Cervical intraepithelial neoplasia

1. CERVICAL INTRAEPITHELIAL NEOPLASIA
PROF. M.C. BANSAL
M.B.B.S , M.S. , M.I.C.O.G, F.I.C.O.G.
Founder Principal& Controller;
JhalawarMedical College and Hospital Jhalawar.
Ex. Principal & Controller;
Mahatma Gandhi Medical college And Hospital, Sitapura, Jaipur.
DR. RIDHI KATHURIA

2. HISTORICAL BACKGROUND
• Mild, moderate, and severe dysplasia were the terms used to describe
premalignant squamous cervical cellular changes.
• RUBIN (1910) introduced the term ‘CARCINOMA IN SITU’ as a
forerunner term of invasive carcinoma.
• WALTERS & REGAN (1956) introduced the concept of neoplasia.
• RICHART (1967) brought forth the concept of CIN wherein cervical
squamous epithelium is replaced by cells with varying degrees of
atypia

4. • WHO in 1975 classified, the CIN
into three categories correlating
with former grading of dysplasia
– CIN 1,2,3 & CIS.
• Grading to be done according to
the thickness occupied by the
undifferentiated cells.

5. • BETHESDA SYSTEM (1988)
classified cytological abnormalities of premalignant
lesions into 3 categories for squamous metaplasia
–
a. Atypical Squamous Cells (ASC)
b. Low Grade Squamous Intraepithelial Lesion
(LSIL)
c. High Grade Squamous Intraepithelial Lesion
(HSIL)

8. DYSPLASIA CIN
Limit of
Histological
changes
Bethesda
MILD CIN 1
Basal 1/3rd
LSIL
MODERATE CIN 2
Basal ½ to 2/3rd
HSIL
SEVERE CIN 3
Whole thickness
except 1 or 2
layers
CIS CIN 3 Whole thickness
There is considerable degree of overlapping regarding the precise
definition of each category of intra-epithelial neoplasia.

10. 1) INFECTION – HPV (16, 18, 31, 33), HIV, CHLAMYDIA
2) EARLY FIRST COITUS
3) STD
4) EARLY 1ST PREGNANCY
5) TOO MANY & TOO FREQUENT BIRTHS
6) LOW SOCIOECONOMIC STATUS
7) MULTIPLE PARTNERS
8) IMMUNOSUPRESSION
9) OCP USERS
10) SMOKING

11. DEMOGRAPHIC
RISK FACTORS
• Ethnicity
• Low Socio-economic
status
• Age
BEHAVIORAL
RISK FACTORS
• Infrequent or
absent cancer
screening Pap
tests.
• Early Coitarche
• Multiple
partners
• Tobacco
smoking
• Male partner
who’s had
multiple
partners
• Dietary
deficiency
MEDICAL RISK
FACTORS
• Infection
• Immuno-supression
• Parity

13. CIN 1 - only mild dysplasia, or abnormal
cell growth.
It is confined to the basal 1/3 of the epithelium.
This corresponds to infection with HPV, and
typically will be cleared by immune response in a
year or so, though can take several years to clear.
CIN 2 - moderate dysplasia confined to the
basal 2/3 of the epithelium
CIN 3 - Severe dysplasia that spans more
than 2/3 of the epithelium, and may involve the
full thickness.

15. CIN 1

16. CIN 2

17. CIN 3

18. Squamo-columnar junction (scj) of the cervix
refers to a transitional area between
squamous epithelium of the vagina and the
columnar epithelium of the endocervix.
This shifts in location through age from being
more external to internal.

20. SCJ is thus a dynamic zone, and
moves up & down acc to phases of life
of the female

21. T
R
A
N
S
F
O
R
M
A
T
I
O
N
Z
O
N
E
Pre-puberty, ectocervix is covered with
squamous epithelium.

22. Heightened estrogen exposes the
columnar epithelium onto the ectocervix

23. Replacement of the columnar epithelium
by the squamous epithelium at to form the
TZ.
New junction is at or slightly outside the
external os during reproductive period.
Following menopause it is drawn back inwards.

24. 1) BASAL LAYER – is a single row of immature cells with large nuclei &
small amounts of cytoplasm.
2) PARABASAL LAYER – includes 2 or 4 rows of immature calls that
have normal mitotic figures & provide the replacement cells for the
overlying epithelium.
3) INTERMEDIATE LAYER – includes 4 to 6 rows of cells with larger
amounts of cytoplasm in a polyhedral shape separated by intercellular
space. Intercellular
bridges where glycogen production differentiation occurs, can be seen on
light microscopy.
4) SUPERFICIAL LAYER – includes 5 to 6 rows of flattened cells with
small uniform nuclei & cytoplasm filled with glycogen. Nucleus is
pyknotic, & cells undergo exfoliation.
These cells for the basis of Pap Smear Testing.

