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its in this process of sqarmous metaplasia when if gets infected with hpv it can lead to dysplasia and neoplasia
The difference between CIN and cancer is whether it has breached the basement membrane.
this is a long process. can take 10-15 years for it to be breach ⇒ during this time can take pap smear and screen for dysplastic changes. 1 can test for hpv infection 2. test for dysplasia via the pap smear 3 take biospy and test for cancer
hpv is obtained through sexual intercourse with partner. hpv is very common but most women clear off the infection in two years by virtue of their own immunity.
once its breeched its no longer cervical intraepithelial neoplasia..it ceomes microinvasive cervical cancer
2 techniques of pap smear ⇒ convectional pap smear and liquid based cytology
ayres spatula to roatate 360 on the ecto cervix trasnformational zone while the cytobrush is to take sample from the edno cervix
if have only one, then better to take from the ecto cervix, transformational zone
sensivity means that if have cancer, 55% chance of it coming as positive. so its very poor and only good if its repeated many imes
but the high specificity means, if it shows positive then it cant be ignored. because most likely cancer
liquid based cytology = there is the brush thats lies i the ectocervix and also goes into to fix in the endocervix. so three main advantages 1. clearer 2 can see each individual cells...chances of smudge are less 3 can do hpv dna samping in the same slide ⇒ otherwise if cnvectnional must take another sample
disad : expensive and un available
the first picture shows a halo around the nucleus which is a sign of hpv infection and lsil
and the second shows dysplastic changes and needs biospy
just need a speculum and white light
in acetic acid any abnormal area will come white.
and lugols iodine it will be yellow and not brown because no glycogen.
so then can treat or investigate there and then...like take for biospy or if have cryotherapy can use it to treat the region
so put speculum...examine....take for papsmear and then applu these tests and then take o treat any adbnormal regions.
those follicles are benigh and demarcate the earlier junctional boundary.
A nabothian cyst (or nabothian follicle) is a mucus-filled cyst on the surface of the cervix. They are most often caused when stratified squamous epithelium of the ectocervix (portion nearest to the vagina) grows over the simple columnar epithelium of the endocervix (portion nearest to the uterus).
vaccinated women should still be screened because how efective the vaccine is depends and we can see only after a couple generation ...so until then better to screen..maybe it would be effective.
if total hysterectomy was done for causes like cin or cevical cancer and a maligant cause, then you need to do vault screening!!
co testing shouldnt be done for a women below 30 years of age because hpv is fairly common and most women clear off their infections ...so if done ealy there will be a lot of false positive.
after 65 years no need as long as regularly done because it takes time to develop into cervical cancer and kill so if not there by 65 then okay
but emphasis on only regualr..because it has poor sensitivy and relies on repeated testing to get good results.
next step is to biospy if coming anything as positive. for hat must idenfity the areas abnormal. so colposcopy is best for that ⇒ seeing under magnification, identifing suspicious areas and then biospying it .
thats because cancer is a hpe diagnosis and needs a biospy
if ascus then can do the two appraoches. but hpv triage is preferred.
coposcopy vs using gols idoine and acetic acid?
coploscopy uses magnifciations and less chance of false areas as apposed to the staining method but the staining methods can be done in low resource centers.
the screen monitor can be on the back of the device or on monitor
can amgninify so much so can find the most best area to biospy
so can identify precisely the abnormal areas to be biospied
in the staining method, its still difficult to know where to take the bisopy from...but with the colposcopy cn find out exactly where to take the biospy from by recogning the patterns of rabnormal areas (like punctuations over a white area or mossaic pattern)
important points of going for a hpv test before a colposcopy?abovr
they are asking he best step...the best step in this case is colposcopy and not pap smear because pap smear isnt very senstive and even if come negative will repeat or do colposcopy because the woman is sympomatic
Management of Cervical Intrapepithelial Neoplasia
the gas is let in until it freezes the tissues and an iceball is formed. should be 5mm iceball...then only we're satisfied,
Then thaw as in letting it to warm up and then aagin freezing....this repeated freeze thaw technique causes the water to crstalise and then it soon bursts the cells open.
and then it dies and is slowly cleared and replaced.
can only be used if the esion is in the ecto cervix and that too near the os and not inside vaginal fonixes etc.
then laser ablation can be used
both refers to the same procedure just different terminilogy used in different places.
these intrumnets ae cnnected to the same caustery machines that are found in the OT
How diagnoscitc and therapuetic in the same setting?
All advnates compaired to the other type of excisional procedure and thats conization
The loop vibrates fast an is used to heat up thermal energy..so it destroys and stops cleeding at the same time causing a creater to be formed.
- cryothrapy 2. ablation 3. LEET/LLETZ 4. conization
HSIL vs CIN. HSIL is for the bethesda classification that the pap smear shows. the pap smear can only show this and not CIN because pap smear just shows individul cells smudged on a slide and not the layers. so can only check HSIL or not but to cooreelate with CIN must take a biospy. but usually grade like HSIL corresponds with a worse stage of CIN.
hystercetomy is not indicated for a benigh condition. This is still a benign condition!
cryotherapy is only for cim 1
Conization is risky and there is special idnications for this
Age doesnt matter in the above example
ITs obviously a huge tumour like thing. so instead of doing composcopy and biospy can directly do LEEP and then see the hpe for the result. Even if cin 1 or whatever its still okay because obviosuly will have to remove it.
But its an invasive ca then need to do further treatment.
the oop surgical technique is painless and doesnt neeed anesthesia. not even iv sedation. its an opd office porceudre but the conization needs anesthesia
if margins are not free then can do the follwing choices,...not free meaning theres dysplasia in the margins stil
conization probably needs OT/ for the anesthesia. its a cone bisopy, an excision biospy that is used to take a huge part of the cervix out. Has complications and thats why now we are preferring to do LEEP which can only be done near tbe os and in ectocervix, junctional zone but it okay because most dysplasia involve that zone only/
so because of this conization has only limited indictions
conization in the above can be both diagnostic for cancer and also therapuetic !!
