1. Cervical Pathology Nilsa C. Ramirez, MD Director of Autopsy Pathology
Medical Director, Biopathology Center
Nationwide Children’s Hospital
Associate Professor – Clinical, Department of Pathology
The Ohio State University
Nilsa C. Ramirez, MD
Director of Autopsy Pathology
Medical Director, Biopathology Center
Nationwide Children's Hospital
Associate Professor - Clinical, Department of Pathology
The Ohio State University

2. Learning Objectives
Discuss benign and cancerous growth of the cervix uteri
Discuss the origin and practice of screening for cervical neoplasia, and how HPV infection relates to the pathogenesis of cervical disease.
Describe the medical and behavioral risk factors that predispose women to develop cervical cancer.
Discuss the clinical and histological features of cervical dysplasia.
Describe the clinical presentation, epidemiology, histopathological features, and prognosis associated with cervical cancer.

3. Female reproductive system
normal ectocervix,
vaginal portio ▼
The cranial unfused portion of the
Mullerian ducts becomes the fallopian
tubes, and the caudal fused portion
becomes the uterus, cervix, and
upper 2/3 of the vagina
Stratified squamous epithelium,
non- keratinizing ◄
To better understand the pathological conditions that affect the female reproductive system, a brief review of developmental facts and histological features is necessary at this time.
During embryogenesis, the cranial unfused portion of the Mullerian ducts becomes the fallopian tubes and the caudal fused portion becomes the uterus, the cervix, and the upper 2/3 of the vagina.
The portion of the cervix that projects into the vagina is referred to as the “vaginal portio” and is lined by non-keratinizing stratified squamous epithelium.

4. The normal endocervix endocervical canal transformation zone
upper vagina
endocervical canal
transformation
zone
Transformation zone: the area in which the glandular epithelium is being replaced by the squamous epithelium. It changes in response to hormones
Squamocolumnar junction: term applied to the junction between two types of epithelium (squamous and mucinous)
The uterine cervix has a central canal known as the endocervical canal. It is lined by multiple infoldings of mucosa, resulting in gland formation. At the microscopic level the mucosa is lined by a single layer of mucinous epithelium. Ciliated metaplastic epithelium can also be seen. The stroma that supports the endocervical mucosa consists of a mixture of fibrous connective tissue and smooth muscle. Mesonephric duct remnants can also be identified.
Two areas of the uterine cervix are important to note at this time. The “transformation zone” is the term applied to the area in which the glandular epithelium is being replaced by the squamous epithelium. This zone changes location in response to the estrogenic and progestational hormonal changes that take place throughout a woman’s life. The “squamocolumnar junction” is the term applied to the junction between the squamous epithelium and the mucinous epithelium and is located in the transformation zone.
Endocervix: mucosal infoldings (glands) lined by a single layer of mucin secreting epithelium. Ciliated metaplasia can be seen.
Stroma: mixture of fibrous connective tissue and smooth muscle
The normal endocervix

5. Cervical neoplasia: dysplasia and squamous cell carcinoma
Epidemiology
Detection
Role of the Pap smear
Cervical infection with Human papilloma virus (HPV)
Dysplasia
Invasive carcinoma
Risk factors for cervical neoplasia indicate a complex interaction between the host and the virus
early age at first intercourse
multiple sexual partners
increased parity
a male partner with multiple previous or current sexual partners
immunosuppression
persistent detection of a high risk HPV (HPV 16 and HPV 18)
certain HLA subtypes
use of oral contraceptives
use of nicotine (cigarette smoking)
During this lecture we are going to emphasize uterine cervical neoplasia. At this time, detection of early cervical cancer and precancerous cervical conditions is high due to screening using the Papanicolau cytological test (best known as the pap smear), colposcopy (which is the technique of visually examining the cervix with a magnifying glass) and biopsy. However, we should keep in mind that in this country more than 1 million precancerous lesions of the uterine cervix are diagnosed every year. A precancerous lesion of the cervix is known as a “dysplasia”, a term that means "disordered growth". Close to 11,000 new cases of invasive cervical cancer are also diagnosed each year. Today cervical squamous cell carcinoma is the 8th leading cause of cancer mortality in American women.
To understand the pathogenesis of cervical cancer you need to understand the factors involved in its development. Human papilloma virus (also known as HPV) is sexually transmitted and is considered the most important agent in cervical carcinogenesis. However, HPV alone is not the cause of cervical cancer. The identification of several risk factors for cervical neoplasia indicate a complex interaction between the host and the virus. Some of the most important risk factors are listed here and include a series of behaviors commonly associated with sexually transmitted diseases, the immunological status of the patient, and cigarette smoking.