25.  The process of carcinogenesis starts at the TZ.
 2 mechanisms are involved in this process –
a) Squamous metaplasia of the subcolumnar reserve
cells.
b) Squamous epidermidisation by ingrowth of the
squamous epithelium of the ectocervix under
columnar epithelium.
 The metaplastic process is very active at menarche
& during and after the 1st pregnancy.
 These are periods of high estrogenic activity and low
vaginal ph.

26.  In presence of estrogen in the vaginal epithelium, glycogen is
accumulated.
 The lactobacilli act on glycogen to produce lactic acid, which lowers the
ph of the vagina.
 The acid ph is an important trigger of metaplastic process.
 The metaplastic cells have potential to transform atypically in lieu of
infection/trauma.
 Prolonged effect of can produce continuous changes in immature cells
which may lead to malignant changes.

27. SQUAMO-COLUMNAR JUNCTION
REPLACEMENT OF COLUMNAR EPITHELIUM
METAPLASIA
OF
RESERVE CELLS
SQUAMOUS
EPIDERMIDAZATIO
IMMATURE UNSTABLE CELLS N
PHYSIOLOGIC METAPLASIA (+) CARCINOGEN
ATYPICAL METAPLASIA
or
CIN
or
CIS
or
++ ( - )
INVASICE CARCINOMA
WELL
DIFFERENTIATED
SQUAMOUS
EPITHELIUM

28. In most cases, CIN is believed to originate from a single focus in
the TZ at the advancing SCJ.
The anterior lip of cervix in twice likely to develop CIN than the
posterior lip. Rarely, CIN originates at the lateral angles.
Once overt, it can progress horizontally to involve the entire TZ,
but does not replace the original squamous epithelium.
Proximally, CIN involves the cervical clefts.
The only way to determine where it all started is to identify the
nabothian cysts or cervical cleft openings, which indicate the
presence of columnar epithelium.
After the metaplastic matures, & forms glycogen, it is called,
HEALED TRANSFORMATION ZONE, and is relatively resistant to
oncogenic stimuli.

29. CIN is most likely to develop during
menarche or after pregnancy, when
metaplasia is most active.
After menopause, little chances of
metaplasia remain, from de novo HPV.

30. The role of this virus in the genesis of essentially all cervical
neoplasia and a significant portion of vulvar, vaginal, and anal
neoplasia is firmly established.
Human papilloma virus is a non-enveloped DNA
virus with a protein capsid.
It infects epithelial cells exclusively and
approximately 30 to 40 HPV types have an affinity
for infecting the lower anogenital tract.

31. More than 100 HPV types have now been identified.
Clinically, HPV types are classified as high-risk (HR) or low-risk (LR)
based upon their cervical cancer oncogenicity.
Low-risk HPV types 6 and 11 cause nearly all genital warts and a
minority of subclinical HPV infections. Low-risk HPV infections are
rarely, if ever, oncogenic.
HR HPV types include 16, 18, 31, 33, 35, 45, and 58 and account for
approximately 95 percent of cervical cancer cases worldwide.
Other HR HPV types less often associated with neoplasia include 39, 51,
52, 56, 59, 68, 73, and 82.
The most common HR HPV types (16, 18, 45, and 31) found in
cervical cancer are also the most prevalent in the general
population.
Specifically, HPV 16 is the dominant cancer-related HPV, accounting
for 40 to 70 percent of invasive squamous cell cervical cancers
worldwide

33. A Koilocyte is a squamous epithelial cell that has undergone a
number of structural changes, which occur as a result of
infection of the cell by HPV.

34. Koilocytes may have the following cellular changes:
 Nuclear enlargement (two to three times normal size)
 Irregularity of the nuclear membrane contour
 A darker than normal staining pattern in the nucleus,
known as Hyperchromasia
 A clear area around the nucleus, known as a Perinuclear
Halo.

35. ₰ High levels of HPV – DNA and capsid antigen has been detected
in the koilocytes.
₰ This indicates productive viral infection in these cells.
₰ The HPV genome is found in all grades of cervical neoplasia.
₰ As the CIN lesion becomes more severe, the koilocytes
disappear, the HPV copy number decreases & capsid antigen
disappears.
This indicates the inability of the virus to reproduce in less
differentiated cells.
₰ Instead portions of hpv – dna becomes integrated in the host
cell.
₰ Integration of the transcriptionally active dna is essential for
malignant transformation.
₰ Malignant transformation requires the expression of E6 and E7
oncoproteins produced by HPV.

