Lower Genital Tract Precancer (eBook)

Albert Singer is a Professor, Department of Women's and Child Health, Whittington Hospital, London. John Monaghan, MD Consultant Gynaecologist, Newcastle, UK. Swee Chong Quek, KK Women's and Children's Hospital, Singapore.

Lower Genital Tract Precancer 1
Contents 7
Preface to the Second Edition 13
Preface to the First Edition 15
Acknowledgements 17
1 The Histopathology of Lower Genital Tract Neoplasia 19
1.1 Introduction 19
1.2 Terminology 19
The concept of cervical cancer precursors 19
Biology and natural history 20
Rationalization of histologic terminology 21
1.3 Histopathological features of CIN or SIL 21
Low-grade disease (mild dysplasia, CIN 1, HPV-CIN 1, LSIL) 21
High-grade disease (moderate or severe dysplasia, CIS, CIN 2 or 3, HSIL) 22
1.4 Cervical glandular intraepithelial neoplasia and adenocarcinoma-in-situ 24
Cervical glandular intraepithelial neoplasia 24
Histologic criteria for CGIN 24
1.5 Early invasive carcinoma (microinvasive carcinoma of the cervix) 25
1.6 Vaginal intraepithelial neoplasia 28
Adenosis 28
Histopathology of vaginal intraepithelial neoplasia 29
1.7 Vulval precancer 29
Vulval intraepithelial neoplasia 29
Paget's disease 29
1.8 Related topics 30
1.9 References and bibliography 30
2 Human Papillomaviruses in Pathogenesis of Lower Genital Tract Neoplasia 33
2.1 Introduction 33
2.2 Characteristics of human papillomavimses 33
2.3 Manifestations of genital HPV infections 34
Clinical infections (predominately condylomata) 35
Subclinical HPV infections 36
Latent HPV infections 38
2.4 Prevalence of genital HPV infections 39
Incidence rates of HPV infections 39
2.5 Transmission of genital HPV infections 40
Sexual transmission 40
Vertical transmission 40
2.6 Risk factors for genital HPV infections 40
2.7 HPV and cancer precursors 41
2.8 HPV infections and the risk for cervical cancer 41
Case reports and case series 41
Cohort studies 41
2.9 Natural history 42
Natural history of cervical HPV infections 42
CIN and HPV have an identical natural history 42
2.10 Molecular pathways of HPV oncogenesis 44
The normal cell cycle 44
The effect of HPV/host cell interaction-a prerequisite for neoplasia 45
2.11 The role of oncogenic HPV detection in the prevention of lower genital tract precancer 46
As an adjunct to cytology in primary screening 46
As an adjunct to colposcopy in the management of women presenting with mild or borderline dyskaryosis (ASCUS/AGUS) 47
2.12 HPV type and type variant as determinants of the natural history 48
2.13 References and bibliography 48
3 Examination for Cervical Precancer-Use of colposcopy 52
3.1 Introduction 52
3.2 Tissue basis for colposcopy 52
The role of the epithelium 52
The role of the stroma 53
The role of the surface configuration 53
3.3 The colposcopic examination 53
The colposcope 53
The examination 53
Decontamination of colposcopy clinic equipment 58
3.4 New developments in colposcopy 59
Video colposcopy, image management and electronic databases 59
3.5 References and bibliography 59
4 Colposcopy of the Normal Cervix -A prerequisite to establish the diagnosis of cervical cancer 61
4.1 Introduction 61
4.2 Cervical epithelium: natural history 61
4.3 Cervical epithelium: topography 62
4.4 Cervical epithelium: colposcopic appearances 64
Original columnar epithelium 64
Original squamous epithelium 64
Transformation zone 64
4.5 Squamous metaplastic epithelium 65
Colposcopic stages of development 65
Histologic features of development 66
Stimulus to development 67
Colposcopic representations of squamous metaplastic epithelium 68
4.6 Colposcopy of the adolescent cervix 70
The frequency of epithelial type 73
4.7 Cervical epithelium during pregnancy and puerperium 74
Ultrastructure and biomechanic properties of subepithelial tissues 75
Physiologic mechanisms operating in the cervix during pregnancy 76
4.8 The effect of vaginal delivery on the cervical epithelium 77
Types of epithelial injury caused by delivery 77
4.9 The cervical epithelium during the menopause 77
4.10 The oral contraceptives and their effect on the cervix 79
4.11 The congenital transformation zone 82
4.12 Summary: the normal (typical) transformation zone 84
4.13 References 87
5 Cytology and Screening for Cervical Precancer 89
5.1 Introduction 89
5.2 Cytological classifications 89
Papanicolaou 89
British Society for Clinical Cytology classification 89
The Bethesda System 90
5.3 Cytological reporting 90
Normal cytology 90
Smear adequacy 91
Atrophic smears 91
Borderline abnormalities 92
Dyskaryotic cellular changes 95
