Dysplasia of the cervix – symptoms and treatment
Vagina is covered with multilayer squamous non-keratised epithelium. Cervical canal of the cervix is covered with single – layered cylindrical epithelium. The boundary between the two epithelia is the external opening of the cervix and forms a so-called transient line. In the epithelial cover of this line there are reserve cells that can differentiate in both directions. Transient line is influenced by age, hormones, vaginal pH and other factors. In gynecological view of the vaginal part of the cervix, multilayer flat epithelium appears pink whitish because of its thickness and difficult show of blood vessels through it. Against this background, thin cylindrical epithelium is red and like a small wound in the cervical canal. That is why in the past, this area was called “erosio” of the cervix. Actually it is a transient shift away line (broundary between two epithelia) and the term “pseudoerosio” is more appropriate. The longer is the transient line (shifted to the vagina), the probability of “success” of carcinogens is greater.
Cervical dysplasia is a disease of young women. In it there is no hormone dependency, opposite to diseases of the endometrium. The average age of its occurrence is 30 years. Early sexual initiation, frequent and indiscriminate change of partners, poor sexual hygiene, low social status, infection with human papilloma virus are risk factors for the occurrence of dysplasia. The crucial importance of intensive sexual life for this condition is apparent from the fact that dysplasia is not present in virgin women and nuns. Most important for its occurrence has genital infection with human papilloma virus, which is proven in the ultra structure of epithelial cells of the cervix in patients with dysplasia.
In these patients are proven and antibodies against the virus in the blood. This infection is very important, especially in very young age, when the epithelial cells of the transformation zone are very sensitive to damage. In these cases, the initial changes characteristic for dysplasia may occur at 14-18 years of age and severe – in the third decade. The relationship between infection with human papilloma virus (HPV) and cervical dysplasia is so great that some authors consider this disease as a sexually transmissive infection.
Currently the term dysplasia is shifting the terms cervical intraepithelial neplasia (CIN) and rarely used – squamous intraepithelial lesion (SLE). Dysplasia is an abnormal cell proliferation occurring in the reparative epithelium of the flat events (most commonly after inflammation) of the border zone between flat and cylindrical epithelium of the cervix. This cellular abnormality is expressed with a nuclear hyperchromasia (darker staining of nuclei) and change the index nucleus/cytoplasm in favor of the nucleus. These are sings of atypia, which characterise the transformation of normal cells into tumor. Because these nuclear abnormalities do not affect all cells in the epithelium, dysplasia is considered to be divided into mild, moderate and severe.
- Mild (CIN I) – abnormal cells occupy only the basal, lower layers.
- Moderate (CIN II) – a significant proportion – 2\3 of the epithelial layer.
- Severe (CIN III) – almost all cells are atypical, so that only in the surface layer can be found flat epithelial cells from mature type.
Layers with marked dysplasia appear darker because of increased number of hyperchromic nuclei. In less severe dysplasia upper layers of epithelial cells are intact and have retained the ability to differentiate. Severe dysplasia goes into carcinoma in situ, in which entire thickness of the epithelial sheet is occupied by abnormal, immature, and monomorphus atypic cells with disturbed polarity and mitoses. Carcinoma “in situ” is still within the multilayered squamous epithelium. It does not invase the basement membranes. In dysplasia and carcinoma in situ basement membrane is preserved.
Micro-invasive carcinoma is the next stage of “development” of severe dysplasia of the cervix. In it come earliest manifestations of invasiveness (in stroma, but not in vessels) in carcinoma in situ. The depth reached by infiltrative growth should not exceed 3mm. Early invasive manifestations are represented as wedges and tongues of atypical cells in the stroma in which there are inflammatory changes (stromal reaction). Here at invasive drags are seen already events of differentiation. The next stage is invasive cancer that has characteristics of squamous cell cancer. In particular, rare histological form is verucosis carcinoma, resembling carcinoma of the vulva and vagina. Carcinoma of the cervix will grow adjacent pelvic organs and metastases by lymph vessels in the pelvic lymph nodes and by blood to distant organs.
Dysplasia is asymptomatic and often found already in advanced forms. Later characteristic clinical symptoms of dysplasia and early cancer of the cervix are postcoital (after intercourse) bleeding. Their cause is mechanical trauma of cervical epithelium by glans penis.
Yearly preventive gynecological examinations aimed at early detection and timely treatment of precancerous cervical changes. Unambiguous results in this respect makes tracking mortality of cervical cancer in different nations. InJapanwhere such inspections are absolutely essential, for years this type of tumor is not causing the death of any woman. By gynecological examinations twice a year this cancer is found in very early stages of primary node and can be radically removed by surgical operation which results in complete cure. In other nations the situation is different because of the ineffectiveness of prophylactic examinations .
Treatment of dysplasia and cervical cancer depends on their stage. Dysplasia is reversible process and may be subject of reversal by conservative treatment, unlike carcinoma in situ. This again shows the importance of preventive examinations and early detection of this precancerous condition. Surgical removal of carcinoma in situ also leads to complete cure! The operation is called conisatio and consists of removing part of the cervix. These women can then have problems getting pregnant, wear fetus and normal birth. Advanced cervical cancer requires hysterectomy (removal of uterus), dissection of lymph nodes in the pelvis and subsequent radiotherapy. The prognosis depends on clinical stage of disease.