La biopsia della cervice, la tecnica
Il polipo della cervice uterina
Leiomyoma or fibroid or fibromyoma
The uterine cervix connects the body of the uterus to the vagina. The "portio vaginalis" or esocervice is that portion of the cervix that protrudes into the vagina and is covered by a multi-layered flat epithelium, while the supravaginal or endocervic portion is covered by a muciparous and ciliated cylindrical epithelium, which lashes outwards cervical mucus to remove any germ from the inside of the uterus and to create a current that promotes the ascent of the sperm when fertilization is possible.
A junction point is therefore present in which the columnar epithelium of the
cervical canal passes through the epithelium of the exocervix. This junction is
the area of the squamous-columnar junction and is important because at this
level a series of pre-neoplastic lesions can occur (other examples of squamous
columnar junction are at the level of the cardias where the esophageal
epithelium pours through the epithelium cylindrical of the stomach, or still in
the anal canal).
Ectropion is the most frequent and unavoidable lesion in all the women who gave
birth, although sometimes it can also be present in the nulliparis: it is the
presence of cylindrical epithelium at the level of the exocervix. In these
women, in fact, the junction is slightly more displaced outwards as a result of
processes of growth of the cervix and, for this reason, it can undergo a series
of benign inflammatory pathologies. The ectropion can be treated using the
technique called "LEEP", that is Loop Electro Excision Procedure, after the use
of electric currents and precision cutting with diathermic loop, in order to
escape the precancerous tissue of the door, when the Papanicolau test is
abnormal and indicates cellular atypia.
In the presence of benign inflammatory pathology, the cylindrical cells in the
exocervix may attempt to repair and undergo squamous metaplasia. The cells of
this epithelium are partly muciparous, partly ciliated and the mucus changes in
the various phases of the cycle: the variations are felt by the woman because
sometimes this secret is very abundant.
Colposcopy is a technique that allows observation of the cervix: a speculum is
inserted into the vaginal dilation and the vaginalis is brought into view,
illuminating it: at this point it is observed with a high-magnification
microscope which is the colposcopy, brushing it later with vital dyes that can
best highlight the surface structure of this mucosa.
Reserve cell hyperplasia
It is already an expression of remarkable epithelial activation. The cells at
the base are totipotent cells that guarantee the replacement of the cylindrical
elements (we see them in all the mucous membranes with a monolayer cylindrical
epithelium, as well as at the pulmonary level). It is therefore an expression of
a hyperplasiagene activation of the epithelium and must therefore also be seen
with some attention.
And then we have the involutive alterations
The epithelium is called metaplastic when the regular cells are gradually
replaced by other cell types through a process of transformation of themselves,
precisely "metaplasia". In this case, there is a zone of transformation of the
exocervix in which the columnar-type endocervical epithelium is transformed into
the squamous epithelium of the ectocervix.
Here there is epidermoid metaplasia, even. We know that the area that should be
coated by cylindrical epithelium because we have glandular septums still lined
with cylindrical epithelium; so we are not in the external portion, but in the
internal one. And here again we have an epidermoidal metaplasia with a
superficial corneification. This clearly determines a clinical picture also
because we notice a white patch, a leukoplakia, which in this case is expressed
as a noxa that acted chronically, inducing this type of modification.
There are inflammatory and hyperplastic diseases at the level of the cervix: a
chronic inflammation may represent a proliferative stimulus for the stroma and
that is why, in many chronic cervicitis, we will have hyperplasies also called
polyposis. Hyperplastic hypertrophic cervicitis is therefore characterized by a
protrusion of the mucosa accompanied by its stroma, with a perfectly normal
architecture and which can present one or more polyps accompanied by hypertrophy
of the glands.
The benign lesion is present in many women: these polyps have a fibro-glandular
type architecture and the glands are more or less infiltrated by lymphocytes. In
hypertrophic cervicitis we have a cylindrical coating and the stroma contains
many vases: this structure can grow and become a vegetative structure but has a
smooth and regular appearance and is different from carcinoma: it is possible to
remove the lesion but we must also investigate the cause of chronic cervicitis
to treat it. The benign squamous lesions of the harpoon are manifold: the most
important are the condyloma acuminata, the flat condyloma and the squamous
papilloma. Condyloma acuminate is caused by exposure to the HPV virus 6, 11
which can then be demonstrated by staining the histological section: cells that
have integrated viral DNA in their genome will be colored and highlighted.
Pre-neoplastic lesions lead to the development of the cancer of the harpoon, a
tumor that is still increasing, even if mortality is reduced. The new
generations thanks to the HPV vaccine should be immunized against this disease.
• Grade I mild dysplasia
• Grade II moderate dysplasia
• Grade III severe dysplasia and carcinoma in situ.
