When the disease is confined to the cervix, patient management depends on the cytology and/or histology specimens. These can reveal a spectrum of changes in the epithelium of the cervix:

♦ Slight dysplastic changes to the cell architecture

♦ Viral cytoplasmic changes

♦ Micro-invasive carcinoma

♦ Frank invasive carcinoma

A number of changes may be present in the same patient at one time. The changes are often maximal at the junction zone where the squa-mous epithelium of the ectocervix meets the cuboidal epithelium of the endocervix close to, or at, the external os. The changes can be a single focus, multiple foci, or confluent change extending up the endocervical canal.

These early changes may first be identified by examination of a smear of cells, collected by a special wooden (Ayers) spatula or a brush, from the vaginal surface of the cervix. The specimen is a sample of the cells that are being shed from the ectocervix along, sometimes, with cells that are being shed from the endocervix and the endome-trium. They are examined on a slide after staining with Papanicolou stain and an impression of the health of the epithelium can be formed.

To accurately map changes in the cervical epithelium patients require colposcopy where the cervix is examined by binocular microscopy at ten times normal magnification. A skilled operator can discriminate between different grades of change identifiable histolog-ically, map the abnormalities, and biopsy the most abnormal areas. If changes extend up the cervical canal the operator will proceed to a formal cone biopsy in which the abnormal ectocervix along with the endocervical canal up to the internal os of the cervix is removed in one piece and examined histologically.

Viral changes, dysplasia, CIN 1 and 2 are common in the sexually active adult female, particularly among those in their 20s when multiple partners and non-barrier contraception are involved. They can all revert to normal without treatment and are monitored by regular smears. CIN 3 changes are more commonly part of a process that can progress over months or years to invasive carcinoma. Invasive cancer can also develop de novo. Most patients have changes to the squamous cell population, some have pure adenomatous cell changes, and others have mixtures of the two cell types. Papillary or small cell carcinomas are seen occasionally.

The pathology report should indicate the cell type(s), the level it has reached relative to the basement membrane, the maximum depth of any invasion below the membrane, and the width of invasion. These last two points are particularly important when invasion is only a few millimetres as this determines whether the problem is micro-invasion (less than 5 mm in depth or 7 mm in width) or invasive carcinoma.

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