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Colposcopy & Management of CIN Dr. Usha Nath, FRCOG Consultant Obstetrics & Gynaecology

Statistics Cervical cancer is one of the most common forms of cancer affecting women worldwide. The good news is that it is highly curable, especially when diagnosed early. Cancer of the cervix is most likely to occur in women between the ages of 30 and 55.

Who's at Risk? Factors increasing the risk include: Cigarette smoking. Early sexual activity. Sexually transmitted diseases (STDs). Human papilloma virus (HPV). Age. Income. Race.

Transformation Zone

The Transformation Zone Over 90% of neoplasia arises from within the transformation zone.

Transformation Zone Is the area of actively maturing epithelium between the present squamo-columnar junction (SCJ) and the original squamous epithelium. This zone is composed of the intermingling of squamous and columnar epithelium. Squamous metaplasia, islands of columnar epithelium, gland openings and Nabothian cysts may be identified. The precise location of the transformation zone varies in relation to the exo and endocervix. This is related to the age of the patient and the degree of squamous metaplasia.

CIN - Cervical Intraepithelial Neoplasia A spectrum of abnormalities of the surface epithelium. Transformation zone changes ranging from CIN I (mild dysplasia). To CIS (carcinoma in-situ).

Cytologic Aberrations Seen in CIN Hyperchromaticity, abnormal chromatin distribution, increased nuclear to cytoplasmic ratio and nuclear pleomorphism. May be seen in exfoliated cells in a pap smear or in a histologic slide from a biopsy specimen.

CIN - Histology CIN grading is based upon. The proportion of the surface epithelium composed of undifferentiated cells characteristic of the basal layer. Increasing grade is associated with a progressive loss of epithelial maturation.

CIN I or Mild Dysplasia Represents atypical cells with increased nuclear to cytoplasmic ratio and hyperchromatic nuclei present in the lower /3 of the epithelial layer from the basement membrane.

CIN II or Moderate Dysplasia Shows further progression of the nuclear abnormalities with greater involvement of the epithelial thickness. In CIN II, immature basaloid cells occupy the lower /3 to 2/3 of the epithelium.

CIN III or Severe Dysplasia Represents almost total involvement of the epithelium with only one or two layers of mature cells remaining at the surface.  When the entire epithelium is involved, the term CIS is applicable.

Invasive Cervical Cancer With all levels of CIN the basement membrane of the epithelium remains intact. Once the membrane is violated, invasive cancer is diagnosed.  With very early invasion the term microinvasion applies.

Staging Cervical Cancer

History of the Colposcope 1924 Hinselmann (Germany). Suggested that cervical cancers began as tumors and it could be detected with magnification and illumination. 1925 Hinselmann & Leitz. Created the first Colposcope. 1943 Papanicolaou & Traut. Publish book on cancer diagnosis by vaginal smear.

History of the Colposcope 1967 Richart. Implies a continuum from mild dysplasia to invasive cancer. Introduces term CIN. 1977 Cartier. First comprehensive atlas of colposcopy published. 2001. Latest colposcopy is of a multispectral digital imaging type. Provides video capability, spectral analysis, zoom. Good integration with software to enhance function.

The Colposcope

Colposcope Usage Usually the abnormal cells are first discovered on a routine pap test. When abnormal cells are seen on a pap test, we must look at the cervix more closely to determine the exact nature of the abnormality. To do this we examine the cervix with a colposcope.

Colposcopic Management Series of lenses designed to magnify the tissue, enabling the physician to examine the organs more directly. Is a follow up to an abnormal pap smear … indicating infection, dysplasia or cancer. Is a minimal risk procedure. Possible cramping, bleeding or rarely infection.

Colposcopic Management Alternatives to a colposcopy are limited, The benefits make the procedure extremely worthwhile for the patient. If a patient opts against colposcopy, the physician may perform a conization – or removal of a cone of tissue – of the cervix. If nothing at all is done, the patient risks dying of cervical cancer.

Colposcopic Management The pap test suggests underlying pathology. The Colposcopy with biopsy will often result in a definitive histological diagnosis for further treatment.

Thank You