36. • Usually, HPV infection
doesn’t persist.
• In majority cases, infection
clears in about 9-15 months.
• Small proportion of women
exposed, have persistent
infection & further progress
to CIN 2/3/CIS.
NOT ALL HPV LEAD TO
CIN, but, ALL CIN ARE
PRECEEDED WITH
HPV INFECTION

38. CERVICAL
EPITHELIUM
CIN 1 CIN 2 CIN 3 / CIS
Regression to
normal (%)
60 40 30
Persistence (%) 30 35 50
Progression to
CIN 3 / CIS (%)
10 20 -
Progression to
invasion (%)
<1 5 20

39. 1.PAP Test
2.Colposcopy
3.HPV – DNA detection
(PCR, Southern Blot Assay,
Hybrid Capture)

40. A standardized method of reporting cytology findings defined under
THE BETHESDA III SYSTEM (2001).
According to this system, potentially premalignant squamous lesions
fall into three categories:
(i) Atypical Squamous Cells (ASC)
(ii) Low-grade Squamous Intraepithelial Lesions (LSIL)
(iii) High-grade Squamous Intraepithelial Lesions (HSIL).
The ASC category is subdivided into two categories:
those of Unknown Significance (ASCUS),
and
those in which High-grade Lesions must be excluded (ASC-H).

41. Low-grade squamous intraepithelial lesions include CIN 1
(mild dysplasia) and the changes of HPV, termed
Koilocytotic Atypia.
The HSIL category includes CIN 2 and CIN 3 (moderate
dysplasia, severe dysplasia, and carcinoma in situ).

42. THE 2001 BETHESDA
SYSTEM
A. SPECIMEN TYPE
Indicate conventional smear (Pap smear) vs. Liquid-based
Preparation vs. Other
B. SPECIMEN ADEQUACY
Satisfactory for evaluation
(describe presence or absence of endocervical/transformation
zone component and any other quality indicators, e.g., partially
obscuring blood, inflammation, etc)
Unsatisfactory for evaluation (specify reason)
Specimen rejected/not processed (specify reason)
Specimen processed and examined, but unsatisfactory for
evaluation of epithelial abnormality because of (specify
reason)

43. C. INTERPRETATION/RESULT
1. NEGATIVE FOR INTRAEPITHELIAL LESION OR
MALIGNANCY
(when there is no cellular evidence of neoplasia, state this in the
General Categorization above and/or in the Interpretation/Result
section of the report, whether or not there are organisms or other non-neoplastic
findings)
Organisms
Trichomonas vaginalis
Fungal organisms morphologically consistent
with Candida spp
Shift in flora suggestive of bacterial vaginosis
Bacteria morphologically consistent with Actinomyces spp
Cellular changes consistent with Herpes simplex virus
Other non-neoplastic findings (Optional to report; list not
inclusive)
Reactive cellular changes associated with:
Inflammation (includes typical repair)
Radiation
Intrauterine contraceptive device (IUD)
Glandular cells status post hysterectomy
Atrophy

44. 2. OTHER
Endometrial cells (in a woman >= 40 years of age)
(Specify if ‘negative for squamous intraepithelial lesion’)
3. OTHER MALIGNANT NEOPLASMS (specify)

45. 4. EPITHELIAL CELL ABNORMALITIES
Squamous cell
Atypical squamous cells
Of undetermined significance (ASC-US)
Cannot exclude HSIL (ASC-H)
Low grade squamous intraepithelial lesion (LSIL)
Encompassing: HPV/mild dysplasia/CIN 1
High grade squamous intraepithelial lesion (HSIL)
Encompassing: moderate and severe dysplasia, CIS; CIN 2 and
CIN 3
With features suspicious for invasion (if invasion is
suspected)
Squamous cell carcinoma

46. Glandular cell
Atypical
Endocervical cells, NOS or specify in comments
Endometrial cells, NOS or specify in comments
Glandular cells, NOS or specify in comments
Atypical
Endocervical cells, favor neoplastic
Glandular cells, favor neoplastic
Endocervical adenocarcinoma in situ
Adenocarcinoma
Endocervical
Endometrial
Extrauterine
Not otherwise Specified (NOS)

47. D. ANCILLARY TESTING - provide brief description of the test
methods & report result such that it is easily understood by the
clinician.
E. AUTOMATED REVIEW – if automated device used to test,
specify device & result.
F. EDUCATIONAL NOTES AND SUGGESTIONS (optional)

