Abnormal papsmear and colposcopy

Cervical anatomy

Squamocolumnar junction epithelium. Its location on the cervix is variable. The squamocolumnar junction (SCJ) .is defined as the junction between the squamous epithelium and the columnar Age and hormonal status are the most important factors influencing location of SCJ. At birth and during premenarchal years, the SCJ is located ator very close to the external os (original SCJ). During reproductive age, the SCJ is located at variable distances from the external os. In a postmenopausal woman, the new SCJ is not visible and has receded into the endocervix.

The transformation zone(TZ) Area between the original SCJ and the new SCJ where the columnar epithelium (ectropion) has been replaced and/or is being replaced by the new metaplastic squamous epithelium. The TZ may be either wide or narrow depending on age, parity, prior infections and exposure to female hormones.

As a result of the metaplastic process a new SCJ is formed. It is visible as a distinct white line after the application of 3 to 5% acetic acid.

27y NG cc:PCB (دو بار در دو ماه اخیر) and Cervical appearance Case 1 27y NG cc:PCB (دو بار در دو ماه اخیر) and Cervical appearance

What is the DX? Ectropion What is the next step?

ECTROPION  Ectropion occurs when eversion of the endocervix exposes columnar epithelium to the vaginal milieu. The everted epithelium has a reddish appearance similar to granulation tissue, and may be covered by a yellow turbid discharge. Ectropion is common in : Adolescence women who are pregnant who taking estrogen-progestin contraceptives who had a cervical laceration during labor and delivery. Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971; 284:878.

Many years ago before development of medicine,ectropion seemed a wound on the cervix and it was named erosion ,at that time because of high incidance of cervical cancer many doctors made treatment and sed if not treated cervical cancer may occur , later with progress medical tecnology with colposcopy and histologic exam found the doctor made a big mistake to types of epithelium. Treatment of cervical erosion …www.aiainews.com

Ectropion should not be treated except in the rare occurrence of excessive mucous discharge or spotting that is very bothersome to the woman. In such cases, malignancy should be excluded before undertaking any treatment. Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971; 284:878.

Ectropion /ablative procedure An ablative procedure using cryocautery or electrocautery Is invasive copious vaginal discharge until healing is completed, which may take weeks. cervical stenosis, which can adversely affect future fertility and, if pregnancy is achieved, labor and delivery Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971; 284:878.

Ectropion/Medical treatment a two-week trial of an acidifying agent, such as boric acid suppositories 600 mg vaginally at bedtime, which may be effective Use of deoxyribonucleic acid 5 mg vaginal suppositories has also been reported

34Y G2P2 CC:ارجاع به علت ظاهر سرویکس

Nabothian cysts =also called mucinous retention cysts form when a cleft of columnar epithelium becomes covered with squamous cells and the columnar cells continue to secrete mucoid material. The cysts vary from microscopic to several centimeters in size; They may appear translucent or opaque . Nabothian cysts may occur following minor trauma or childbirth. Comprehensive Visual Inspection of the Cervix with Acetic Acid (VIA) and Lugol’s Iodine (VILI) http://www.gfmer.ch/vic/

indication for treatment is relief from pain a bothersome feeling of fullness in the vagina. Ablation of the cyst using electrocautery is the usual approach; if the diagnosis is uncertain, excision to evaluate histopathology is advised. The main disadvantage to surgical treatment is the possibility of causing scar tissue, which itself can lead to dyspareunia. Comprehensive Visual Inspection of the Cervix with Acetic Acid (VIA) and Lugol’s Iodine (VILI) http://www.gfmer.ch/vic/

Colposcopy

Abnormalities that should be noted during cervical colposcopy include: Acetowhite epithelium ●Abnormal vascular patterns: •Mosaicism •Punctation •Atypical vessels

Features suggestive of high-grade disease: dense acetowhite epithelium, rapid appearance of acetowhitening, cuffed crypt (gland openings), coarse mosaic, coarse punctation, sharp border, inner border sign, ridge sign

Features suggestive of invasive cancer: atypical vessels, fragile vessels, irregular surface, exophytic lesion, necrosis, ulceration (necrotic), tumor/gross neoplasm

Case 3

معاینه با اسپکولوم - شرح حال بیمار - معاینه با اسپکولوم - شرح حال بیمار -

Biopsy: CIN I -thin acetowhite epithelium -geographic border -fine mosaic - fine punctation

Case4 36y G2L2 Papsmear:LSIL

Focal mild dysplasia(CIN I) Colposcopy aw/ Punctation /Mosaicism biopsy بیوپسی: Focal mild dysplasia(CIN I)

Case 5 34y G3P2Ab1 Papsmear:LSIL Colposcopy /Biopsy Biopsy:CIN I

28y NG Pap smear :LSIL HPV testing : Positive Biopsy:CIN I

Case 7 36yG3L2Ab1 Papsmear:HSIL what is the next step?

بیوپسی: CIN II

36yG3l1Ab2 Papsmear :HSIL Colposcopy and Biopsy Was done بیوپسی: CIN2 with endocervical invasion What is the next step?

21yNG Papsmear: ASC H What is the next step?

27yNG Papsmear:ASC H What is the next step?

Squamous metaplasia + focal erosion بیوپسی: Squamous metaplasia + focal erosion

توصیه به: -بازخوانی لام پاپ اسمیر - conization

Case 10 61yG3L3 Papsmear:AGC What is the next step? Cervical colposcopy with directed cervical biopsies and sampling of the endocervical canal 2.Endometrial sampling is performed for all women ≥35 years old and for younger women at risk for endometrial neoplasia

Sonography: ET=2mm EMC Biopsy: chronic cervicitis

16y Virgin cc: ضایعات زگیلی در ناحیه ران Case 11 16y Virgin cc: ضایعات زگیلی در ناحیه ران

Biopsy?

Indications for pretreatment biopsy The diagnosis is uncertain. ●The lesion has any suspicious features, such as fixation (infiltration of dermis) ●The patient is postmenopausal or immunocompromised. ●The lesion is refractory to medical therapy.

-Treatment: Medical therapy :Podophyllotoxin/Trichloroacetic acid  (TCA)/5-Fluorouracil and …. APPLIED THERAPIES :exision-Cryotherapy — Electrosurgery (Risk for transmission of human papillomavirus (HPV) to oral or nasal mucosa of health care workers during electrosurgery or laser treatment of anogenital warts ) Silvera RJ, Smith CK, Swedish KA, Goldstone SE. Anal condyloma treatment and recurrence in HIV-negative men who have sex with men. Dis Colon Rectum 2014; 57:752.

Is vaccination necessary? Is it necessary to check other STD? The presence of genital warts alone is not an indication for screening for additional sexuality transmitted disease Is HPV typing necessary? Determining the human papillomavirus (HPV) type of the warts is unnecessary Is vaccination necessary? HPV vaccines are effective in the primary prevention of HPV infection. prevention of recurrent disease is investigational

. Follow-up? How can we manage Recurrence? are based on patient symptoms and satisfaction with treatment results. How can we manage Recurrence? most are within three to six months of therapy. We can treat her with previuos treatment

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