Cytologic indications of invasion 97
5.4 Clinical referral 98
5.5 Cytodiagnosis of cervical glandular intraepithelial neoplasia/adencarcinoma-in-situ 99
High-grade CIN/AIS 99
AGCUS/borderline glandular cells 100
Atypical metaplasia 100
5.6 Cytologic features of adenocarcinoma 102
5.7 Screening for cervical cancer 102
Introduction 102
Cytologic screening 102
Effectiveness 102
Accuracy 103
5.8 Improvements to cervical screening 103
Improving cytological screening 103
5.9 Sampling techniques 103
Slide preparation - thin layer technology 103
5.10 Cytologic interpretation 104
Automation in screening 104
5.11 Adjunctive tests 106
HPV-DNA testing 106
HPV-DNA testing as triage 106
HPV-DNA testing as an adjunctive test to cytology 107
Cervicography 107
TruScan* (formerly called The PolarProbe) 108
Visual inspection-based techniques 109
New developments 110
5.12 Problems in cytologic screening in the postmenopausal era 110
Alterations in function 110
Screening in the postmenopausal era 111
5.13 References 112
6 Diagnosis of Cervical Precancer -The use of colposcopy 115
6.1 Introduction 115
6.2 Which cytologic abnormalities need further investigation? 115
6.3 Colposcopy: the initial clinical examination 115
6.4 The rationale for the use of colposcopy in the diagnosis of cervical precancer 115
6.5 Colposcopic appearance of the abnormal (atypical) cervical epithelium 116
Morphology of the abnormal (atypical) epithelium 117
Atypical vessels 121
The vascular pattern of early invasion 125
6.6 The classification of colposcopically abnormal (atypical) cervical epithelium 126
6.7 Colposcopic examination of the precancerous/cancerous cervix 127
A satisfactory or an unsatisfactory colposcopy 127
Grading of the abnormal (atypical) colposcopic findings 127
Unsatisfactory colposcopy: examination of the endocervical canal 132
Colposcopic biopsy 138
Microcolpohysteroscopic examination of the endocervical canal 139
Other cervicoscopic appearances and pathologic findings 141
Endocervical curettage 143
Identification of the abnormal (atypical) epithelium: Schiller’s iodine test 144
6.8 The concept of human papillomavirus infection and cervical precancer 146
Colposcopic appearance of condylomatous and subclinical papillomavirus lesions 149
Colposcopic appearances of condylomata and their differentiation from malignant lesions 150
Further pathologic appearances of HPV and HPV/CIN-associated lesions 151
6.9 Correlation of diagnostic methods in the detection of cervical squamous precancer 151
Examples of the correlation of diagnostic methods 154
In moderate-grade epithelial lesions 156
In high-grade epithelial lesions 156
6.10 Lack of correlation between diagnostic methods 157
6.11 The diagnosis of early invasion 159
Early invasive squamous cell carcinoma: colposcopic diagnosis 159
Importance of pathology in diagnosis 161
6.12 Preclinical invasive carcinoma (colposcopically overt/suspect): colposcopy and pathology 165
6.13 Precancerous glandular lesions of the cervix 167
Epidemiology 167
Colposcopic diagnosis 167
Relevance to management 171
6.14 Colposcopic diagnosis of early adenocarcinoma of the cervix 171
6.15 References 176
7 Management of Cervical Precancer 179
7.1 Introduction 179
7.2 Rationale behind treatment 179
7.3 Colposcopic and pathologic characteristics of CIN lesion: a prerequisite to treatment 179
The limits and nature of the abnormal (atypical) epithelium 179
Glandular involvement 180
Endocervical extension 181
7.4 Colposcopically directed biopsy 181
7.5 Which lesions to treat 182
High-grade lesions: CIN 2 to 3/HSIL 182
Low-grade lesions: CIN 1 /LSIL 182
7.6 Prerequisites for treatment 183
7.7 Methods of treatment 183
Local destructive techniques 183
7.8 Excision techniques for treating CIN 191
Special problems of endocervical extension 192
The cold knife cone biopsy 192
Laser cone biopsy 196
Loop diathermy excision and cone biopsy 199
7.9 Management of extension of the abnormal (atypical) transformation zone 205
Technique 205
7.10 Follow-up after treatment 205
7.11 Hysterectomy in the treatment of CIN 206
7.12 Summary: the optimal method of CIN treatment and of follow-up 208
Follow-up of CIN management 208
7.13 Long-term complications of CIN treatment 208
Stenosis and constriction 208
Surgical treatment and reconstruction following stenosis 211
Excessive eversion of the columnar epithelium (post-treatment) 212
Subsequent pregnancy 212
Recurrence 212
7.14 Precancer in pregnancy 215
Management of invasive cervical cancer during pregnancy 215
Management of the abnormal smear in pregnancy 215
