Cone biopsy of cervix - Rcpa.tv

Cone biopsy of cervix. An
example of histological
reporting in Australia.
Dr Saurabh Prakash
Royal Melbourne Hospital

Indications for cone biopsy
• Persisting low grade squamous
dysplasia
• High grade squamous dysplasia
• Microinvasive carcinoma
• Adenocarcinoma in-situ (ACIS)

Terminology
• Cervical intraepithelial neoplasia (CIN)
• Squamous dysplasia assessed as mild
(CIN I), moderate (CIN II) or severe
(CIN III)
• Low grade squamous intraepithelial
lesion (LGSIL) = HPV effect or CIN I
• High grade squamous intraepithelial
lesion (HGSIL) = CIN II or CIN III

Terminology
• Glandular dysplasia (ACIS) assessed
as being present or absent
• Microinvasive carcinoma defined
(FIGO) as maximal depth of stromal
invasion of less than 1mm, and, with
absent lymphovascular space invasion.
The entire lesion should be examined
histologically.

Contents of histology report
• Patient details (name, date of birth)
• Clinical information
• Macroscopic description
• Microscopic description including
ancillary tests
• Diagnosis.

Macroscopic description
1. Measure the specimen in three
dimensions (mm).
2. Make note of orientating sutures which
are usually attached.
3. Place specimen in front of you, with
orientating suture (usually indicating
anterior) at 12 o’clock position.

Macroscopic description
4. Ink 12 o’clock half of specimen
(anterior) one colour and 6 o’clock half
(posterior) another colour.
5. Serial sagittal sections (in 12-6 o’clock
plane) taken, commencing at 3 o’clock
end of specimen and continuing to 9
o’clock end.
6. Submit entire specimen for histology in
sequential blocks.

Orientation of specimen
Suture = anterior or 12 o’clock
A portion of cervix, 14x25x10mm, with an attached
suture indicating anterior. The mucosa is smooth.

Mark margins
The anterior half of the specimen is marked black and the
posterior half is marked green.

Take sagittal sections of
specimen.
Commence sectioning at 3 o’clock and continue
to 9 o’clock end of specimen.

Sagittal sections for
processing.
1 2 3 4 5

Microscopic description
1. Three levels should be taken of each
block.
2. State tissue type (cervix) and included
mucosa (squamous and glandular
epithelium).
3. Is transformation zone (squamocolumnar
junction) included?

Microscopic description
4. Assess both squamous and glandular
mucosa, particularly for dysplasia or
reactive changes.
5. Assess stroma for invasion or benign
features such as inflammation.
6. If dysplasia or invasive tumour is
present, state margins of excision.

Cervical squamous dysplasia
• Dysplastic cells are crowded, show
nuclear enlargement and
hyperchromasia with coarse chromatin
• There are increased numbers of
suprabasilar mitoses
• Atypical koilocytes and dyskeratoses
are seen in Human Papilloma Virus
infection (HPV)

Cervical squamous dysplasia
• CIN I - changes confined to lower
(basal) third of epithelium
• CIN II - changes confined to lower twothirds
of epithelium
• CIN III - changes involved full thickness
of epithelium

Adenocarcinoma in-situ
• Crowded glands in which there are
columnar cells showing nuclear
hyperchromasia, elongation and
enlargement.
• The basement membrane is intact.
• Nuclear features may resemble those
seen in nuclei of dysplastic adenomas
in colon.

Microscopic description
Transformation zone
at low power
Transformation zone

Microscopic description
• Squamous epithelium
shows crowding and
nuclear atypia
• Koilocytes are present
• Lower third of
epithelium involved =
CIN I (low grade
dysplasia)

Microscopic description
• Squamous epithelium
shows crowding,
nuclear atypia with
scattered mitoses
• Entire thickness of
epithelium involved =
CIN III (high grade
dysplasia)
mitosis

Microscopic description
• No stromal invasion is
present
• No glandular dysplasia
is identified
• Note chronic stromal
inflammation
mitosis

Microscopic description
• Must also assess for presence of
stromal invasion
• Comment on margins of excision if
dysplasia is present - measure in
millimetres from endocervical or
ectocervical margin.

Immunoperoxidase stains
• Can be useful in some contexts (eg CIN
III Vs immature squamous metaplasia)
• P16 positivity indicates integration of
high risk HPV virus
• Positive defined as cytoplasmic and
nuclear staining of full thickness of
epithelium. Basal staining may be seen
but may not be significant.

P16 immunostain
• Nuclear and
cytoplasmic staining of
full thickness of the
squamous epithelium
• Endocervical glands
are negative
• Non-dysplastic
epithelium is negative.

Immunoperoxidase stains
• Ki67 (MIB1) immunostain is a
proliferation marker
• Positive defined as nuclear staining of
any degree
• CIN shows positive staining
suprabasilar squamous cells

Ki67 immunostain
• Positive cells in all
parts of the squamous
epithelium
• Non-dysplastic
epithelium shows
scattered isolated cells
in only the basal
layers.

Example of histopathology
report

References
• The Bethesda system for reporting
gynaecological cytology. Definitions, criteria
and reporting notes. 2nd eg. Solomon et al.
2005.
• Screening to prevent cervical cancer.
Guidelines for management of asymptomatic
women with screen detected abnormalities.
NHMRC. Australian Government. 2005.
• Pathology and Genetics Tumours of the
Breast and Female Genital Organs. WHO
classification of tumours. Tavassoli et al.
2003.