The classification of Bethesda has allowed to standardize language and
diagnosis allowing a greater degree of communication between pathologists and
clinicians and making the diagnostic and therapeutic process more standardized.
Some HPV strains are involved in carcinogenesis and therefore we need to go to
the typing to know if the woman is at low or high risk.
If we have a grade 1 intraepithelial lesion, this affects only the basal portion
of the epithelial lining and the maturation remains normal; when these cells
move higher they will be desquamated: cells with nuclear alterations will
therefore be recognizable on the surface.
This type of tumor tends, like that of the breast, to anticipate more and more
the age of onset; cervical cancer is a tumor of fertile women, while carcinoma
of the uterus is characteristic of postmenopausal women. Around the 1930s the
desquamated cells of the cervix were studied to make cytological screening of
malignant tumors: this screening is represented by the PAP test. It was
Papanicolaou who disseminated this method of polychrome coloring that is the
same used to color the cells of the vagina: the nuclei are colored with the blue
hematoxylin, the cytoplasm in different ways: the red-orange acidophile cells,
the blue-green basophilic cells . We can thus distinguish the responsive
estrogen cells, the responsive progestogen cells, and those with squamous
metaplasia that have a yellowish color.
Papanicolaou's method was used until 1988, when the Bethesda classification was
formulated, which puts a series of important points in the evaluation method of
the smear.
1. The first most important criterion is that of adequacy: many neoplasias
develop initially within the cervical canal, so the dysplasia is not seen on the
outside. This means that a smear affecting only the protruding portion in the
vagina will not allow me to obtain cells that come from the innermost part and
therefore I could underestimate a potentially malignant process. So small
spatulas are used that take the material inside the cervical canal and also at
the level of the arch: the presence of these normal or altered cervical cells is
the criterion of adequacy. There must be endocervical elements and cell
morphology must be preserved.
If in a smear, due to inflammation or lactobacillus, we come to have cells not
clearly visible because they are full of artifacts, this makes the preparation
inadequate and the collection must be repeated.
2. The second criterion is to see normal findings, then the cells of estrogenic
type and those of the progestin type (?); in addition to the presence of
endocervical cells, an adequate number of well-preserved and visible squamous
cells is required. Finally inflammatory and reparative lesions that are
generally both of the vaginal canal and of the vagina (most of the inflammatory
pathologies are cervicovaginal and not only vaginal pathologies).
With the Classification of Bethesda we will have:
• ASC-US group (Atypical Squamous Cells of Undetermined Significance), ie a
group of cells whose type is not well understood and repetition of the sample is
therefore necessary.
• L-SIL (low-grade intraepithelial squamous lesion, referring to low-risk
strains, HPV 6.11 and corresponding to CIN I, mild dysplasia);
• H-SIL (high-grade intraepithelial squamous lesion, referring to high-risk HPV
strains 16.18 and corresponding to CIN II and III, moderate, severe dysplasia
and CIS).
If we see cells containing cytokeratin in the smear, these are the expression of
a mature squamous metaplasia with hyperkeratinization.
At the cervix level there can also be the adenocarcinoma that we see with
neoplastic cells, atypical, but they are not squamous: they do not have that
differentiation or cytokeratin within the cytoplasm.
Unfortunately, the efficiency of screening is not constant and therefore we
still see infiltrating carcinomas: for this reason it is important, at the time
of screening, to take into account the classification of Bethesda and above all
the adequacy criterion so as to recognize a possible lesion at the canal level.
cervical.
The infiltrating carcinoma is distinguished in
- squamous differentiated;
- widely differentiated;
- poorly differentiated.
It is a flat but ulcerated, hardened, increased consistency lesion affecting the
harbors, but it can also affect the arches, vagina, parameters and pelvic organs.
The metastases of this tumor are in the parametrial, iliac, obturator and para
aortic lymph nodes. Before being extensively infiltrating, the carcinoma can
present itself as micro-invasive and the coloration allows to detect the
presence of neoplastic cells. The expectation of survival without recurrence is
100% when in situ, but falls to 75% when there is already a micro invasion for
which it is essential to recognize it first; when the tumor is invasive, the
life expectancy drops to peak and this tumor will respond very badly to the
antineoplastic therapy. Squamous cancer is the most common and its prevention is
essential. Adenocarcinoma, a glandular cervical lesion, is very reminiscent of
the normal lining and therefore the diagnosis can be difficult, especially when
a small part of the fabric is available.
Could be:
-in situ (theoretically possible but very rare to find because you should
be lucky and take the neoplastic cells at a time when they are still not
invasive);
-treatment (15% of cervical neoplasia).
We also distinguish mucinous adenocarcinoma, with clear, papillary or
endometrioid cells. The mucinous one is the most frequent.
index of tumors