CIN Cervical cancer I have taken help of other presentations on slide share.

1. Cervical cancer
DR JASMINE GUJARATHI
PROFESSOR &HEAD
DEPT OF PRASUTI TANTRA AND STRI ROGA
G J PATEL INSTITUTE OF AYURVEDA STUDIES AND RESEARCH
NEW VALLABH VIDYANAGAR, ANAND, GUJARAT

6. Dysplasia : the presence of cells of an abnormal type within a tissue, which may
signify a stage preceding the development of cancer.
Metaplasia : is the transformation of one differentiated cell type to another
differentiated cell type. The change from one type of cell to another may be part of a
normal maturation process, or caused by some sort of abnormal stimulus

7. Neoplasia is new, uncontrolled growth of cells that is not under physiologic control. A "tumor"
or "mass lesion" is simply a "growth" or "enlargement" which may not be neoplastic (such as
a granuloma). The term "cancer" implies malignancy, but neoplasms can be subclassified as
either benign or malignant.

8. Three Types
Squamous cell Carcinomas
◦ Cancer of flat epithelial cell (squamous)
◦ 80% to 90%
Adenocarcinomas
◦ Cancer arising from glandular epithelium (columnar)
◦ 10% - 20%
Mixed carcinoma
◦ Features both types
Source: American Cancer Society

10. Cervical intraepithelial neoplasia
It is a histopathological condition where a part or whole
thickness of cervical squamous epithelium is replaced by
cells with severe degree atypia.
CIN I – Mild – one third of thickness
CINII – Moderate – two third of thickness
CIN III – CIS – Whole thickness

16. CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA)
as Seen in Colposcopy
16
CIN 1 CIN 2 CIN 3
1. Wright TC Jr, Cox JT, Massad LS, et al, for the ASCCP-Sponsored Consensus Congress. JAMA. 2002;287:2120–2129. 2. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ,
eds. Washington, DC: American Society for Microbiology Press; 2002:557–596. 3. Canadian Cancer Society. Cervical Cancer: What you need to know. Available at:
http://www.cancer.ca/vgn/images/portal/cit_86751114/63/40/151140772cw_library_wyntk_cervical_en.pdf. Accessed March 13, 2006. 4. Reprinted with permission from
Sellors JW, Sankaranarayanan R, eds. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s Manual. Lyon, France: International Agency for Research
on Cancer; 2003.
Photo courtesy of Dr. J. Monsonego Photo courtesy of Dr. J. Monsonego From IARC, 2003.4
Colposcopy findings confirmed by histology1

19. CIN Symptoms
Post coital bleeding
Vaginal discharge
Vaginal spotting
No symptoms

21. Risk factors
EARLY MARRIAGE
YOUNG AGE AT FIRST PREGNANCY
SHORT INTEVAL BETWEEN PREGNANCY
POOR NUTRITION
POOR HYGEINE
WOMEN WITH STD
WOMEN WITH MULTIPLE SEXUAL PARTNER
HUSBAND WITH MULTIPLE SEXUAL PARTNER
SMOKING
8/10/2020DR JASMINE GUJARATHI

23. Investigations
❑Pap smear
❑HPV –DNA
❑VIA
❑VILI
❑Colposcopy
❑Biopsy

24. PAP SMEAR
The cells are taken from the cervix
region by speculum & spatula, then
smear is prepared which is then
observed under microscope.
25

26. How to take a Pap Smear ?
➢Spatula is rotated through 360 degrees
maintaining contact with ectocervix
➢Do not use too much force [bleeding
/pain]
➢Do not use too less force [inadequate
sample]
➢Sample is smeared evenly on the slide
and fixed immediately
➢Both sides of spatula are to be smeared

27. How to take a Pap Smear ?
➢Endocervical sample is collected using
an endocervical brush
➢Insert the cytobrush into canal, so
that last bristles of brush are visible
➢Rotate the brush through 180
degrees. [more rotations increase the
chance of bleeding]
➢Sample is rolled on the slide and
fixed.

