Cervical dysplasia and cervical cancer: Clinical sciences

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Introduction0:00–0:58

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.

Focused History and Physical0:58–2:13

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.

Age 21-242:13–5:17

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.

Age ≥ 25 years5:17–9:40

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+.
Recommendations for surveillance, colposcopy, or treatment are based on the patient’s risk. Remember that treatment recommendations are for nonpregnant patients.
An excisional procedure during pregnancy is only advised if invasive cancer is suspected. Alright, patients with an immediate CIN3+ risk of less than 4% should undergo surveillance according to the ASCCP guidelines.
However, if the immediate CIN3+ risk is between 4 and 24%, your next step is to perform a colposcopy with 2 to 4 targeted biopsies that represent all abnormal areas identified.
This is where it gets a bit tricky. Update the patient’s information in the ASCCP app by inputting the pathology results.
Further treatment and follow-up recommendations are made from the recalculated risk of CIN3+. For example, if the histologic results from cervical biopsy show CIN1 and the previous cytology was ASC-H, surveillance per the ASCCP guidelines is recommended.
However, if histology shows CIN1 and the previous cytology was HSIL, then either a diagnostic excisional procedure or observation is acceptable.
Now, reports do not always specify a CIN diagnosis. Patients with unspecified HSIL could have CIN3, which is a direct cervical cancer precursor.
The safest approach for these patients is treatment. Alternatively, you can contact the pathologist to specify the CIN diagnosis further and issue an additional report.
Okay, patients with histologic CIN2 are recommended to undergo treatment unless the patient’s concerns about the effect of treatment on future pregnancies outweigh concerns for cervical cancer.
The risk of preterm birth may be increased in patients with large excisions for the treatment of cervical dysplasia or a short interval from excision to conception.
Observation is acceptable in these patients if the entire lesion is visualized on colposcopy and the results of endocervical sampling are less than CIN2.
Lastly, patients without concern for the effect of treatment on future pregnancies, and patients with histologic CIN3, should undergo treatment.
Excisional treatment is preferred, and treatment with ablation is acceptable. Observation with CIN3 is never acceptable except during pregnancy.
Okay, that was a lot of info, so let’s go back to CIN3+ risk assessment and talk about some simpler stuff. If your patient has an immediate CIN3+ risk between 25 and 59%, you can go with expedited excisional treatment without biopsy confirmation.
Alternatively, colposcopy is acceptable for patients at this risk level. When considering treatment versus colposcopy, have a thorough discussion with patients regarding the risks and benefits.
Treatment without preceding histologic diagnosis can be performed in one visit. Reasons for choosing this may include personal preference, limited healthcare access, financial concerns, and cancer-related anxiety.
Finally, if your patient’s immediate CIN3+ risk is between 60 and 100%, expedited excisional treatment without previous biopsy confirmation is preferred but colposcopy with biopsy is acceptable.
Before we wrap up, here’s a clinical pearl! Research shows that administering adjuvant HPV vaccination to previously unvaccinated individuals undergoing treatment for CIN2 or worse reduces the recurrence of cervical dysplasia.
However, the optimal timing of adjuvant vaccination is currently unknown.Alright, as a quick recap… Cervical dysplasia refers to the presence of abnormal cells on the cervix typically caused by high-risk types of HPV.

Review9:40–10:19

You should start your assessment with history and physical, but the patient’s age will determine further steps. If your patient is between 21 and 24, you need to assess screening results.
If there is low-grade cytology, you can repeat the cytology in 1 and 2 years, but if the cytology is high-grade, you’ll need to do a colposcopy.
For patients who are 25 or older, you can use an ASCCP app to calculate immediate CIN3+ risk, which will help you determine the next best step.