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

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 a 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

Spread and staging of malignant disease of the cervix

• 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

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 of malignant cervix

• Depends on lymph node involvement, clinical stage and histological grade
• Overall 65% 5 year survival rate