Cervical Pathology 4
Cervical Pathology 4
Pathology
Strongly associated
with HPV
Prevalention of high risk HPV in cervix
age
• 14-19: 33%
• 20-29: 28%
• 30-39: 14%
• 40-49: 11%
• 50-65: 6%
apoptose
•What age?
•How often?
•Cytology?, what types
•HPV?
•Effect of screening
Screening?
Netherlands experience
• Colposcopy
Diagnostic procedure abnormal
cytology:
colposcopy combined with biopsy
Diagnosis of CIN
colposcopy
without appl. acetic acid jodine (lugol)
Diagnosis of CIN
colposcopy
without appl. acetic acid jodine (lugol)
Diagnosis of CIN
colposcopy
• abnormal maturation
• nuclear enlargement
• atypia
pleomorphism
coarse chromatin clumping
irregular nuclear contours
• CIN grade 1,2 and 3
• CIN is limited by the border with the
native squamous epithelium of the
ectocervix
• proximally CIN can extend even to the
endometrium and rarely to the
peritoneal surface.
Squamous Intraepitelial Neoplasia (CIN)
• abnormal maturation
• nuclear enlargement
• atypia
pleomorphism
coarse chromatin clumping
irregular nuclear contours
• CIN grade 1,2 and 3
• CIN is limited by the border with the
native squamous epithelium of the
ectocervix
• proximally CIN can extend even to the
endometrium and rarely to the
peritoneal surface.
Atypia in CIN
• three-group metaphases
• two group metaphases
• ring mitosis
• V-shaped metaphase
• tripolar and quadripolar mitosis
• dispersed metaphase
• giant mitosis
Treatment of CIN
•CINI: wait and see
•CIN II – III:
• Destruction
Cryo
Laser
Excision
LLETZ
Exconisation (always in case of
suspicion of invasion or abnomal cyl.)
Treatment
Cryo
Disadvantage: no pathology
Treatment
LLETZ
Advantage: easy technique
fast
local anaesthesia needed
pathology
L R
Diagnostic dilemma
Basement membrane
Lymph/blood
vessel
Endothelial
cell
Micrometastasis
MT
Macrometastasis
from Thierry et al
Pathological report cervical carcinoma
• Microinvasive squamous cell carcinoma
• depth of invasion
0,15mm
Microinvasive cervical
carcinoma:
•St Ia:
• Lin extension < = 7 mm
• Depth of invasion < 5 mm
St Ia1
St Ia2
Microinvasive cervical
carcinoma: treatment
•Invasion ≤ 3 mm ± vsi (Ia1)
•Invasion 3 - 5 mm, vsi - (Ia2)
• Fertility wish +: exconisation
• Fertility wish -: hysterectomy
•Invasion 3 – 5 mm, vsi + (Ia2)
• Fertility wish +: lapsc.lymphadenectomy
+ radical trachlectomy (SN -) or 2 tempi
• Fertility wish -: Radical hysterectomy
Macro invasive cervical
carcinoma
Macro invasive cervical
carcinoma
symptoms findings
irregular bloodloss exophytic tumor
contact bleeding endophytic tumor
fluor ulceration
pain (late)
Cervical carcinoma
diagnostics
► General and gynecological evaluation
► Cystoscopy only in combination with eua in
advanced stages (> St Ib)
► MRI pelvis in advanced cases CT (paraaortic
ly. nodes)
► X-thorax
► tumor markers (response evaluation)
SCC with squamous cell carcinoma
CA125, CEA with adenocarcinoma
Cervical carcinoma
• dissemination:
•Lymphogenic
•Local extension
•Hematogenic
•Clinical Staging
(FIGO)
Cervical carcinoma
imaging
Cervix carcinoma macroinvasive
treatment
► stageIB-IIA: radical hysterectomy
with bilateral pelvic lymphadenectomy
• Pelvic lymphadenectomy:
• Commune nodes (+ -> PAO irr)
• External nodes
• Obturator nodes
• Evt. other places
Lymphnodes from different regions
Frozen section
indication
•Only if consequences: stop or
adjustment procedure (ovaries?)
•Suspicious lymph nodes (communis)
•Bulky lymph nodes (> 2,5 cm)
•Extention of tumor outside uterus?
• Bladder/rectum
• Parametrium
Frozen section
Problems
•Duration of procedure
•Selection
•How many slides
•Freeze artefacts
•No optimal diagnostic possibilities
Radical hysterectomy schedule
Cervical carcinoma radical surgery
1 incision vagina
final steps
2 ligm vesicocervicale
3 ligm vesicovaginale
4 ureter
5 paravaginal tissue
6 insertion lateral
parametrium
7 divided lateral
parametrium
8 a uterina
Pathology Report Cervix
► Macroscopical
Specimen, surgical procedure
(exconisation, LLETZ, hysterectomy
radical or simple etc)
Tumor diameter after fixation
Macroscopic extension
Configuration (exophytic, barrel shaped)
Pathology Report Cervix
► Microscopical
Histological type
Grade
Depth of invasion (measurement in mm)
Size / linear extension
Margins / radicality of tumor
Pathology Report Cervix
► Microscopical
Parametrial involvement
Involvement of vagina
If positive, mention CIN or invasive
cancer
Margins parametrium/vagina, if positive
distance to surgical resection plane
vsi
Pathology Report Cervix
► Microscopical
Lymphnodes: number involved/examined
Region: commune, external, obturator,
PAO
Extracapsular growth
Try to examine at least 10 lymph nodes
per left and right pelvis
Cervical carcinoma
• glandular budding
• depth of invasion
• squamous cell carcinoma