Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Chapter 1 Fundus Fallopian tube Body of uterus Supravaginal cervix Internal os Portio vaginalis Endocervical canal Endocervix Lateral fornix External os Ectocervix Vagina Cervix Bladder Anterior fornix Pubic bone Urethra Uterus Posterior fornix Rectum Sacrum Vagina FIGURE 1.1: Gross anatomy of the uterine cervix readily visible on speculum examination. The portion proximal to the external os is called the endocervix and the external os needs to be stretched or dilated to view this portion of the cervix. The endocervical canal, which traverses the endocervix, connects the uterine cavity with the vagina and extends from the internal to the external os, where it opens into the vagina. It varies in length and width depending on the woman’s age and hormonal status. It is widest in women in the reproductive age group, when it measures 6-8 mm in width. The space surrounding the cervix in the vaginal cavity is called the vaginal fornix. The part of the fornix between the cervix and the lateral vaginal walls is called 2
An introduction to the anatomy of the uterine cervix the lateral fornix; the portions between the anterior and posterior walls of the vagina and the cervix are termed the anterior and posterior fornix, respectively. The stroma of the cervix is composed of dense, fibro-muscular tissue through which vascular, lymphatic and nerve supplies to the cervix pass and form a complex plexus. The arterial supply of the cervix is derived from internal iliac arteries through the cervical and vaginal branches of the uterine arteries. The cervical branches of the uterine arteries descend in the lateral aspects of the cervix at 3 and 9 o’clock positions. The veins of the cervix run parallel to the arteries and drain into the hypogastric venous plexus. The lymphatic vessels from the cervix drain into the common, external and internal iliac nodes, obturator and the parametrial nodes. The nerve supply to the cervix is derived from the hypogastric plexus. The endocervix has extensive sensory nerve endings, while there are very few in the ectocervix. Hence, procedures such as biopsy, electrocoagulation and cryotherapy are well tolerated in most women without local anaesthesia. Since sympathetic and parasympathetic fibres are also abundant in the endocervix, dilatation and curettage of the endocervix may occasionally lead to a vasovagal reaction. The cervix is covered by both stratified nonkeratinizing squamous and columnar epithelium. These two types of epithelium meet at the squamocolumnar junction. Stratified non-keratinizing squamous epithelium Normally, a large area of ectocervix is covered by a stratified, non-keratinizing, glycogen-containing squamous epithelium. It is opaque, has multiple (15-20) layers of cells (Figure 1.2) and is pale pink in colour. This epithelium may be native to the site formed during embryonic life, which is called the native or original squamous epithelium, or it may have been newly formed as metaplastic squamous epithelium in early adult life. In premenopausal women, the original squamous epithelium is pinkish in colour, whereas the newly formed metaplastic squamous epithelium looks somewhat pinkish-white on visual examination. The histological architecture of the squamous epithelium of the cervix reveals, at the bottom, a single layer of round basal cells with a large darkstaining nuclei and little cytoplasm, attached to the basement membrane (Figure 1.2). The basement membrane separates the epithelium from the underlying stroma. The epithelial-stromal junction is usually straight. Sometimes it is slightly undulating with short projections of stroma at regular intervals. These stromal projections are called papillae. The parts of the epithelium between the papillae are called rete pegs. The basal cells divide and mature to form the next few layers of cells called parabasal cells, which also have relatively large dark-staining nuclei and greenish-blue basophilic cytoplasm. Further Superficial cell layer Intermediate cell layer Basement membrane Parabasal layer Basal cell layer Stromal papilla Stroma FIGURE 1.2: Stratified squamous epithelium (x 20) 3
Page 1 and 2: Colposcopy and Treatment of Cervica
Page 3 and 4: INTERNATIONAL AGENCY FOR RESEARCH O
Page 5 and 6: Published by the International Agen
Page 7 and 8: Contents 11 Management that provide
Page 9 and 10: Acknowledgements The authors gratef
Page 11 and 12: Preface Health care providers have
Page 13: Chapter 1 An introduction to the an
Page 17 and 18: An introduction to the anatomy of t
Page 25 and 26: Chapter 2 An introduction to cervic
Page 27 and 28: An introduction to cervical intraep
Page 33 and 34: Chapter 3 An introduction to invasi
Page 35 and 36: An introduction to invasive cancer
Page 41 and 42: Chapter 4 Table 4.1: Indications fo
Page 43 and 44: Chapter 4 FIGURE 4.2: Colposcope wi
Page 45 and 46: Chapter 4 FIGURE 4.6: Endocervical
Page 47 and 48: Chapter 4 Table 4.2: Preneoplastic
Page 49 and 50: Chapter 5 between the two ocular le
Page 51 and 52: Chapter 5 Obtain specimens for labo
Page 53 and 54: Chapter 5 FIGURE 5.2: Biopsy techni
Page 55 and 56: Chapter 5 tissue tends to mimic inv
Page 57 and 58: Chapter 6 invasive carcinoma. Even
Page 59 and 60: Chapter 6 ages (Figures 1.7d, 1.7e,
Page 61 and 62: Chapter 6 FIGURE 6.7: The colour ch
Page 63 and 64: Chapter 6 Crypt openings Immature s
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Chapter 6 a FIGURE 6.17: An area of
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Chapter 7 The colposcopic diagnosis
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Chapter 7 appears as individual sma
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Chapter 7 acid stain is correlated
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Chapter 7 FIGURE 7.15: Moderately d
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Chapter 7 FIGURE 7.23: A dense acet
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Chapter 7 FIGURE 7.30: Mustard yell
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Chapter 7 We recommend that the stu
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Chapter 8 highlights this responsib
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Chapter 8 Appearance before applica
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Chapter 8 diagnosis of AIS and aden
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Chapter 8 a ↑ FIGURE 8.10: Adenoc
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Chapter 9 Inflammatory lesions of t
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Inflammatory lesions of the uterine
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Inflammatory lesions of the uterine
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Chapter 10 Table 10.1: Common sourc
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Chapter 10 Table 10.2 (cont.): A su
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Chapter 11 FIGURE 11.1: Flow chart
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Chapter 11 treatment policies for p
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Chapter 11 Vaginal delivery can be
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Chapter 12 involvement increases wi
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Chapter 12 Table 12.1: Eligibility
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Chapter 12 a b c d e f FIGURE 12.6:
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Chapter 12 during the follow-up in
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Chapter 13 (2) (1) FIGURE 13.2: Ele
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Chapter 13 (1) (2) (3) (4) (5) (8)
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Chapter 13 Once the specimen has be
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Chapter 13 in the endocervical cana
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Chapter 14 Decontamination, cleanin
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Decontamination, cleaning, high-lev
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References Herrero, R. (1997) Preva
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Further reading Suggestions on furt
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Appendix Leukoplakia Condylom
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Appendix regardless of your pregnan
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Appendix Monsel’s paste Ingredien
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Appendix 5 The modified Reid colpos
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Index Acetowhitening . . . . . . .
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Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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