28. Fixation of smear
➢ Fixation is done immediately with
fixative like 95% alcohol or cytofix
spray to avoid air drying
➢ Spray should be kept at 10 inches,
to avoid destruction of cells by
propellent in the spray
➢ Smear should monolayer for proper
penetration of cell surface by
fixative

34. https://www.youtube.com/watch?v=7AWbs-OUV6Y

38. Schiller’s test
Application of
iodine solution
(schiller’s 0.3% or
Lugol’s 5%)

39. Brown colour staining – glycogen – Schiller’s negative
Yellow – Dysplasia, trauma

42. COLPOSCOPY
Colposcopy is the examination of the cervix &
vagina with a light magnifying instrument
colposcope after the application of a vinegar
(acetic acid) to the cervix.
6-16 times magnification
43

43. Colposcopy
Magnified visual examination of uterine cervix by a low power ,stereoscopic
microscope with a powerful light source to help in diagnosis of cervical neoplasia .
Key ingradients –observations of features of cervical epithelium after application of
normal saline , 3-5% dilute acetic acid and Lugol’s iodine solution .

44. INDICATIONS
OF
COLPOSCOPY
Squamous or glandular cell abnormalities
Persistence of inflammatory cells despite adequate
tt
Presence of keratinized cells .
Evaluation of HPV +ve women .
Postcoital ,postmenopausal bleeding .
Unhealthy cervix .
Treatment and monitoring of women with CIN
Anogenital condylomas ,VIN and VAIN.
DES exposure in utero.

45. Colposcopy -
Objectives
ØDetermines the presence of invasive
cancer
ØLocalizes the squamocolumnar junction
ØIdentifies the most severe disease for
biopsy
ØEvaluates the extent of disease
Øhttps://www.youtube.com/watch?v=PVm
ATws8gBs

47. Abnormal colposcopy findings
White epithelium – leukoplakia
Acetowhite epithelium – turning white due to cell protein coagulation
Punctuation – dilated capillaries which appears on surface as dots
Mosaic – capillaries encircling polygonal shaped block of epithelial cells
Atypical blood cells – irregular diameter
Irregular surface contour – with ulceration and friability

48. Post Menopausal Cervix:
Epithelium is pale, brittle, lacks lusture,
shows sub-epithelial petichiae, SCJ not visualized
The entire new SCJ is visible
colposcopic examination is satisfactory.
the TZ is fully visualized. The metaplastic
squamous epithelium is pinkish-white compared
to the pink original squamous epithelium

49. Squamous metaplasia
Earliest colposcopic changes in
immature squamous metaplasia (after
5% AA) in which tips of columnar villi
stain white & adjacent villi start fusing
together
Prominent white line corresponds to the
new SCJ & tongues of immature
Squamous metaplasia a) with crypt
openings at 4-8 o’clock positions
b) after application of AA

50. Immature squamous metaplastic epithelium (narrow arrow)
on the polyp with intervening areas of columnar epithelium
a) after application of AA
The endocervical polyp &
the immature squamous metaplasia
surrounding the os partially take up
iodine.

51. Immature squamous metaplastic epithelium (narrow arrow)
on the polyp with intervening areas of columnar epithelium
a) after application of AA
The endocervical polyp &
the immature squamous metaplasia
surrounding the os partially take up
iodine.

52. Leukoplakia
➢ Usually benign
➢ May obscure an underlying
neoplasia
➢ Therefore, all patches observed
before application of acetic acid
must be biopsied
Hyperkeratosis ( Leukoplakia)

53. CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA)
as Seen in Colposcopy
54
CIN 1 CIN 2 CIN 3
1. Wright TC Jr, Cox JT, Massad LS, et al, for the ASCCP-Sponsored Consensus Congress. JAMA. 2002;287:2120–2129. 2. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ,
eds. Washington, DC: American Society for Microbiology Press; 2002:557–596. 3. Canadian Cancer Society. Cervical Cancer: What you need to know. Available at:
http://www.cancer.ca/vgn/images/portal/cit_86751114/63/40/151140772cw_library_wyntk_cervical_en.pdf. Accessed March 13, 2006. 4. Reprinted with permission from
Sellors JW, Sankaranarayanan R, eds. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s Manual. Lyon, France: International Agency for Research
on Cancer; 2003.
Photo courtesy of Dr. J. Monsonego Photo courtesy of Dr. J. Monsonego From IARC, 2003.4
Colposcopy findings confirmed by histology1

54. Geographic satellite lesion
condyloma low-grade lesion

55. Thin acetowhite lesion with
geographic margins in the upper
lip. Histology indicated CIN 1
Moderately dense acetowhite lesions
with irregular margins in the anterior
& posterior lips ( CIN 1)

