LR) based upon their cervical cancer

oncogenicity.

Low-risk HPV types 6 and 11 cause nearly all genital warts and a minority of subclinical HPV infections. Low-risk

HPV infections are rarely, if ever, oncogenic.

HR HPV types include 16, 18, 31, 33, 35, 45, and 58 and account for approximately 95 percent of cervical

cancer cases worldwide.

Other HR HPV types less often associated with neoplasia include 39, 51, 52, 56, 59, 68, 73, and 82.

The most common HR HPV types (16, 18, 45, and 31) found in cervical cancer are also the most prevalent in the general population.

Specifically, HPV 16 is the dominant cancer-related HPV, accounting for 40 to 70 percent of invasive

squamous cell cervical cancers worldwide

BIOLOGY OF HPV INFECTION

KOILOCYTE(S)A Koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which

occur as a result of infection of the cell by HPV.

Koilocytes may have the following cellular changes:

Nuclear enlargement (two to three times normal size)

Irregularity of the nuclear membrane contour

A darker than normal staining pattern in the nucleus, known as Hyperchromasia

A clear area around the nucleus, known as a Perinuclear Halo.

₰ High levels of HPV – DNA and capsid antigen has been detected in the koilocytes.₰ This indicates productive viral infection in these cells.₰ The HPV genome is found in all grades of cervical neoplasia.₰ As the CIN lesion becomes more severe, the koilocytes disappear, the HPV copy number decreases & capsid antigen disappears. This indicates the inability of the virus to reproduce in less differentiated cells.₰ Instead portions of hpv – dna becomes integrated in the host cell.₰ Integration of the transcriptionally active dna is essential for malignant transformation.₰ Malignant transformation requires the expression of E6 and E7 oncoproteins produced by HPV.

• Usually, HPV infection doesn’t persist.

• In majority cases, infection clears in about 9-15 months.

• Small proportion of women exposed, have persistent infection & further progress to CIN 2/3/CIS.

NOT ALL HPV LEAD TO CIN, but, ALL CIN ARE PRECEEDED

WITH HPV INFECTION

CERVICAL EPITHELIUM CIN 1 CIN 2 CIN 3 / CIS

Regression to normal (%) 60 40 30

Persistence (%) 30 35 50

Progression to CIN 3 / CIS (%) 10 20 -

Progression to invasion (%) <1 5 20

SCREENING 1.PAP Test

2.Colposcopy

3.HPV – DNA detection (PCR, Southern Blot Assay,

Hybrid Capture)

PAPANICOLAOU TESTA standardized method of reporting cytology findings defined under THE BETHESDA III

SYSTEM (2001).

According to this system, potentially premalignant squamous lesions fall into three categories:

(i) Atypical Squamous Cells (ASC)

(ii) Low-grade Squamous Intraepithelial Lesions (LSIL)

(iii) High-grade Squamous Intraepithelial Lesions (HSIL).

The ASC category is subdivided into two categories: those of Unknown Significance (ASCUS),

and those in which High-grade Lesions must be

excluded (ASC-H).

Low-grade squamous intraepithelial lesions include CIN 1 (mild dysplasia) and the changes of HPV, termed Koilocytotic

Atypia.

The HSIL category includes CIN 2 and CIN 3 (moderate dysplasia, severe dysplasia,

and carcinoma in situ).

THE 2001 BETHESDA SYSTEM

A. SPECIMEN TYPE Indicate conventional smear (Pap smear) vs. Liquid-based Preparation vs. Other  B. SPECIMEN ADEQUACY 

Satisfactory for evaluation(describe presence or absence of endocervical/transformation zone component and any other quality indicators, e.g., partially obscuring blood, inflammation, etc)

Unsatisfactory for evaluation (specify reason)Specimen rejected/not processed (specify reason)

Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of (specify reason)

C. INTERPRETATION/RESULT  1. NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY (when there is no cellular evidence of neoplasia, state this in the General Categorization above and/or in the Interpretation/Result section of the report, whether or not there are organisms or other non-neoplastic findings)

OrganismsTrichomonas vaginalisFungal organisms morphologically consistent with Candida sppShift in flora suggestive of bacterial vaginosisBacteria morphologically consistent with Actinomyces sppCellular changes consistent with Herpes simplex virus

Other non-neoplastic findings (Optional to report; list not inclusive)

Reactive cellular changes associated with:Inflammation (includes typical repair)RadiationIntrauterine contraceptive device (IUD)

Glandular cells status post hysterectomyAtrophy

2. OTHEREndometrial cells (in a woman >= 40 years of age) (Specify if ‘negative for squamous intraepithelial lesion’)

3. OTHER MALIGNANT NEOPLASMS (specify)

4. EPITHELIAL CELL ABNORMALITIESSquamous cell

Atypical squamous cellsOf undetermined significance (ASC-US)Cannot exclude HSIL (ASC-H)

