Cancer of the Cervix
Here is the case of a 28-year-old female w ho presented with a very large ulcerating and necrotic mass on the cervix. The preoperative diagnosis from the clinician was carcinoma. On biopsy, there was an area of ulceration, then endocervical stroma with lots of congested big vessels. On higher power, the area of ulceration showed numerous acute and chronic inflammatory cells. In these areas of ulceration were very large multinucleated cells with rather intranuclear ground glass-type inclusions. These are very characteristic of the herpes virus. This was a case of herpes cervicitis. One of the reasons I chose to bring this case to you today is because it is an example of a benign inflammatory process of the cervix and because it clinically, as in this case, can be mistaken for carcinoma. The herpes virus received considerable attention many years ago in its role in the pathogenesis of cervical carcinoma. Since then, there have been numerous conflicting studies as to whether or not it does play a role. Some studies support the association of herpes cervicitis with cervical carcinoma and its precursor lesions, while other studies refute it. It appears that further studies are needed to define the role better in the pathogenesis ofo cervical carcinoma. The cervical involvement in patients with primary herpes genital lesions is usually around about ninety percent. In patients with recurrent genital herpes, involvement of the cervix is about twelve to twenty percent.
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The second case is a 30-year-old lady who went to her gynecologist for a routine checkup and on Pap. smear. smear she was shown to have atypical cells, most likely dysplastic in nature. Thereafter, a biopsy was performed. Normal squamous epithelium of the cervix is a single basal cell layer, which is very orderly and organized. The cells in the basal cell layer are small and have a scant amount of cytoplasm. If one is going to see mitoses, normally it will be seen in the basal cell layer. As the cells mature, the nuclei get smaller and there becomes more abundant cytoplasm with increasing amounts of glycogen. At the top, the nuclei are very small and slightly spindle shaped. This is the underlying endocervical stroma. Our patient’s squamous epithelial layer is very different. She had very atypical cells in the more superficial layers. The basal cell layer was slightly thickened and slightly disorganized, but not particularly so. On higher power, koilocytotic atypia was noted. There was nuclear enlargement, nuclear hyperchromasia, which means that the chromatin was very, very dark, and there was marked wrinkling and irregularity of the nuclear membrane. In addition, one could see perinuclear cytoplasmic vacuolization and in some cells, showed multinucleation. These are the cytopathic effects of the human papilloma virus. The terminology for cervical cancer precursor lesions includes two groups of thought. The WHO and the International Society of Gynecologic Pathologists have a three-tier system – Mild dysplasia to severe dysplasia. Bethesda has adopted a two-tier grading system – the mild dysplasias are called the low-grade squamous intraepithelial lesions and the higher-grade cells will basically incorporate both the moderate dysplasia and the severe dysplasia. The grading of the cervical intraepithelial neoplasia cells is basically based on the proportion of epithelium occupied by those very basaloid, undifferentiated cells – the cells at the base. Cheap cymbalta online. This basically reflects progressive loss of epithelial maturation. The lower third of the epithelium is occupied by these type of cells; moderate occupies the lower third to two-thirds; severe occupies two-thirds to full thickness. It is very important to note that even if the basal cell layer is orderly and you don’t have many basaloid undifferentiated cells in the lower third, but you have marked HPV effect, that is still classified as mild dysplasia with HPV effect. As you know, the precursor lesions are associated with the human papilloma virus. The low-grade lesions tend to be associated with any of the anogenital HPVs. The higher-grade lesions, however, are associated with 16, 18, 31 and 33, which is important to remember. So our patient has mild dysplasia.