56. circumorificial acetowhite CIN 1
lesion with irregular margin & fine mosaics

57. Moderately dense acetowhite lesions with well
defined margins & coarse punctations in the anterior
lip & in 3 o’clock position (CIN 2 lesion
Dense well defined acetowhite area
with regular margins & coarse mosaic
( CIN 2 lesion )

58. A dense acetowhite lesion with varying colour
intensity &
coarse mosaics (a) in a CIN 2 lesion
Acetowhite lesions with coarse punctation
(a) & mosaics (b) in a CIN 2 lesion

59. A circumoral dense opaque acetowhite area with
coarse mosaics ( CIN 3 lesion)
A dense acetowhite lesion with regular margin
& coarse,
irregular punctation in a CIN 3 lesion.

60. Carcinoma in Situ

61. Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking mosaics (b),
surface irregularity & the atypical vessels after the application of 5% AA
Preclinical invasive Carcinoma

62. Reddish “angry-looking”, inflamed columnar epithelium
with loss of the
villous structure & with inflammatory exudate (before
application of 5% AA)
Inflammatory lesions of the
Uterine Cervix
Chronic cervicitis: This cervix is
extensively inflammed with a reddish
appearance &
bleeding on touch, there are ill-defined,
patchy acetowhite areas
scattered all over the cervix after the
application of AA

63. TV after Acetic acid
T.V. After Lugol’s
Multiple red spots (a) suggestive of Trichomonas
vaginalis colpitis ( strawberry appearance), after
application of 5% AA
Trichomonas vaginalis colpitis after
application of Lugol’s iodine
(leopard-skin appearance)

64. Large loop excision of the
transformation zone
Loop electrosurgical
excision procedure
Loop of 2-3 cm of thin
stainless steel wire is used
for excision of TZ.
https://www.youtube.com
/watch?v=BWuJ95gNxIM
https://www.youtube.com/watch?
v=ZOMpugExDKY
https://www.youtube.com/watch?
v=fCh8h1K8Rjc

68. CERVICAL CARCINOMA
Gross pathology
1. Exophytic – arise from ectocervix and form friable mass in upper
vagina
2. Ulcerative - lesion excavates cervix and involves vaginal fornices
3. Infiltrative – Endocervical growth

69. Mode of spread
1. Direct extension –Parametrium, paracervical and paravaginal
tissues. Compress ureter. Backwards along with uterosacral ligament
involve rectum and base of bladder.
2. Lymphatic
3. Hematogenous
4. Direct implantation

72. Stage I

73. Stage II

74. Stage III

75. Stage 4

77. Staging procedures
Lymph node palpation
Colposcopy
Hysteroscopy
Cystoscopy
Biopsy
Endocervical curettage
Conization
Chest X ray
Urogram / USG
Barium Enema
Proctoscopy
MRI
PET Scan
CT Scan

78. Contact bleeding
Intermenstrual bleeding
Pelvic pain
Back pain – involvement of sacral plexus and
uterosacral ligament
Leg edema – obstruction of lymphatics
Bladder symptoms – frequency, dysuria,
hematuria, incontinence - due to fistula
Rectal symptoms – Diarrhoea, rectal pain,
bleeding per rectum, rectovaginal fistula
Urethral obstruction – due to tumor,
pyelonephritis
Cachexic, anaemia and later uremia

79. Complications
Pyelitis, pyometra, hydronephrosis, fistula, sepsis, haemorrhage

80. 81
Preventing aspects-lifestyle change
❑Social change –avoid early marriages
❑Multiparity_ role of family planning
❑Avoid multiple partners
❑Use of condom to avoid STD,and HPV diseases
❑Improve nutrition and personal hygiene
❑Prevents smoking ,alcoholism ,etc
❑Regular exercise
❑Health awareness-health check up

81. Primary Prevention
by HPV Vaccine
GARDASIL®
[Human Papillomavirus Quadrivalent
(Types 6, 11, 16, and 18)
Vaccine 0.5ml prefilled syringe]
CERVERIX
[Human Papillomavirus Bivalent
(Types 16 and 18)
Vaccine 0.5ml prefilled syringe]
8209-2009-GRD-2008-AP-(IN)-1601-SS

