Cervical dysplasia and cervical cancer: Clinical sciences

Cervical dysplasia refers to abnormal cells on the uterine cervix usually caused by persistent infection with high-risk types of the human papillomavirus, or HPV for short. Cervical abnormalities are classified as either low-grade dysplasia, also called cervical intraepithelial neoplasia 1, or CIN1; or high-grade dysplasia, which includes CIN2 and CIN3. High-grade dysplasia, especially CIN3, is a precursor to invasive cervical cancer, and its progression to cancer is usually gradual over several years.

Cervical cancer screening is crucial for detecting dysplasia at an early stage when it’s more easily treatable. Most patients diagnosed with high-grade dysplasia are aged 25 years or older. However, individuals aged 21 to 24 can also develop high-grade dysplasia.

Your first step in evaluating a patient with a chief concern suggesting cervical dysplasia or cervical cancer is to obtain a focused history and physical exam.

The most important information to look for is the patient’s current and previous cervical cancer screening results along with any history of treatment and the associated findings on pathology. Other important findings include the presence of abnormal vaginal bleeding that could implicate cervical cancer; a compromised immune system from an HIV infection or the use of immunosuppressive medications for a chronic illness, which can increase the patient’s risk for cervical cancer; and a history of vaccination against high-risk HPV types.

Additionally, determine if your patient is pregnant. That’s important because endocervical curettage, endometrial biopsy, and expedited treatment without cervical biopsy are unacceptable for patients who are pregnant. Furthermore, a diagnostic excisional procedure or repeat cervical biopsy during pregnancy is recommended only if cancer is suspected. As for the physical exam, you’ll want to look for a visual cervical lesion. If one is present, biopsy it to evaluate for invasive cervical cancer. Okay, your next step is to assess the patient’s age.

Patients aged 21 to 24 are at low risk of cervical cancer, so evaluation and treatment are often more conservative than for older patients. Start by assessing the abnormal cervical cancer screening results.

In some cases low-grade cytology is present, which includes low-grade squamous intraepithelial lesions, or LSIL; atypical squamous cells of undetermined significance, or ASC-US, that is HPV-positive; or ASC-US without HPV testing. These results have a high probability for regression and a low risk for rapid progression to cancer, so you can repeat cytology at 1 and 2 years after the initial abnormal result.

Another option is to find high-grade cytology, including high-grade squamous intraepithelial lesions, or HSIL; atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion, or ASC-H; atypical glandular cells, known as AGC; and adenocarcinoma in situ, referred to as AIS. In these cases, colposcopy is recommended to make a formal diagnosis.

To keep it simple, this procedure is performed by a colposcope to visualize a patient’s cervix. The colposcope uses lighted magnification to get a close-up view of the cervix and the transformation zone, which helps identify abnormal areas for biopsy. During the procedure, acetic acid and Lugol’s iodine solution are applied to aid in the detection of abnormal cervical changes. Once biopsies are taken, they are sent to pathology to assess for CIN or cervical cancer.

Here’s a high-yield fact to keep in mind! HSIL and LSIL refer to cytology samples and are considered screening results. On the other hand, CIN 1, 2, or 3 refer to tissue samples like biopsies and reflect histology diagnoses. Be sure not to mix them up.

Alright, in patients younger than age 25 with a pathology result of CIN1 or less, follow the guidelines for observation established by the American Society for Colposcopy and Cervical Pathology, or ASCCP. If HSIL is present but is unspecified as CIN2 or CIN3, observation or treatment is acceptable. In patients with histologic CIN2, observation is preferred and treatment is acceptable. Finally, in patients with histologic CIN3, treatment is recommended and observation is unacceptable, even in this young patient population.

Here’s a clinical pearl! When treatment of histologic high-grade dysplasia is planned, excision is preferred over ablation because the excised tissue can be evaluated for unsuspected invasive cancer and positive margins. Excisional treatment includes the loop electrosurgical excision procedure, or LEEP; cold-knife conization; or laser cone biopsy. Ablation with cryotherapy, laser ablation, or thermoablation is an acceptable alternative when excisional procedures are unavailable.

Okay, let’s now take a step back and talk about patients who are 25 or older. In this case, start with a risk assessment for CIN3 or worse findings, known as CIN3+. This assessment includes information such as current and previous screening results; biopsy results; age; and immune function. Luckily, you don’t have to calculate this yourself. You can input this information into the available ASCCP smartphone or web application to assess the patient’s immediate risk of CIN3+.