Lower Genital Tract Precancer : Colposcopy, Pathology and Treatment

by Singer, Albert; Monaghan, John M.; Quek, Swee Chong; Deery, Alastair R. S.

• ISBN13: 9780632047697
• ISBN10: 0632047690
• Edition: 2nd
• Format: Hardcover
• Copyright: 2000-02-29
• Publisher: Wiley-Blackwell

Summary

The new Second Edition of Lower Genital Tract Precancer has been extensively revised and expanded to provide a definitive and contemporary reference on this subject. Providing a comprehensive examination of the applications and benifits of the applications and benefits of modern diagnostic and therapeutic practices in managing lesions of the female lower genital tract, the book is presented in a clear, easy-to-read style and is extensively illustrated. The text covers investigative procedures and techniques, reviews the normal and abnormal cervix and fully appraises the diagnosis and management of both benign and malignant lesions.Vaginal, vulvular and perianal premalignant diseases are discused, and a separate section is devoted to those conditions which mimic, and can thus be confused with, precancer. A new section on AIDS has been included and an entire chapter on pathology is also incorporated.

Table of Contents

Preface to the Second Edition	xi
Preface to the First Edition	xiii
Acknowledgements	xv
The Histopathology of Lower Genital Tract Neoplasia	1	(14)
Introduction	1	(1)
Terminology	1	(2)
The concept of cervical cancer precursors	1	(1)
Biology and natural history	2	(1)
Rationalization of histologic terminology	3	(1)
Histopathological features of CIN or SIL	3	(3)
Low-grade disease (mild dysplasia, CIN 1, HPV-CIN 1, LSIL)	3	(1)
High-grade disease (moderate or severe dysplasia, CIS, CIN 2 or 3, HSIL)	4	(2)
Cervical glandular intraepithelial neoplasia and adenocarcinoma-in-situ	6	(1)
Cervical glandular intraepithelial neoplasia	6	(1)
Histologic criteria for CGIN	6	(1)
Early invasive carcinoma (microinvasive carcinoma of the cervix)	7	(3)
Vaginal intraepithelial neoplasia	10	(1)
Adenosis	10	(1)
Histopathology of vaginal intraepithelial neoplasia	11	(1)
Vulval precancer	11	(1)
Vulval intraepithelial neoplasia	11	(1)
Paget's disease	11	(1)
Related topics	12	(1)
References and bibliography	12	(3)
Human Papillomaviruses in Pathogenesis of Lower Genital Tract Neoplasia	15	(19)
Introduction	15	(1)
Characteristics of human papillomaviruses	15	(1)
Manifestations of genital HPV infections	16	(5)
Clinical infections (predominately condylomata)	17	(1)
Subclinical HPV infections	18	(2)
Latent HPV infections	20	(1)
Prevalence of genital HPV infections	21	(1)
Incidence rates of HPV infections	21	(1)
Transmission of genital HPV infections	22	(1)
Sexual transmission	22	(1)
Vertical transmission	22	(1)
Risk factors for genital HPV infections	22	(1)
HPV and cancer precursors	23	(1)
HPV infections and the risk for cervical cancer	23	(1)
Case reports and case series	23	(1)
Cohort studies	23	(1)
Natural history	24	(2)
Natural history of cervical HPV infections	24	(1)
CIN and HPV have an identical natural history	24	(2)
Molecular pathways of HPV oncogenesis	26	(2)
The normal cell cycle	26	(1)
The effect of HPV/host cell interaction---a prerequisite for neoplasia	27	(1)
The role of oncogenic HPV detection in the prevention of lower genital tract precancer	28	(2)
As an adjunct to cytology in primary screening	28	(1)
As an adjunct to colposcopy in the management of women presenting with mild or borderline dyskaryosis (ASCUS/AGUS)	29	(1)
HPV type and type variant as determinants of the natural history	30	(1)
References and bibliography	30	(4)
Examination for Cervical Precancer---Use of colposcopy	34	(9)
Introduction	34	(1)
Tissue basis for colposcopy	34	(1)
The role of the epithelium	34	(1)
The role of the stroma	35	(1)