Hysterectomy is too much a procedure. like over treating.
cryotherapy for cin 1
LEEP might miss certain areas in endocervix so conixation is the best
above imortant we usually pair up colposcopy with ECC (endocervica curettage)
conization also done when there's discrepnacy in the report....like in the baive case the pap seamr showed hsil and with this you expect a cin 2/3 and so went with bisooy on colposcopy but that shoed ony cin 1. maybe the histopathologist got it wrong? Maybe you didnt biospy the best area and the pap smear cells came from a another source . s better to do a conization (cone bisopy) to find where this souce is.
its unlikely the pap semar report is wrong because its very specific. if its hsil then unlikely to be a false psoitive. remmeber pap smear has high specificaly but low sensitivity.,Thhats why have to be repeated to be reliable but if positive must take it seriusly.
for conization will only do for reports that come up with HSIL
HSIl usually corresponds to cin 2/3
and LSIL usually corresonds to cin and conization is not done for this.
the above three case scenarios are actually the indications for conizations!!!!!!!
fourth indication is above. must also be done if the colposopy was unsatisfactory. but what does unsatsfactory mean? 1, cant determine the squarmous columnar junction 2. the white abnomal areas in staining is unsatisfcatory. for example we dont know how deep it will go into the os...so better do conization to be suee.
no cryotherapy for cin2/3. And no hysterectomy too. So must do TOC LEEP.
the glandular cells are coming from the ebdocervix...so must do conization,
nulliparous women, conization isnt preferred, but there isnt any nulliparous young women with cin 2/3 and with cancer because it takes a lot of time for this kinda dysplasia to develop.
in exam only clear cut selected cases will be given.
HPV vaccination
long term data is required to see the real efficacy of these vaccines. so far its promisig and shows its vey effective but need long terms results to find out the exact efficacy rates and to see its impacts on cervical cancer
so far no indication that a booster dose is needed?
but most effective if given before the onset of seual activity..can give later on but cant guarantee efficacy so far
until long term data is acquired women who gets vaccinated still need to be screened for the cancer
Cervical cancer
high parity is a risk factor. contrast with other gyne cancer where its not a risk facto but rather a prtective factor!
concomitant stds is not a correlation factor but actual risk factor because it tends to lead to persistence of the infection vs them clearing it out as what happens in most cases
also in adenocarcinoma the diagnosis can sometimes be delayed. because it involved the endocarvix and the cervical canal
1, type 2. site 3 hpv types 4 smoking 5 ocp 6 younger women and prognsis
we dont want to have any women with cervicsl cancer. they should be already screened and stopped before it reacjes the cancer stage. should be stopped at the stage of cin itself
exophytic growth vs ulcerative growth. exophytic is prtruding out. ulcerative is as if its been eaten.
can do speculum exam and then take puncg biospy ...but if cant see any visible growth and if coming with post coital bleeding then must do a colposcopy and then bisopy.
paracervical and parametrial and uterine all refers to the same set of lymphnodes
Direct extension spread down to the vagina and also to the sides to the bladder etc can be seen as well. But upward direct extension is rare and incvolvement of the ovaries is even more rarer
to find out the spread to other organs now all investigations are allowed and can be done.
1B is visible and then diagnosed by punch biospy
so if we consider 1a ..what if more than 5mm and still not visible? We then put it to 1b1!! because 1b1 is anything less than two which is visible or if not visible then should be more than 5mm. check below question
IVP is important because the cancer can spread laterally and then obstruct the ureter and then cause hydronephrosis as well.
it causes renal failure not because of direct spread or spread to the kidneys but by blocking the ureters and causing kidney damage that way. Most common cause of death in cervical cancer.
surgery is an advantage becauuse in surgery, ovaries can be preserved as opposed to surgery for other gyn cancers. (ovaries are involved less than 1% of the time). So its preferred fr young women (remmeber cervical cancer has a bimodal incience with 30s to 40s peak as well.
But raditaion can sorta preserve the ovaries if the ovaries are placed in the paracolic gutters...so this can be done in younger women as well.
What do you mean ovaries are not preserved in radiation? is it cause of they lose their function ad lead to menapause?
chemotherapy is not used for cervical cancer...but something called chemoradiation is used. The chemo part is just to senstiize the tissue to radiation...so in the end its mainly radiation doing its job.
when is chemotherapy(not chemotherapy but chemoradiation) preferred? whats its 1. 2b and beyond and 2, size is more than 4 cm (that is 1b and 2 A2). so actucally two main groups/indications where chemotherapy is oreferred
LVSI = lymphovascular space involvement ...this is ontained from the hpe report!!
fertility sparing surgeries (which by defintion can be uterus sparing surgeries) can be done only upto 1b1 and then after that cant do anything but radical hysterectomy.
After the things are removed then the body of the uterus is stiched back to the vagina.
There are only hundreds of cases of successful trachelectomy and only a few surgeons who have actually done it. so its not widely performed or available but only mostly exists in theory.
only three cases where chemoradiation is needed as above.
its the step for the most seevre cancer.
notice above that conization was done for other indications and then hpe report sent back as margins free...so then you can stage there and then and then you can relaise that you've already done the treatment for this stage of cancer.
fertility sparing surgeries can nly be done until stage 1b1 beyong which whatever the case, even if nulliparous, cant offer fertility sparing surgeries. her life is more important. ad sugrery upto 4 cm and not beond 2b then oly chemoradiation.
and if size more than 4 cm then always chemoradiation. nothing esle.
above risk stratification depends on the final hpe report