Cervix Carcinoma
Cervix Carcinoma
One of the major causes of cancer-related death in women, specially in
developing world.
Most common cervical cancer is squamous cell carcinoma. Other types are
adenocarcinoma, neuroendocrine carcinoma etc.
Nowadays there is dramatic improvement because of early diagnosis and
treatment.
The wide use of PAP screening lowered the incidence of invasive cancer .
Precancerous lesion
Squamous Intraepithelial Lesion (SIL) is the pre-cancerous(non invasive) lesion
and detection of these lesions made curative treatment is possible.
All invasive squamous cell carcinomas arise from pre-cancer epithelial changes
referred as Cervical Intraepithelial Neoplasia (CIN ) or Squamous intraepithelial lesions.
Not all cases of CIN progress to invasive cancer.
The majority of cancers are preceded by a precancerous lesion. This lesion may exist in
the noninvasive stage for as long as 20 years and shed abnormal cells that can be detected
on cytologic examination.
These precancerous changes
(1) they do not invariably progress to cancer and may spontaneously regress,
the risk of persistence or progression to cancer increases in the high grade
precancerous lesions;
(2) they are associated with papillomaviruses, and high-risk HPV types are found
in increasing frequency in the higher-grade precursors
CIN
Cytologic examination can detect CIN (SIL) long before any abnormality can be
seen grossly .
Pre-cancer changes can precede the development of an overt cancer by many
years.
CIN lesions may begin as Low Grade CIN and progress to High Grade CIN, or
they might start as HG lesion.
CIN histology.
On the basis of histology ,pre-cancer lesions are graded as follows:
-CIN I = Mild Dysplasia: Lower 1/3rd of the epithelium is replaced by pleomorphic cells
-CIN II = Moderate Dysplasia: Lower 2/3rd of the epithelium is replaced by pleomorphic
cells
-CIN III = Severe Dysplasia and Carcinoma in situ. All levels of the epithelium is
replaced by pleomorphic cells, (full thickness)
Cancer is invasive once the basement membrane is ruptured and tumor cells
extend into the underlying tissue.
On gross examination the cervix looks relatively normal. There is no tumor mass.
Cytology screening for precancerous lesions
The cervix is examined and the cells lining the cervical wall at the transformation
zone are scrapped/ sampled with a spatula and then spread on a slide. They are then fixed,
stained (Papanicolaou stain/pap stain) and examined under a light microscope.
Cytological cervical Screening with pap stain
In cytology smears we separate pre-cancer lesions into two groups :
Low Grade SIL
High Grade SIL
Of Low Grade SIL 1-5 % become invasive
Of High Grade SIL incidence is 6-74%
CIN I = Low grade SIL
CIN II = High grade SIL
CIN III = High grade SIL
Risk Factors for CIN and invasive cervical carcinoma
Early age at first intercourse
Multiple sexual partners
A male partner with multiple previous sexual partners
Persistent infection by high risk papillomaviruses
Some other risky factors; low socioeconomic groups
rare among virgins, multiple pregnancies.
Human papilloma virus
HPV is the number one reason for abnormal cells of the cervix.
HPV is a skin virus, which results in warts, common warts ,flat warts, genital
warts (condylomas), and planter warts.and precancerous lesions
HPV can be detected in 85 -90 % of pre-cancer lesions
High risk types HPV : 16, 18, 31, 33, 35, 39, 45, 52, 56, 58, and 59 .
Low risk types HPV :6, 11, 42, 44 . These types result in condylomas.
NOTE: There are no visible symptoms that you have dysplasia of the cervix ,without a
Pap smear or Pap exam .This is why we have annual pap exams ,as to detect any
abnormal cells . The Pap smear detects early HPV infection.
The common testing procedure for HPV infection is an annual pap exam .
There is the HPV DNA ISH test ,the Diegene Hyprid Capture test . This test will
determine whether you carry high or low risk strains of the virus.
Cervical Carcinoma ,Invasive
75 -90% of invasive cancers are Squamous cell carcinomas ,which generally
evolves from pre-cancer CIN.
The remainder are Adenocarcinoma.
Squamous cell cancers are appearing in increasingly younger women ,now with a
peak incidence at about 45 years, about 10-15 years after detection of their precursors.
Cervical Carcinoma ,Morphology
Mainly in the region of the transformation zone ,and range from microscopic foci
of early stromal invasion to grossly frank tumors encircling the Os .
The tumors may be invisible or exophytic .
Cervical carcinomas are graded from 1 to 3 based on cellular differentiation and
staged from 1 to 4 depending on clinical spread.
Cervical Carcinoma, Staging
0 Carcinoma in Situ
1 Confined to the cervix
2 Extension beyond the cervix without extension to the lower third of Vagina or Pelvic
Wall
3 Extension to the pelvic wall and / or lower third of the vagina
4 Extends to adjacent organs
Cervical Carcinoma ,Clinical Course
Many of cervical cancers are diagnosed in early stages , and the vast majority are
diagnosed in the pre-invasive phase.
More advanced cases are seen in women who either have never had a Pap smear
or have waited many years since the prior smear.
Cervical Carcinoma ,Survival
laser or cone biopsy is the most effective method of managing patients with High
grade SIL in cancer prevention .