The role of the surface configuration	35	(1)
The colposcopic examination	35	(6)
The colposcope	35	(1)
The examination	35	(5)
Decontamination of colposcopy clinic equipment	40	(1)
New developments in colposcopy	41	(1)
Video colposcopy, image management and electronic databases	41	(1)
References and bibliography	41	(2)
Colposcopy of the Normal Cervix---A prerequisite to establish the diagnosis of cervical cancer	43	(28)
Introduction	43	(1)
Cervical epithelium: natural history	43	(1)
Cervical epithelium: topography	44	(2)
Cervical epithelium: colposcopic appearances	46	(1)
Original columnar epithelium	46	(1)
Original squamous epithelium	46	(1)
Transformation zone	46	(1)
Squamous metaplastic epithelium	47	(5)
Colposcopic stages of development	47	(1)
Histologic features of development	48	(1)
Stimulus to development	49	(1)
Colposcopic representations of squamous metaplastic epithelium	50	(2)
Colposcopy of the adolescent cervix	52	(4)
The frequency of epithelial type	55	(1)
Cervical epithelium during pregnancy and puerperium	56	(3)
Ultrastructure and biomechanic properties of subepithelial tissues	57	(1)
Physiologic mechanisms operating in the cervix during pregnancy	58	(1)
The effect of vaginal delivery on the cervical epithelium	59	(1)
Types of epithelial injury caused by delivery	59	(1)
The cervical epithelium during the menopause	59	(2)
The oral contraceptives and their effect on the cervix	61	(3)
The congenital transformation zone	64	(2)
Summary: the normal (typical) transformation zone	66	(3)
References	69	(2)
Cytology and Screening for Cervical Precancer	71	(26)
Introduction	71	(1)
Cytological classifications	71	(1)
Papanicolaou	71	(1)
British Society for Clinical Cytology classification	71	(1)
The Bethesda System	72	(1)
Cytological reporting	72	(8)
Normal cytology	72	(1)
Smear adequacy	73	(1)
Atrophic smears	73	(1)
Borderline abnormalities	74	(3)
Dyskaryotic cellular changes	77	(2)
Cytologic indications of invasion	79	(1)
Clinical referral	80	(1)
Cytodiagnosis of cervical glandular intraepithelial neoplasia/adencarcinoma-in-situ	81	(3)
High-grade CIN/AIS	81	(1)
AGCUS/borderline glandular cells	82	(1)
Atypical metaplasia	82	(2)
Cytologic features of adenocarcinoma	84	(1)
Screening for cervical cancer	84	(1)
Introduction	84	(1)
Cytologic screening	84	(1)
Effectiveness	84	(1)
Accuracy	85	(1)
Improvements to cervical screening	85	(1)
Improving cytological screening	85	(1)
Sampling techniques	85	(1)
Slide preparation---thin layer technology	85	(1)
Cytologic interpretation	86	(2)
Automation in screening	86	(2)
Adjunctive tests	88	(4)
HPV-DNA testing	88	(1)
HPV-DNA testing as triage	88	(1)
HPV-DNA testing as an adjunctive test to cytology	89	(1)
Cervicography	89	(1)
TruScan&ast (formerly called The PolarProbe)	90	(1)
Visual inspection-based techniques	91	(1)
New developments	92	(1)
Problems in cytologic screening in the postmenopausal era	92	(2)
Alterations in function	92	(1)
Screening in the postmenopausal era	93	(1)
References	94	(3)
Diagnosis of Cervical Precancer---The use of colposcopy	97	(64)
Introduction	97	(1)
Which cytologic abnormalities need further investigation?	97	(1)
Colposcopy: the initial clinical examination	97	(1)
The rationale for the use of colposcopy in the diagnosis of cervical precancer	97	(1)
Colposcopic appearance of the abnormal (atypical) cervical epithelium	98	(10)
Morphology of the abnormal (atypical) epithelium	99	(4)
Atypical vessels	103	(4)
The vascular pattern of early invasion	107	(1)
The classification of colposcopically abnormal (atypical) cervical epithelium	108	(1)
Colposcopic examination of the precancerous/cancerous cervix	109	(19)
A satisfactory or an unsatisfactory colposcopy	109	(1)
Grading of the abnormal (atypical) colposcopic findings	109	(5)
