Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Chapter 1 Vaginal acidity Columnar epithelium Papillae Squamous metaplasia Crypt opening Nabothian follicles Columnar epithelium Crypts FIGURE 1.10: Squamous metaplastic epithelium covering the crypt openings, leading to the formation of nabothian retention cysts Nabothian cysts FIGURE 1.11: Multiple nabothian cysts in the mature squamous metaplastic epithelium occupying the ectocervix purposes, the latter resembles the original stratified squamous epithelium. Some residual columnar cells or vacuoles of mucus are seen in the mature squamous metaplastic epithelium, which contains glycogen from the intermediate cell layer onwards. Thus, it stains brown or black after application of Lugol’s iodine. Several cysts, called nabothian cysts (follicles), may be observed in the mature metaplastic squamous epithelium (Figures 1.10 and 1.11). Nabothian cysts are retention cysts that develop as a result of the occlusion of an endocervical crypt opening or outlet by the overlying metaplastic squamous epithelium (Figure 1.10). The buried columnar epithelium continues to secrete mucus, which eventually fills and distends the cyst. The entrapped mucus gives an ivory-white to yellowish hue to the cyst on visual examination (Figure 1.11). The columnar epithelium in the wall of the cyst is flattened and ultimately destroyed by the pressure of the mucus in it. The outlets of the crypts of columnar epithelium, not yet covered by the metaplastic epithelium, remain as persistent crypt openings. The farthest extent of the metaplastic epithelium onto the ectocervix can be best judged by the location of the crypt opening farthest away from the squamocolumnar junction. Squamous metaplasia is an irreversible process; the transformed epithelium (now squamous in character) cannot revert to columnar epithelium. The metaplastic process in the cervix is sometimes referred to as indirect metaplasia, as the columnar cells do not transform into squamous cells, but are replaced by the proliferating sub-columnar cuboidal reserve cells. Squamous metaplasia may progress at varying rates in different areas of the same cervix, and hence many areas of widely differing maturity may be seen in the metaplastic squamous epithelium with or without islands of columnar epithelium. The metaplastic epithelium adjacent to the squamocolumnar junction is composed of immature metaplasia, and the mature metaplastic epithelium is found near the original squamocolumnar junction. Further development of the newly formed immature metaplastic epithelium may take two directions (Figure 1.12). In the vast majority of women, it develops into a mature squamous metaplastic epithelium, which is similar to the normal glycogencontaining original squamous epithelium for all practical purposes. In a very small minority of women, an atypical, dysplastic epithelium may develop. Certain oncogenic human papillomavirus (HPV) types may persistently infect the immature basal squamous metaplastic cells and transform them into atypical 10
An introduction to the anatomy of the uterine cervix cells with nuclear and cytoplasmic abnormalities. The uncontrolled proliferation and expansion of these atypical cells may lead to the formation of an abnormal dysplastic epithelium which may regress to normal, persist as dysplasia or progress into invasive cancer after several years. It is also thought that some metaplasia may occur by in-growth of the squamous epithelium from the squamous epithelium of the ectocervix. FIGURE 1.12: A schematic diagram of further maturation of immature squamous metaplasia Transformation zone This region of the cervix where the columnar epithelium has been replaced and/or is being replaced by the new metaplastic squamous epithelium is referred to as the transformation zone. It corresponds to the area of cervix bound by the original squamocolumnar junction at the distal end and proximally by the furthest extent that squamous metaplasia has occurred as defined by the new squamocolumnar junction (Figures 1.7, 1.13 and 1.14). Original (native) squamous epithelium Original squamocolumnar junction Metaplastic squamous epithelium Columnar epithelium External os New squamocolumnar junction Transformation zone FIGURE 1.13: A schematic diagram of the transformation zone Original squamous epithelium Original SCJ Mature squamous metaplasia Acetowhite area indicating dysplasia New SCJ Immature squamous metaplasia FIGURE 1.14: (a) A schematic diagram of the normal transformation zone; (b) a schematic diagram of the abnormal or atypical transformation zone harbouring dysplasia 11
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 and 14: Chapter 1 An introduction to the an
Page 15 and 16: An introduction to the anatomy of t
Page 21: 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
Page 65 and 66: Chapter 6 a FIGURE 6.17: An area of
Page 67 and 68: Chapter 7 The colposcopic diagnosis
Page 69 and 70: Chapter 7 appears as individual sma
Page 71 and 72: Chapter 7 acid stain is correlated
Page 73 and 74:
Chapter 7 FIGURE 7.15: Moderately d
Page 75 and 76:
Chapter 7 FIGURE 7.23: A dense acet
Page 77 and 78:
Chapter 7 FIGURE 7.30: Mustard yell
Page 79 and 80:
Chapter 7 We recommend that the stu
Page 81 and 82:
Chapter 8 highlights this responsib
Page 83 and 84:
Chapter 8 Appearance before applica
Page 85 and 86:
Chapter 8 diagnosis of AIS and aden
Page 87 and 88:
Chapter 8 a ↑ FIGURE 8.10: Adenoc
Page 89 and 90:
Chapter 9 Inflammatory lesions of t
Page 91 and 92:
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
Page 99 and 100:
Chapter 11 FIGURE 11.1: Flow chart
Page 101 and 102:
Chapter 11 treatment policies for p
Page 103 and 104:
Chapter 11 Vaginal delivery can be
Page 105 and 106:
Chapter 12 involvement increases wi
Page 107 and 108:
Chapter 12 Table 12.1: Eligibility
Page 109 and 110:
Chapter 12 a b c d e f FIGURE 12.6:
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Chapter 12 during the follow-up in
Page 113 and 114:
Chapter 13 (2) (1) FIGURE 13.2: Ele
Page 115 and 116:
Chapter 13 (1) (2) (3) (4) (5) (8)
Page 117 and 118:
Chapter 13 Once the specimen has be
Page 119 and 120:
Chapter 13 in the endocervical cana
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Chapter 14 Decontamination, cleanin
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Decontamination, cleaning, high-lev
Page 125 and 126:
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
Page 133 and 134:
Appendix Monsel’s paste Ingredien
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Appendix 5 The modified Reid colpos
Page 137 and 138:
Index Acetowhitening . . . . . . .
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Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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