Low grade squamous intraepithelial lesion (LSIL) Encompassing: HPV/mild dysplasia/CIN 1

High grade squamous intraepithelial lesion (HSIL) Encompassing: moderate and severe dysplasia, CIS; CIN 2 and CIN 3

With features suspicious for invasion (if invasion is suspected)

Squamous cell carcinoma

Glandular cell

AtypicalEndocervical cells, NOS or specify in commentsEndometrial cells, NOS or specify in commentsGlandular cells, NOS or specify in comments

AtypicalEndocervical cells, favor neoplasticGlandular cells, favor neoplastic

Endocervical adenocarcinoma in situ

AdenocarcinomaEndocervicalEndometrialExtrauterineNot otherwise Specified (NOS)

D. ANCILLARY TESTING - provide brief description of the test methods & report result such that it is easily understood by the clinician. E. AUTOMATED REVIEW – if automated device used to test, specify device & result. F. EDUCATIONAL NOTES AND SUGGESTIONS (optional)  

DIAGNOSTIC MODALITIES

☺Exfoliative Cytology

☺ HPV – DNA Testing

☺ Visual Inspection with Acetic Acid

☺ Colposcopy

☺ Cervicography

☺ Endo cervical Curettage & Biopsy (with / without colposcopy)

☺ Diagnostic Conisation

Visual Inspection with Acetic Acid (VIA)

 5% acetic acid is applied to the cervix with a large cotton swab and left for 30-60 seconds, after which the cervix is

visually examined with the colposcope.

Pre-cancerous lesions, with a higher ratio of intracellular proteins, turn white when combined with acetic acid.

Normal cervices without any precancerous lesions, do not change color.

COLPOSCOPYA colposcope is used to identify visible clues

suggestive of abnormal tissue.

It functions as a lit binocular microscope to magnify the view of the cervix, vagina, and vulvar

surface.

Low power (2x to 6x) may be used to obtain a general impression of the surface architecture.

Medium (8x to 15x) and high (15x to 25x) powers are utilized to evaluate the vagina and cervix.

The higher powers are often necessary to identify certain

vascular patterns that may indicate the presence of more

advanced pre-cancerous or cancerous lesions.

Various light filters are available to highlight different aspects of the surface of the cervix. 

Acetic acid solution and Iodine solution (Lugol's or Schiller's)

are applied to the surface to improve visualization of abnormal

areas.

Colposcopy is performed with the woman lying back, legs in stirrups, and buttocks at the lower edge of the table

(dorsal lithotomy position).

A speculum is placed in the vagina after the vulva is examined for any suspicious lesions.

Three percent acetic acid is applied to the cervix using cotton swabs.

Areas of aceto-whiteness correlate with higher nuclear density.

Areas of the cervix which turn white after the application of acetic acid or have an abnormal vascular pattern are often

considered for biopsy.

If no lesions are visible, an iodine solution may be applied to the cervix to help highlight areas of abnormality.

Punctation - A stippled appearance to capillaries seen end-on, often found within acetowhite area appearing as fine to coarse

red dots.

Mosaicism - An abnormal pattern of small blood vessels suggesting a

confluence of "tile" or "chickenwire" reddish borders.

Leukoplakia (hyperkeratosis) - Typically an elevated, white plaque seen prior to the

application of acetic acid.

Abnormal blood vessels - Atypical, irregular vessels with abrupt courses and

patterns, often appearing as commas, corkscrews, or spaghetti.

No definite pattern is recognized, as with punctation or mosaicism. Suspect invasive cancer. Complex pattern consisting of roughened, irregular cervical epithelium, typically with abundant irregular vessel patterns. Blood vessels take bizzare forms, which

appear as commas, hair pins, spaghetti, or long, dilated, unbranching vessels with irregular diameters. 

OTHER COLPOSCOPIC FINDINGS

Vaginocervicitis - Cervicitis may cause abnormal Pap smears and make colposcopic assessment more difficult. Many authorities recommend treatment before biopsy when a STD is strongly suspected.

Traumatic erosion - most commonly caused by speculum insertion and over vigorous Pap smears but can also result from such irritants as tampons, diaphragms, and intercourse.

Atrophic epithelium - Atrophic vaginal or cervical epithelium may also cause abnormal Papanicolaou smears. Colposcopists will often prescribe estrogen for 2 to 4 weeks before a colposcopy in order to "normalize" the epithelium before the examination. This is generally felt to be safe even if dysplasia or cancer is present because the duration of therapy is short and these lesions do not express any more estrogen receptors than a normal cervix.

Nabothian cysts - They are areas of mucus producing epithelium that are "roofed over" with squamous epithelium. They do not require any treatment. They provide markers for the transformation zone since they are in squamous areas but are remnants of columnar epithelium. 

CERVICOGRAPHYPhotographs of the cervix and submitted to

an expert for opinion

CERVICAL CONIZATION 

Refers to an excision of a cone-shaped sample of tissue from the cervix.