82. 83
HPV Vaccines- made by
recombinant DNA technology

83. Cone biopsy
https://www.youtube.com/watch?v=fCh8h1K8Rjc
https://www.youtube.com/watch?v=DLxBTVgyrrE

84. INDICATION
FOR Gardasil
For the prevention of
➢Cervical Cancer
➢Vulvar/ Vaginal Precancers
➢Cervical Dysplasia
➢Genital Warts
Cerverix is only indicated for
Cervical cancer
85

85. 86
Effectiveness
▪Gardasil vaccine’s efficacy is 98 to 100%.
▪Cerverix vaccine’s efficacy is 92 to 94%

86. 87
When we can give this vaccine?
▪This vaccine can be given to any girl above
9 years. Recommended for women of 9-45
years age group
▪The most effective time to vaccinate girls
and young women is before they become
sexually active.
Educational Program 2009 87

87. 88
How many dose recommended?
▪Three doses
▪First .(as elected date)
▪Second (after 2 month of first dose)
▪Third (after 6 month of first dose)
Cerverix – 0,1 & 6
Educational Program 2009 88
6
months
2
Months0

88. 89
Side effects
HPV Vaccines demonstrated a favorable safety profile.
Following injection-site reactions occurred at a greater
incidence in the group that received VACCINE
◦ Very common: erythema, pain, and swelling.
◦ Common: pruritis.
◦ Most injection-site reactions were mild to moderate.
◦ Very Common (≥1/10); Common (≥1/100, <1/10); Uncommon (≥1/1,000, <1/100); Rare
(≥1/10,000, <1/1,000); Very Rare (<1/10,000)
Educational Program 2009 89

89. 90
Special Population
PREGNANT WOMEN
▪Because of insufficient trial there is no
recommendation of this vaccine in pregnancy.
▪If woman gets pregnant after first dose ,then
remaining dose should be taken after delivery.
LACTATING MOTHER
▪Lactating woman can take this vaccine.
Cerverix is not indicated during lactation
Educational Program 2015 90

90. 91
Is vaccine costly?
▪No, if we can see the mortality rate of the cervical cancer or its treatment
,vaccine cost is nothing against it.
▪If we see the modern life style of people ,vaccine cost is nothing.
▪People give lacks of rupees of dowry to their daughters ,vaccine cost is
nothing against it.
▪It is cost effective
Educational Program 2009
91

91. 92
Screening & Vaccination
➢Pap testing and screening for HPV DNA or HPV antibody
are not needed before vaccination at any age.
• Benefits may be limited to protection against HPV
genotypes with which they have not been infected.
• Women infected with vaccine HPV-type and have cleared
the cervical infection appears to have similar protective
effects as in HPV naïve to the same vaccine HPV-type.

92. TREATMENT OPTIONS
Primary surgery
Primary radiotherapy
Chemotherapy
Combination therapy

93. Surgery
1. Werthiem’s radical hysterectomy
Removal of uterus, tubes, ovaries, upper half of vagina, parametrium –
cardinal uterosacral ligaments, Draining cervical lymph nodes
2. Laproscopy assisted vaginal radical trachelectomy with pelvic and aortic
lymphadenectomy (LAVRT) – Uterus is preserved
Pelvic and aortic lymph dissection, Cervical, vaginal, paracervical and
paravaginal tissues.
(child bearing function is preserved)

94. Radiotherapy
EBRT – External Beam Radiation therapy – Teletherapy
Brachytherapy – implanting radioactive material directly
into tumor or close to it
IU tandem of small radioactive sources
Radium, cesium, cobalt

95. One application
120 hours duration
One IU tandem
Vaginal ovoid – 2 or 3

96. Three application s
24 hours at weekly interval
Vaginal plaque

97. Two applications
72 hours interval of 7 days
IU tandem
Vaginal colpostat

99. Neo adjuvant chemotherapy
Reduces tumor volume
Improves survival rate
IB – IIB
Cisplastin, Ifofamide or Paclitaxel

103. 106

104. To produce a Cancer Free Society
Screening and identification of High Risk groups
Education – Think of Cervical Cancer as an extension of STD
Behavioral changes
Limit number of sexual partners
Delay initial age of sexual intercourse
Avoid STD – Use of Condoms/ Spermicidals; Avoid Smoking
HPV Vaccines to be promoted at the right age