53. ☺Exfoliative Cytology
☺ HPV – DNA Testing
☺ Visual Inspection with Acetic Acid
☺ Colposcopy
☺ Cervicography
☺ Endo cervical Curettage & Biopsy (with / without
colposcopy)
☺ Diagnostic Conisation

54. 5% acetic acid is applied to the cervix with a large cotton swab and left
for 30-60 seconds, after which the cervix is visually examined with the
colposcope.
Pre-cancerous lesions, with a higher ratio of intracellular proteins, turn
white when combined with acetic acid.
Normal cervices without any precancerous lesions, do not change color.

55. A colposcope is used to identify visible clues suggestive of
abnormal tissue.
It functions as a lit binocular microscope to magnify the view
of the cervix, vagina, and vulvar surface.
Low power (2x to 6x) may be used to obtain a general
impression of the surface architecture.
Medium (8x to 15x) and high (15x to 25x) powers are utilized
to evaluate the vagina and cervix.

56. The higher powers are often necessary to identify certain
vascular patterns that may indicate the presence of more
advanced pre-cancerous or cancerous lesions.
Various light filters are available to highlight different aspects of
the surface of the cervix.
Acetic acid solution and Iodine solution (Lugol's or Schiller's)
are applied to the surface to improve visualization of abnormal
areas.

57. Colposcopy is performed with the woman lying back, legs
in stirrups, and buttocks at the lower edge of the table
(dorsal lithotomy position).
A speculum is placed in the vagina after the vulva is examined for
any suspicious lesions.
Three percent acetic acid is applied to the cervix using cotton swabs.
Areas of aceto-whiteness correlate with higher nuclear density.
Areas of the cervix which turn white after the application of acetic
acid or have an abnormal vascular pattern are often considered for
biopsy.
If no lesions are visible, an iodine solution may be applied to the
cervix to help highlight areas of abnormality.

58. Punctation - A stippled appearance to capillaries
seen end-on, often found within acetowhite area
appearing as fine to coarse red dots.

59. Mosaicism - An abnormal pattern of small
blood vessels suggesting a confluence of "tile"
or "chickenwire" reddish borders.

60. Leukoplakia (hyperkeratosis) - Typically an
elevated, white plaque seen prior to the application
of acetic acid.
Abnormal blood vessels - Atypical, irregular
vessels with abrupt courses and patterns, often
appearing as commas, corkscrews, or spaghetti.
No definite pattern is recognized, as with punctation or mosaicism. Suspect
invasive cancer. Complex pattern consisting of roughened, irregular cervical
epithelium, typically with abundant irregular vessel patterns. Blood vessels
take bizzare forms, which appear as commas, hair pins, spaghetti, or long,
dilated, unbranching vessels with irregular diameters.

61. OTHER COLPOSCOPIC FINDINGS
Vaginocervicitis - Cervicitis may cause abnormal Pap smears and make
colposcopic assessment more difficult. Many authorities recommend
treatment before biopsy when a STD is strongly suspected.
Traumatic erosion - most commonly caused by speculum insertion and over
vigorous Pap smears but can also result from such irritants as tampons,
diaphragms, and intercourse.
Atrophic epithelium - Atrophic vaginal or cervical epithelium may also
cause abnormal Papanicolaou smears. Colposcopists will often prescribe
estrogen for 2 to 4 weeks before a colposcopy in order to "normalize" the
epithelium before the examination. This is generally felt to be safe even if
dysplasia or cancer is present because the duration of therapy is short and
these lesions do not express any more estrogen receptors than a normal
cervix.
Nabothian cysts - They are areas of mucus producing epithelium that are
"roofed over" with squamous epithelium. They do not require any treatment.
They provide markers for the transformation zone since they are in squamous
areas but are remnants of columnar epithelium.

62. Photographs of the cervix and submitted to an expert for
opinion

63. Refers to an excision of a cone-shaped sample of tissue from the cervix.
Conization may be used either for diagnostic purposes as part of
a biopsy, or for therapeutic purposes to remove pre-cancerous cells.
Types include:
Cold Knife Conization (CKC). Usually outpatient, occasionally
inpatient.
Loop Electrical Excision Procedure (LEEP). Usually outpatient.
Conization of the cervix is a common treatment for dysplasia following
abnormal results from a pap smear.