Conization may be used either for diagnostic purposes as part of a biopsy, or for therapeutic purposes to remove pre-cancerous cells.

Types include:Cold Knife Conization (CKC). Usually outpatient, occasionally inpatient.

Loop Electrical Excision Procedure (LEEP). Usually outpatient.

Conization of the cervix is a common treatment for dysplasia following abnormal results from a pap smear.

Side effects –

a. Cervical Stenosis

b. Incompetent Os

c. Hematometra

d. Adjacent tissue trauma

ABLATION OF LOCAL LESION

FOLLOWING CRITERIA TO BE FULFILLED –

Entire lesion should be visualized within the TZ.

No evidence of Microinvasion or Invasion.

No endocervical glandular involvement.

No discrepency b/w Biopsy, Cytology & Colposcopy report.

CRYOSURGERY Principle is crystallization of intracellular water at

temperatures of -90o C. Uses Nitrous Oxide or CO2

Depth of tissue destruction = 5 mm

Ideal for – minor grades of CIN, localized lesions.

DOUBLE FREEZE TECHNIQUE (Freeze-Thaw-Freeze) increases efficacy.

COLD COAGULATION

Destroys tissues at temperatures of -100 to -120o C

No anaesthesia needed

4 mm depth destruction

ELECTRODIATHERMY

8-10 mm depths destroyed.

Using a unipolar electrode.

General Anaesthesia.

CARBON DIOXIDE LASER Depth = 7 mm

Method of choice when CIN extends onto vaginal fornices.

Done through colposcopic guidance

Destroy epithelium by vaporisation.

HYSTERECTOMY CIN lesion associted with other gynaecological

problems like prolapse, fibroid, PID, endometriosis.

Extension into vagina.

Persistent dyskaryotic smear even after treatment.

High grade CIN in elderly women.

Patients with CIN 3

Poor follow up compliance.

Cancer Phobia.

REMOVE VAGINAL CUFF IF LESION EXTENDS TO FORNICES

MANAGEMENT GUIDELINESThe American Society for

Colposcopy & Cervical Pathology (ASCCP)

Guidelines developed in 2001, revised in April

2013, define the guideline algorithms.

PROPHYLACTIC VACCINATION

Rationale for Development of a Cervical Cancer Vaccine

Identifiable etiologic factor

Worldwide burden of cervical cancer

Financial, medical and emotional burden of HPV-related genital neoplasia

Preventive HPV vaccines are based on hollow virus-like particles (VLPs) assembled from recombinant HPV coat proteins

Vaccines target the two most common high-risk HPVs, types 16 and 18

Elicit virus-neutralizing antibody responses that prevent initial infection with the HPV types represented in the vaccine

Gardasil (Merck) • Quadrivalent vaccine

• HPV types 16,18 , 6 & 11

• HPV types 16 and 18 currently cause about 70% of cervical cancer

• Type 16 associated with oropharyngeal squamous-cell carcinoma

• HPV types 6 and 11 cause about 90% of genital

wart cases

• Prophylactic HPV vaccine

• 3 doses at 0 , 2 & 6 month 0.5ml IM (Deltoid)

Vaccines have been shown to offer 100 percent protection against the development of cervical

precancerous lesions & genital warts

Protective effects of the vaccine are expected to last a minimum of 4.5 years after the initial vaccination

( Randomised Control Trial, Lancet. 2006 Apr)

Cervarix (GlaxoSmithKline)

• Bivalent vaccine

• HPV types 16 & 18

• Cross-reactive protection against virus strains 45 and 31

• Prophylactic vaccine

• Created using the L1 protein of the viral capsid

• Vaccine contains no live virus & DNASo it cannot infect the patient.

• 3 doses over a six-month span 0 month, 1 month, and 6 months 0.5ml IM (Deltoid)

o 92% reduction in abnormal Pap smears

o 94-100% reduction in persistent infection o 98% Seropositivity up to 4-5 yrs

o Phase II trials demonstrated 100% protection of the vaccine against types 16 and 18 HPV

Indications & Prevalence Prophylactic vaccines For maximum efficacy, vaccines recommended prior to

becoming sexually active (11-12 yrs of age)

Vaccine can prevent almost 100% of disease caused by HPV targeted by the vaccine

Vaccine should not be considered a substitute for routine Pap smears

Eliminates 90% cases of genital warts (HPV 6 & 11)

Prevents anal cancer (HPV 16 & 18)

CATCH UP VACCINATION

Vaccine is also recommended for girls & women 13-26 years of age who did not receive it when

they were younger

Additional (booster) doses are not recommended

HPV vaccine may be given at the same time as other vaccines

Pain at the injection site Redness or swelling at the injection site

Mild fever Itching at the injection site

GI symptoms Joint pains

Anaphylactic reactions - rare Guillan – Barre Syndrome (GBS) – very rare

(Department of health and human services, Centers for Disease Control and Prevention)

SIDE EFFECTS & COMPLICATIONS