TANISHA BIASPAL 0910714016

MODUL TASK CERVICAL CANCER 1. Describe the natural history of cervical cancer. Natural History of HPV 4 Major Steps of Cervical Carcinogenesis 1. HPV infection via sexual contact 2. Persistence 3. Progression to precancer 4. Progression to invasive cancer Backward steps can occur: clearance of HPV; regression of precancer to normal (uncommon)

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2. Explain the strategy of cervical cancer early detection

All women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse, but no later than 21 years old. Screening should be done every year with the regular Pap test or every 2 years using the newer liquid-based Pap test. Beginning at age 30, women who have had 3 normal Pap test results in a row may get screened every 2 to 3 years. Women older than 30 may also get screened every 3 years with either the conventional or liquid-based Pap test, plus the human papilloma virus (HPV) test. Women 70 years of age or older who have had 3 or more normal Pap tests in a row and no abnormal Pap test results in the last 10 years may choose to stop having Pap tests. Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having Pap tests, unless the surgery was done as a treatment for cervical cancer or pre-cancer. Women who have had a hysterectomy without removal of the cervix should continue to have Pap tests.

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3. What is SCJ (Squamous Columnar Junction) on Cervix and what are the difference of SCJ appearance in women during menarche, reproductive age, and menopausal period? The squamocolumnar junction (SCJ) is defined as the junction between the squamous epithelium and the glandular epithelium. The squamo-columnar junction is located at the point where the squamous epithelium and the columnar epithelium meet. The location varies throughout a womans life due to the process of metaplastic changes in the cervical epithelium which occur after puberty and in pregnancy. The transformation zone is the name given to the area of the cervix comprised of epithelium which has undergone metaplastic change. In the cervix, metaplastic change involves transformation of the endocervical epithelium to squamous epithelium. Three histological stages have been identified:

Stage 1: Reserve cell hyperplasia - the reserve cells in the endocervical epithelium start to divide. Stage 2 :Immature squamous metaplasia - the reserve cells proliferate to form a multilayer of undifferentiated cells. A surface layer of mucinous columnar cells can often be seen on the surface. Stage 3: Mature squamous metaplasia the undifferentiated cells have differentiated into mature squamous epithelium which is nearly indistinguishable from the original squamous epithelium.

Histological section to illustrate reserve cell hyperplasia in the glandular epithelium of the cervix.

Histological section to illustrate immature squamous metaplastic epithelium in the cervix.

Histological section to illustrate mature squamous metaplastic epithelium in the cervix.

Illustrates metaplastic change from columnar to squamous epithelium in the uterine cervix.

Metaplastic change in the cervix and its physiological basis

From birth until puberty the endocervical epithelium is composed of columnar epithelium and the ectocervix of native squamous epithelium. The interface between the two is termed the original squamocolumnar junction.

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During puberty and at the first pregnancy the cervix increases in volume in response to hormonal changes. The endocervical epithelium everts onto the ectocervix (portio vaginalis) exposing it to the acid pH of the vagina. This provides a stimulus for metaplastic change of the columnar epithelium. The process of metaplasia is a patchy one: It starts initially in the crypts and at the tips of the endocervical villae which gradually fuse. Eventually the whole of the everted endocervical epithelium may be replaced by squamous epithelium.

Squamocolumnar junction prior to puberty.

Eversion of the endocervical epithelium at puberty and first pregnancy

Metaplastic change of Relocation of SCJ in endocervical the endocervical canal epithelium in the after the menopause transformation zone Key:

1: native squamous epithelium 2: columnar epithelium of endocervix 3: squamocolumnar junction (SCJ) 4: Eversion of endocervical epithelium 5: Metaplastic change in transformation zone

Clinical significance of squamous metaplasia in the cervix In the cervix, the area of the epithelium that has undergone metaplastic change is called the transformation zone (TZ). Numerous studies have shown that the immature metaplastic epithelial cells are susceptible to carcinogens and most, if not all, cervical cancers arise here. 4. Describe in brief the management of cervical cancer. The treatment of cervical cancer varies with the stage of the disease. For early invasive cancer, surgery is the treatment of choice. In more advanced cases, radiation combined with

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chemotherapy is the current standard of care. In patients with disseminated disease, chemotherapy or radiation provides symptom palliation.