Unsatisfactory colposcopy: examination of the endocervical canal	114	(6)
Colposcopic biopsy	120	(1)
Microcolpohysteroscopic examination of the endocervical canal	121	(2)
Other cervicoscopic appearances and pathologic findings	123	(2)
Endocervical Curettage	125	(1)
Identification of the abnormal (atypical) epithelium: Schiller's iodine test	126	(2)
The concept of human papillomavirus infection and cervical precancer	128	(5)
Colposcopic appearance of condylomatous and subclinical papillomavirus lesions	131	(1)
Colposcopic appearances of condylomata and their differentiation from malignant lesions	132	(1)
Further pathologic appearances of HPV and HPV/CIN-associated lesions	133	(1)
Correlation of diagnostic methods in the detection of cervical squamous precancer	133	(6)
Examples of the correlation of diagnostic methods	136	(2)
In moderate-grade epithelial lesions	138	(1)
In high-grade epithelial lesions	138	(1)
Lack of correlation between diagnostic methods	139	(2)
The diagnosis of early invasion	141	(6)
Early invasive squamous cell carcinoma: colposcopic diagnosis	141	(2)
Importance of pathology in diagnosis	143	(4)
Preclinical invasive carcinoma (colposcopically overt/suspect): colposcopy and pathology	147	(2)
Precancerous glandular lesions of the cervix	149	(4)
Epidemiology	149	(1)
Colposcopic diagnosis	149	(4)
Relevance to management	153	(1)
Colposcopic diagnosis of early adenocarcinoma of the cervix	153	(5)
References	158	(3)
Management of Cervical Precancer	161	(53)
Introduction	161	(1)
Rationale behind treatment	161	(1)
Colposcopic and pathologic characteristics of CIN lesion: a prerequisite to treatment	161	(2)
The limits and nature of the abnormal (atypical) epithelium	161	(1)
Glandular involvement	162	(1)
Endocervical extension	163	(1)
Colposcopically directed biopsy	163	(1)
Which lesions to treat	164	(1)
High-grade lesions: CIN 2 to 3/HSIL	164	(1)
Low-grade lesions: CIN 1/LSIL	164	(1)
Prerequisites for treatment	165	(1)
Methods of treatment	165	(8)
Local destructive techniques	165	(8)
Excision techniques for treating CIN	173	(14)
Special problems of endocervical extension	174	(1)
The cold knife cone biopsy	174	(4)
Laser cone biopsy	178	(3)
Loop diathermy excision and cone biopsy	181	(6)
Management of extension of the abnormal (atypical) transformation zone	187	(1)
Technique	187	(1)
Follow-up after treatment	187	(1)
Hysterectomy in the treatment of CIN	188	(2)
Summary: the optimal method of CIN treatment and of follow-up	190	(1)
Follow-up of CIN management	190	(1)
Long-term complications of CIN treatment	190	(7)
Stenosis and constriction	190	(3)
Surgical treatment and reconstruction following stenosis	193	(1)
Excessive eversion of the columnar epithelium (post-treatment)	194	(1)
Subsequent pregnancy	194	(1)
Recurrence	194	(3)
Precancer in pregnancy	197	(4)
Management of invasive cervical cancer during pregnancy	197	(1)
Management of the abnormal smear in pregnancy	197	(1)
Colposcopic examination	198	(1)
Biopsy under colposcopic direction	198	(1)
Treatment	199	(2)
Interpretation of a biopsy specimen during pregnancy	201	(1)
Precancer in the HIV-positive patient	201	(2)
CIN/SIL (squamous intraepithelial lesions) in HIV-infected women	202	(1)
Risk factors for the development of CIN in HIV-infected women	202	(1)
HPV-HIV coinfection	202	(1)
Screening for cervical disease in HIV-affected women	203	(1)
Treatment of CIN in HIV-infected women	203	(1)
Summary	203	(1)
Management of early invasive squamous carcinoma of the cervix (FIGO stage I)	203	(6)
History of ``microinvasion''	203	(3)
Adenocarcinoma-in-situ and early invasive adenocarcinoma of the cervix	206	(1)
Stage Ib cancer of the cervix	207	(2)
Recommended treatment: summary	209	(1)
References	209	(5)
Vaginal Intraepithelial Neoplasia	214	(19)
