Heather P. Adams, MPAS, PA-C, Erica L. Carnright, PA-S
References
DIAGNOSIS AND STAGING The Bethesda staging system provides uniform terminology to classify all abnormal Pap smears and cytology reports (see Table 434). Patients with abnormal cytology typically undergo a colposcopic examination to further evaluate the abnormality. During a colposcopy, the clinician examines the cervix with the use of a lighted microscope, known as a colposcope, which magnifies the cells of the cervix and allows for localized sampling of abnormal-appearing areas through punch biopsy.7,9 The area of focus is the transformation zone because of its known vulnerability to HPV infections. A colposcopy is considered inadequate if the SCJ, and therefore the transformation zone, is not fully visualized.
Acetic acid is applied to the cervix during colposcopy, and any dysplastic cells present take up the acid and turn white, a process known as acetowhitening. Indications for a punch biopsy include acetowhitening, leukoplakia, and abnormal vasculature marked by punctation, bizarre-appearing vessels, or the appearance of a mosaic pattern.16 Indications for sampling of the endocervical canal through endocervical curettage include inadequate colposcopy, presence of a lesion that extends beyond the view of the colposcope, or atypical glandular cells on cytology.16 The biopsy results help to determine if a diagnostic conization is needed for further evaluation of the lesion.16
After a cervical biopsy is performed, the abnormal cells may be classified as CIN 1, 2, or 3 or carcinoma in situ (see Table 516). These stages of intraepithelial neoplasia are determined by the depth to which abnormal, immature cells have invaded the cervical epithelium.16 CIN 2 and 3 are more likely to develop into cervical cancer if they are not properly treated.5,16,17 The majority of CIN 1 lesions do not progress into cancer and typically resolve on their own or are cleared by the patient’s immune system. While most CIN 1 lesions are caused by high-risk HPV, these may be less oncogenic subtypes.7,17
The two most common histologic subtypes of cervical cancer are squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma comprises more than 70% of cervical cancers, while adenocarcinoma makes up approximately 25%.39 Neuroendocrine, small cell, and mixed-cell carcinomas make up the remainder of cervical cancers.9 Squamous cell carcinoma arises from the squamocolumnar junction or ectocervix, and adenocarcinoma tends to arise from the glandular cells of the endocervix.7,9,17 Studies show that adenocarcinoma is slowly becoming more prevalent in the US than squamous cell carcinoma.9
Once a diagnosis of cervical cancer has been established, additional testing and procedures are performed to rule out lymph node and organ involvement.9,16 The International Federation of Gynecology and Oncology system is then used to clinically stage the cervical cancer40 (see Table 67,40,41). This staging system, updated in 2009, is based solely on clinical examination findings. Once cervical cancer is staged, measures are taken to assess which treatment option is most appropriate.
