Cervical Disorders
- Blood supply from upper vaginal and uterine arteries
- Lymph drains to the obturator and internal and external iliac nodes and then to the para-aortic nodes
- Cervical carcinoma commonly spreads via the lymph
Benign conditions of the cervix
Cervical ectopy
- Also called erosion
- When the columnar epithelium of the endocervix is visible as a red area around the os
- Normal in younger women especially those that are pregnant or those that are on the contraceptive pill
Cervical ectropion
- Results from minor lacerations during childbirth
- Appears as more irregular redness
- Can cause vaginal discharge or post coital bleeding
- Treated by cyrotherapy
- Exposed columnar epithelium is more susceptible to infection
Acute cervicitis
- Rare
- Often results from STD
- May result in vaginal discharge
- Cervix appears red, congested and swollen
Chronic cervicitis
- Chronic inflammation/infection
- Often involves an ectopy or ectropion
- Presentation is with pelvic pain, discharge or superficial dyspareunia
Cervical polyps
- Benign tumours of the endocervical epithelium
- Most common over the age of 40
- May cause IMB or PCB
Nabothian follicles
- Occurs where squamous epithelium has formed by metaplasia over endocervical cells
- Columnar cell excretions are trapped, forming cysts which appear as white swellings on the ectocervix
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Premalignant conditions of the cervix – CIN
- CIN is the presence of atypical, mitotic, dykaryotic cells with large nuclei within the squamous epithelium
- CIN is a histological diagnosis, graded I-III
- CIN I – mild dysplasia, atypical cells found only in the lower 1/3 of epithelium
- CIN II – moderate dysplasia, atypical cells found in lower 2/3 of epithelium
- CIN III – severe dysplasia, atypical cells in the full thickness of the epithelium. Also called carcinoma in situ
- If untreated 1/3 of the women with CIN II/III will develop cervical cancer over 10 years
- CIN I can progress to CIN II/III but often spontaneously regresses
- CIN is becoming more common, it is more prevalent in women aged 35-45 and in lower socio-economic classes
Investigation/Treatment
- Colposcopy - grades of CIN have characteristic appearance when stained with 5% acetic acid
- If CIN II or III is present the transformation zone is excised with cutting diathermy. This is called ‘large loop excision of transformation zone’ or diathermy loop excision
- Cervical screening reducing the cumulative incidence of cervical carcinoma by 91%
Malignant disease of the cervix
- Incidence falling
- Most common between ages of 45-55
Pathology
- 90% of cervical malignancies are squamous cell carcinomas
- 10% are adenocarcinomas from columnar epithelium with a poorer prognosis
Clinical features
- Occult carcinoma is when there are no symptoms, diagnosis is made by biopsy
- Clinical carcinoma may present with PCB, vaginal discharge and PMB. Pain is not an early feature.
- In later stages involvement of the ureters, bladder, rectum and nerves causes uraemia, haematuria, rectal bleeding and pain
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Spread and staging
- FIGO classification does not include lymph node involvement, so is therefore not s good indicator of survival
- Stage 1 – lesions confined to cervix
- 1a(i) < 3mm in depth, <7mm across, 1a(ii)<5mm in depth, < 7mm across, Ib(i) tumour size <4cm, 1b(ii) tumour size >4cm
- Stage 2 – invasion into the vagina but not the pelvic side wall
- 2a not in parametrium, 2b in paramterium
- Stage 3 – invasion of lower vagina or pelvic wall or causing ureteric obstruction
- Stage 4 – invasion of bladder or rectal mucosa or beyond true pelvis
- Stage 1 – lesions confined to cervix
Treatment for each stage
- Stage 1a(i) – cone biopsy or simple hysterectomy
- Stage 1a (ii)-2a – radical hysterectomy +/- chemo-radiotherapy or chemo-radiotherapy alone of greater than 1b(ii).
- Stage 2b and above – chemo-radiotherapy alone
Prognosis
- Depends on lymph node involvement, clinical stage and histological grade
- Overall 65% % year survival rate