65. Side effects –
a. Cervical Stenosis
b. Incompetent Os
c. Hematometra
d. Adjacent tissue trauma

66. FOLLOWING CRITERIA TO BE FULFILLED –
 Entire lesion should be visualized within the TZ.
 No evidence of Microinvasion or Invasion.
 No endocervical glandular involvement.
 No discrepency b/w Biopsy, Cytology &
Colposcopy report.

67. CRYOSURGERY
 Principle is crystallization of intracellular water at temperatures of
-90o C.
 Uses Nitrous Oxide or CO2
 Depth of tissue destruction = 5 mm
 Ideal for – minor grades of CIN, localized lesions.
DOUBLE FREEZE TECHNIQUE
(Freeze-Thaw-Freeze) increases efficacy.

68. COLD COAGULATION
Destroys tissues at temperatures of -100 to
-120o C
No anaesthesia needed
4 mm depth destruction

69. ELECTRODIATHERMY
 8-10 mm depths destroyed.
 Using a unipolar electrode.
 General Anaesthesia.

70. CARBON DIOXIDE
LASER
 Depth = 7 mm
 Method of choice when CIN extends onto vaginal
fornices.
 Done through colposcopic guidance
 Destroy epithelium by vaporisation.

71.  CIN lesion associted with other gynaecological problems like
prolapse, fibroid, PID, endometriosis.
 Extension into vagina.
 Persistent dyskaryotic smear even after treatment.
 High grade CIN in elderly women.
 Patients with CIN 3
 Poor follow up compliance.
 Cancer Phobia.
REMOVE VAGINAL CUFF IF LESION EXTENDS TO
FORNICES

72. The American Society for
Colposcopy & Cervical
Pathology (ASCCP) Guidelines
developed in 2001, revised in
April 2013, define the
guideline algorithms.

92. Rationale for Development of a Cervical
Cancer Vaccine
Identifiable etiologic factor
Worldwide burden of cervical
cancer
Financial, medical and emotional
burden of HPV-related genital
neoplasia

93. Preventive HPV vaccines are based on hollow virus-like particles
(VLPs) assembled from recombinant HPV coat proteins
Vaccines target the two most common high-risk HPVs, types 16
and 18
Elicit virus-neutralizing antibody responses that prevent initial
infection with the HPV types represented in the vaccine

94. Gardasil (Merck)
• Quadrivalent vaccine
• HPV types 16,18 , 6 & 11
• HPV types 16 and 18 currently cause about 70% of cervical
cancer
• Type 16 associated with oropharyngeal squamous-cell carcinoma
• HPV types 6 and 11 cause about 90% of genital wart cases
• Prophylactic HPV vaccine
•3 doses at 0 , 2 & 6 month
0.5ml IM (Deltoid)

95. Vaccines have been shown to offer 100 percent protection against the
development of cervical precancerous lesions & genital warts
Protective effects of the vaccine are expected to last a minimum of 4.5
years after the initial vaccination
( Randomised Control Trial, Lancet. 2006 Apr)

96. Cervarix
(GlaxoSmithKline)
• Bivalent vaccine
• HPV types 16 & 18
• Cross-reactive protection against virus strains 45 and 31
• Prophylactic vaccine
• Created using the L1 protein of the viral capsid
• Vaccine contains no live virus & DNA
So it cannot infect the patient.
• 3 doses over a six-month span
0 month, 1 month, and 6 months
0.5ml IM (Deltoid)

97. o 92% reduction in abnormal Pap smears
o 94-100% reduction in persistent infection
o 98% Seropositivity up to 4-5 yrs
o Phase II trials demonstrated 100% protection of the vaccine against
types 16 and 18 HPV

98. Indications & Prevalence
 Prophylactic vaccines
 For maximum efficacy, vaccines recommended prior to
becoming sexually active (11-12 yrs of age)
 Vaccine can prevent almost 100% of disease caused by HPV
targeted by the vaccine
 Vaccine should not be considered a substitute for routine Pap
smears
 Eliminates 90% cases of genital warts (HPV 6 & 11)
 Prevents anal cancer (HPV 16 & 18)

99. CATCH UP
VACCINATION
Vaccine is also recommended for girls &
women 13-26 years of age who did not
receive it when they were younger
Additional (booster) doses are not
recommended
HPV vaccine may be given at the same
time as other vaccines

100. SIDE EFFECTS & COMPLICATIONS
 Pain at the injection site
 Redness or swelling at the injection site
 Mild fever
 Itching at the injection site
 GI symptoms
 Joint pains
 Anaphylactic reactions - rare
 Guillan – Barre Syndrome (GBS) – very rare
(Department of health and human services, Centers for Disease Control and Prevention)