Colposcopic examination 216
Biopsy under colposcopic direction 216
Treatment 217
Interpretation of a biopsy specimen during pregnancy 219
7.15 Precancer in the HIV-positive patient 219
CIN/SIL (squamous intraepithelial lesions) in HIV-infected women 220
Risk factors for the development of CIN in HIV-infected women 220
HPV-HIV coinfection 220
Screening for cervical disease in HIV-affected women 221
Treatment of CIN in HIV-infected women 221
Summary 221
7.16 Management of early invasive squamous carcinoma of the cervix (FIG0 stage I) 221
History of "microinvasion" 221
Adenocarcinoma-in-situ and early invasive adenocarcinoma of the cervix 224
Stage Ib cancer of the cervix 225
Recommended treatment: summary 227
7.17 References 227
8 Vaginal Intraepithelial Neoplasia 232
8.1 Introduction 232
8.2 Natural history of VAIN 232
8.3 Etiology 233
8.4 Clinical presentation 233
Vaginoscopy 233
VAIN seen as an extension of the cervical atypical transformation zone 233
VAIN as seen in association with HPV lesions 234
8.5 VAIN following hysterectomy 236
Presentation after hysterectomy: value of cytology 236
8.6 Biopsy of the VAIN lesion 239
8.7 Pathology of VAIN: is it a precancerous lesion? 239
8.8 Vaginal precancer and cancer: part of the lower genital tract neoplastic syndrome 240
Pathology 240
Non-malignant lesions masquerading as vaginal neoplasia 243
8.9 Treatment of VAIN 245
Use of the CO2 laser 246
Partial vaginectomy 246
Local excision 247
8.10 References 249
9 Vulvar Intraepithelial Neoplasia 251
9.1 Introduction 251
9.2 Epidemiology and pathogenesis 251
Prevalence and incidence 251
Association between VIN and CIN 252
Viral etiology 253
Sexually transmitted diseases as etiologic factors 254
Human immunodeficiency virus and VIN 3 254
Smoking risk 255
9.3 Natural history of VIN: the rationale for treatment? 255
9.4 Pathology 257
Differential diagnosis of VIN 258
9.5 Clinical presentation 259
Vulvoscopy: magnified illumination of the vulva with a colposcope 260
Collins toluidine blue test 261
9.6 Biopsy of the vulva 262
9.7 Clinical appearances of VIN 263
White lesions 264
Red lesions 266
Dark lesions 267
9.8 VIN affecting the pilosebaceous unit 269
9.9 Early invasive carcinoma of the vulva 270
Clinical features 271
Risk of nodal spread: depth and volume measurements 272
Assessment of the pathologic specimen 272
Diagnosis 273
Recurrence of early invasive vulvar carcinoma 274
9.10 Lichen sclerosus 276
Clinical presentation 276
Histopathology 276
Management 276
9.11 Paget's disease (non-squamous intraepithelial neoplasia) 278
Clinical presentation 279
Histopathology 279
Management 279
9.12 Vulvar lesions masquerading as cancer or precancer 279
Syphilis 280
Behqet's disease 281
Condylomata acuminata 282
Granuloma inguinale 283
Lichen planus 284
Subclinical epithelial changes 284
9.13 Skin and accessory appendages that are important for the management of VIN 286
9.14 Management of VIN 288
Rationale for treatment 288
Treatment options and procedures 289
Which approach for treating VIN 3? 302
9.15 Treatment of early invasive vulvar carcinoma 303
Is lymphadenectomy necessary? 303
Results 303
9.16 References 303
10 Perianal and Anal Intraepithelial Neoplasia 308
10.1 Epidemiology 308
10.2 Etiology 308
10.3 Association with other genital intraepithelial neoplastic diseases 309
10.4 Examination 309
10.5 Presentation 310
10.6 Lesions masquerading as intraepithelial neoplasia 311
10.7 Anal canal involvement 311
10.8 Treatment 313
Laser vaporization 314
Localized surgical excision 314
Extensive surgical excision 316
10.9 References 317
11 Genital Tract Adenosis 318
11.1 Developmental anatomy 318
11.2 Developmental anomalies caused by DES 318
Experimental evidence 318
Epidemiology 319
Clinical findings 319
Pathology 321
Treatment 321
11.3 References 322
12 Infective and Other Conditions Causing Confusion in Diagnosis of Lower Genital Tract Precancer 323
12.1 Introduction 323
12.2 Trichoinorifls uflgindis 323
12.3 Candidiasis 323
12.4 Herpes genitalis infection 324
Clinical presentations 324
Herpes simplex cytology 324
Colposcopic and histologic appearances of infection 325
Vulvar lesions 326
12.5 HPV infection 327
12.6 Cervical deciduosis in pregnancy 330
12.7 Polypoid lesions of the cervix 330
Clinical presentation and management 330
12.8 References 333
Index 335

" The authors are to be congratulated on producing this fine reference text book, a useful addition to the library of both the novice and expert colposcopist." (Australian & New Zealand Journal of Obstetrics & Gynaecology)