Singer and Monaghan's Cervical and Lower Genital Tract Precancer

Diagnosis and Treatment

Albert Singer, Ashfaq Khan

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN:
  9780470674413
• eBook ISBN:
  9781118800812
• Edition: 3
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

 The guide to effective practice management of precancerous lesions in cervix and lower genital tract.

This third edition contains in-depth examination of the different modalities that contribute to the safe and scientific management of precancerous lesions in the female genital tract. One of the most important is colposcopy which provides an accurate and effective route to their identification.

Professor Albert Singer is internationally recognized as a master of colposcopy. His training courses throughout the world are in high demand. In this edition, he has teamed with fellow expert Ashfaq Khan to present a very accessible, authoritative and highly illustrated guide to the power of colposcopy.

Practical pictorial guidance to recognizing potentially cancerous abnormalities in the cervix, vagina, and vulva is framed by internationally agreed disease classifications. Consensus guidelines from the US and Europe provide a rigorous platform for management advice. The latest information on HPV, the role of biomarkers, and new methods in diagnosis and treatment are all featured.

Cervical and Lower Genital Tract Precancer is the ideal companion for anyone wishing to incorporate safe and scientific methods of diagnosis and treatment into their clinical practice.

CHAPTER 1
The histopathology of lower genital tract neoplasia

1.1 Introduction

Approximately 1 in 10 female cancers diagnosed worldwide are cancers of the cervix. Except in countries with effective screening programs the incidence has changed little. The discovery of cytologically detectable and anatomically confirmed premalignant phases has successfully shifted the presentation of cervical squamous tumors from the clinical to the preclinical stage; this being associated with dramatic falls in the prevalence of the disease when effective screening is undertaken.

1.2 Terminology

It is critical that the terminologies used for cytologic and histologic diagnosis are comparable so that they can be correlated with the colposcopic findings. In the last 15 years, our understanding of the molecular events associated with lower anogenital tract neoplasia has developed rapidly. In response to this knowledge, the terminology has changed with each new classification system providing a higher degree of sophistication. Gradually the terminology has become more uniform and a histologist's implications and a clinician's inferences have become more reliable. It is imperative that the nomenclature is uniform throughout the world for ease with statistics, although currently there still remain differences in terminologies between the USA and the rest of the world.

The concept of cervical cancer precursors

The concept of cervical cancer precursors dates back to 1886 when Williams noticed, next to invasive cancers, areas of epithelium that he recognized as non-invasive. The term “carcinoma in situ” (CIS) was introduced by Broders in 1932, and this term has been used from its introduction to the present day. Smith and Pemberton in 1934 reported a relationship between CIS and invasive cancer when they found that the changes described as CIS by Broders were present in a retrospective review of biopsies from patients who subsequently developed invasive cancer. This combination of histologic observations and retrospective clinical analysis led to the concept that invasive squamous cell carcinoma develops from precursor lesions that can be identified by the pathologist (Figure 1.1).

Figure 1.1 The concept of cervical cancer precursor progression and human papillomavirus infection. CIN, cervical intraepithelial neoplasia; HPV, human papillomavirus.

Carcinoma in situ

With the advent of exfoliative cytology it was recognized that not all cervical abnormalities had full-thickness atypical changes as described for CIS. The lesions, which were morphologically less complex than CIS but still contained many cytologic and histologic features of that entity, were recognized to form a broad histologic spectrum, ranging from minimal deviation changes, which closely resembled the normal epithelium, through epithelia with increasingly severe atypia and disorganization to the classical CIS. Reagan and coworkers in 1956 introduced the term “dysplasia” to designate those abnormalities with histologic and cytologic features that were intermediate between normal epithelium and CIS. Following this, Walters and Reagan in 1956 subclassified the dysplasia into three groups—mild, moderate, and severe—depending upon the degree to which full thickness of the epithelium was replaced by the atypical cells. The higher the histologic grade, the more likely the lesion was to progress to invasive cancer and the higher the risk of developing cancer.

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Cervical cancer precursors

• Cervical cancer has precursor lesions which can be detected by cytology.
• These precursors can be classified as mild (cervical intraepithelial neoplasia 1/low-grade squamous intraepithelial lesion), moderate (cervical intraepithelial neoplasia 2/high-grade squamous intraepithelial lesion), or severe (cervical intraepithelial neoplasia 3/high-grade squamous intraepithelial lesion).

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Terminology and management (Figure 1.2a)

When the terminology was originally proposed and generally accepted, the prevailing clinical management of patients with dysplasia and CIS was that patients with CIS required a hysterectomy to prevent the development of cancer. Women with a histologic diagnosis of dysplasia, whose clinical course was not well understood but could vary from remission to persistence and progression to CIS, were ignored, followed up, or treated by a variety of means, depending upon the clinician's understanding and acceptance of the natural history data. However, the distinction between dysplasia and CIS was frequently based upon poorly defined and arbitrary histologic distinctions. It gradually became clear that the enormous differences in approaches to treatment were the result of the unreliability of the diagnoses because of the high interobserver variability.

Figure 1.2 (a) Diagrammatic representation of the cytologic equivalents of cervical intraepithelial disease. (b) Normal cervical epithelium. The epithelium is uniform in pattern and cytology. The cells mature progressively as they move toward the surface, the nuclei become pyknotic, and glycogenation occurs. (c) Human papillomavirus infection “alone” (low-grade squamous intraepithelial lesion). There is mild, full-thickness, cellular enlargement and hyperchromasia with karyopyknosis (1), binucleation (2), and a raisin-like nucleus with a surrounding halo (3). In the bottom three cell layers there is variable nuclear and cell size, irregular variable condensed chromatin aggregation, degenerative nucleoplasmic clearing, nucleolar increase, and some visible early koilocytes (4). These features at (4) are typical of regenerative or hyperplastic epithelial layers with some degenerative or poorly preserved features added in (e.g., nuclear clearing). They are not the features of neoplasia. ASCUS, atyp...

Table of contents

• Cover
• Dedication
• Titlepage
• Copyright
• Preface to the third edition
• Preface to the first edition
• Acknowledgements
• Chapter 1: The histopathology of lower genital tract neoplasia
• Chapter 2: Human papillomaviruses in the pathogenesis of lower genital tract neoplasia
• Chapter 3: Examination for cervical precancer: Use of colposcopy
• Chapter 4: Colposcopy of the normal cervix: A prerequisite to establishing the diagnosis of cervical precancer
• Chapter 5: Cytology and screening for cervical precancer
• Chapter 6: Diagnosis of cervical precancer: Use of colposcopy
• Chapter 7: Management of cervical precancer
• Chapter 8: Vaginal intraepithelial neoplasia
• Chapter 9: Vulval intraepithelial neoplasia
• Chapter 10: Perianal and anal intraepithelial neoplasia
• Chapter 11: Genital tract adenosis
• Chapter 12: Infective and other conditions causing confusion in diagnosis of lower genital tract precancer
• Index
• End User License Agreement