Introduction	214	(1)
Natural history of VAIN	214	(1)
Etiology	215	(1)
Clinical presentation	215	(1)
Vaginoscopy	215	(1)
VAIN seen as an extension of the cervical atypical transformation zone	215	(1)
VAIN as seen in association with HPV lesions	216	(5)
VAIN following hysterectomy	218	(1)
Presentation after hysterectomy: value of cytology	218	(3)
Biopsy of the VAIN lesion	221	(1)
Pathology of VAIN: is it a precancerous lesion?	221	(1)
Vaginal precancer and cancer: part of the lower genital tract neoplastic syndrome	222	(5)
Pathology	222	(3)
Non-malignant lesions masquerading as vaginal neoplasia	225	(2)
Treatment of VAIN	227	(4)
Use of the CO2 laser	228	(1)
Partial vaginectomy	228	(1)
Local excision	229	(2)
References	231	(2)
Vulyar Intraepithelial Neoplasia	233	(57)
Introduction	233	(1)
Epidemiology and pathogenesis	233	(4)
Prevalence and incidence	233	(1)
Association between VIN and CIN	234	(1)
Viral etiology	235	(1)
Sexually transmitted diseases as etiologic factors	236	(1)
Human immunodeficiency virus and VIN 3	236	(1)
Smoking risk	237	(1)
Natural history of VIN: the rationale for treatment?	237	(2)
Pathology	239	(2)
Differential diagnosis of VIN	240	(1)
Clinical presentation	241	(3)
Vulvoscopy: magnified illumination of the vulva with a colposcope	242	(1)
Collins toluidine blue test	243	(1)
Biopsy of the vulva	244	(1)
Clinical appearances of VIN	245	(6)
White lesions	246	(2)
Red lesions	248	(1)
Dark lesions	249	(2)
VIN affecting the pilosebaceous unit	251	(1)
Early invasive carcinoma of the vulva	252	(6)
Clinical features	253	(1)
Risk of nodal spread: depth and volume measurements	254	(1)
Assessment of the pathologic specimen	254	(1)
Diagnosis	255	(1)
Recurrence of early invasive vulvar carcinoma	256	(2)
Lichen sclerosus	258	(2)
Clinical presentation	258	(1)
Histopathology	258	(1)
Management	258	(2)
Paget's disease (non-squamous intraepithelial neoplasia)	260	(1)
Clinical presentation	261	(1)
Histopathology	261	(1)
Management	261	(1)
Vulvar lesions masquerading as cancer or precancer	261	(7)
Syphilis	262	(1)
Behcet's disease	263	(1)
Condylomata acuminata	264	(1)
Granuloma inguinale	265	(1)
Lichen planus	266	(1)
Subclinical epithelial changes	266	(2)
Skin and accessory appendages that are important for the management of VIN	268	(2)
Management of VIN	270	(15)
Rationale for treatment	270	(1)
Treatment options and procedures	271	(13)
Which approach for treating VIN 3?	284	(1)
Treatment of early invasive vulvar carcinoma	285	(1)
Is lymphadenectomy necessary?	285	(1)
Results	285	(1)
References	285	(5)
Perianal and Anal Intraepithelial Neoplasia	290	(10)
Epidemiology	290	(1)
Etiology	290	(1)
Association with other genital intraepithelial neoplastic diseases	291	(1)
Examination	291	(1)
Presentation	292	(1)
Lesions masquerading as intraepithelial neoplasia	293	(1)
Anal canal involvement	293	(2)
Treatment	295	(4)
Laser vaporization	296	(1)
Localized surgical excision	296	(2)
Extensive surgical excision	298	(1)
References	299	(1)
Genital Tract Adenosis	300	(5)
Development anatomy	300	(1)
Development anomalies caused by DES	300	(4)
Experimental evidence	300	(1)
Epidemiology	301	(1)
Clinical findings	301	(2)
Pathology	303	(1)
Treatment	303	(1)
References	304	(1)
Infective and Other Conditions Causing Confusion in Diagnosis of Lower Genital Tract Precancer	305	(12)
Introduction	305	(1)
Trichomonas vaginalis	305	(1)
Candidiasis	305	(1)
Herpes genitalis infection	306	(3)
Clinical presentations	306	(1)
Herpes simplex cytology	306	(1)
Colposcopic and histologic appearances of infection	307	(1)
Vulvar lesions	308	(1)
HPV infection	309	(3)
Cervical deciduosis in pregnancy	312	(1)
Polypoid lesions of the cervix	312	(3)
Clinical presentation and management	312	(3)
References	315	(2)
Index	317