Premalignant lesions of the cervix

Applied anatomy

Cervical intraepithelial neoplasia It is a continuum from atypia to HSIL Confined to epithelium Thus non-invasive Thus a precursor of cervical cancer Pathologically described as CIN 1-3 Of CIN1: most will regress. Of CIN 2: about a third will regress. Of CIN 3: ALL WILL PROGRESS TO CaCx

Epidemiology Disease of sexually active women Caused by high risk types of HPV namely 16, 18 and also 31,33,48, 52 and some other types Epidemiological risk factors: early age of first coitus, multiple partners, smoking, immune suppression Concerns: long term use of OC, multiple pregnancies, poor nutritional status

Prevalence USA data: up to 80% of college graduates are HPV+ By age 30: rate down to 30% HPV + About 15% of women will have abnormal cytology Every year in SA >20 new cases of CaCx per women As common as (or more common than) breast cancer

Pathogenesis Pubertal developments: E leads to outgrowth of columnar epithelium: Exposed SCJ: leads to METAPLASIA If HPV present: DYSPLASIA Typically HPV -> atypia -> LSIL -> HSIL Majority will regress but not all and not much from HSIL Transmission time varies and can be years

Clinically Mean age 30 (SA screening policy: will miss many; ? Role of HIV) Mainly asymptomatic, may have PCB Cx may appear normal or have a red lesion COLPOSCOPY with acetic acid allows detection of abnormal area (acetowhite) -> biopsy (diagnosis made histologically)

Management of patient with abnormal smears See flow diagram (is in GEP and textbook) Preferred option is “one step” management where patients with abnormal smears are referred for colposcopy and also LLETZ at the same visit This may be excessive for LSIL unless repeated or have follow-up problems

Treatment methods Local destruction: cryotherapy, laser Local excision: LLETZ, cone biopsy Surgical options: hysterectomy (uncommonly) LLETZ is current first choice management with >95% effectiveness and very few complications and side effects Bi-to annual cytology for follow-up

Outcomes If left untreated: –HPV, LSIL: most will regress –HSIL: all will probably develop CaCx over time If HSIL is treated: <5% risk for recurrence (and then esp. when HIV+) If treated and followed: <<1% risk for later CaCx

Counselling issues Very hard to trace original source of HPV – not worth the trouble Normal PAP smear result is good but follow-up screening should be performed Male partner: most will have HPV but few will develop visible lesions (and then usually warts)