6. Pathogenesis of cervical neoplasia
HPVs are typed based on their DNA sequence and subgrouped into high and low grade oncogenic risk
Sexually transmitted
Low oncogenic risk HPVs: HPV 6 and HPV 11
High oncogenic risk HPVs: HPV 16 and HPV 18
HPV: The most important agent in cervical carcinogenesis
HPV Infection: how the mature and immature cervical epithelial cells are infected
Transformation zone: The majority of the dysplasias arise in that area (>95%)
Cervical carcinoma:
Preceded by a precancerous lesion (dysplasia) that can be confined to the mucosal lining of the cervix (intraepithelial neoplasia, a non invasive process) for as much as 20 years
Dysplasia (disordered growth): Manifested by cellular (microscopic) changes involving cell size, contours, quality of the cytoplasm, nuclear size, chromaticity (quality of staining), configuration and loss of architectural orientation
Shed abnormal cells that can be detected on cytologic smears (Pap smears)
HPVs are typed based on their DNA sequence and sub-grouped into high and low grade oncogenic risk. In this setting, the most important low oncogenic risk HPVs are types 6 and 11. They are associated with the development of vulvar, perineal, cervical and perianal viral lesions. Of the high oncogenic risk HPVs, 16 and 18 are considered the most important ones, together responsible for close to 70% of the cases of cervical cancer.
HPVs infect immature basal cells in areas of epithelial breaks, or damage, or at the squamocolumnar junction. They don't infect mature cells but can replicate in them and induce cellular changes that manifest as “dysplasia”. More than 95% of the dysplasias arise in the cervical transformation zone. HPV induces synthesis in the host cell by reactivating the mitotic cycle and extending the lifespan of the cell. HPVs can also infect glandular and neuroendocrine cervical cells, causing the less common types of cervical malignancies, including adenocarcinomas and small cell carcinomas.
Cervical squamous cell carcinomas are preceded by a precancerous dysplastic lesion that can be confined to the mucosal lining of the cervix as an intraepithelial process for as much as 20 years.
Dysplasia (or "disordered growth") is manifested at the microscopic level by cellular changes involving cell size, contours, quality of the cytoplasm, nuclear size, chromaticity, configuration, and loss of architectural orientation. When these abnormal poorly cohesive cells shed they can be detected on Pap smears.

7. Cervical precancers – Three classification systems
Dysplasia/
Carcinoma in situ (3 grades)
Cervical Intra-epithelial Neoplasia (3 grades)
Squamous Intra-epithelial Lesion (2 grades)
Mild dysplasia (lower)
CIN I (lower)
Low grade SIL
Moderate dysplasia
CIN II
High grade SIL
Severe dysplasia/
CIS (higher)
CIN III (higher)
Three systems are presently available to classify cervical dysplasia, as noted in this table. The dysplasia/carcinoma in situ classification has 3 grades, the cervical intraepithelial neoplasia classification has 3 grades, and the squamous intraepithelial lesion classification has 2 grades. The dysplasia/CIS classification and the CIN classification are commonly used in the diagnosis of tissue samples like cervical biopsies and hysterectomy specimens. The SIL classification system is used to diagnose Pap smears. The schematic representation of the dysplastic process noted here can assist you in interpreting these terms and the classification systems.

8. How are samples obtained? Different methods:
colposcopy
How are samples obtained? There are different methods, and some are illustrated here. Please note how the Pap smear is obtained, and how is a colposcopy performed. During colposcopy a cervical biopsy or a cold cone biopsy (also known as a cold knife biopsy) can be obtained.

9. HPV related lesions Condyloma acuminatum Acetowhite change
Grossly, HPV related lesions can present as raised cervical lesions (condyloma acuminatum, often low-risk HPV) or papular (flat condyloma, often high-risk HPV) lesions ►
On colposcopic examination they appear as white patches following application of acetic acid (acetowhite change). Can also show distinct punctuate or mosaic vascular patterns ▼
Acetowhite change
Condyloma acuminatum
Grossly, HPV related lesions can present as raised lesions, an example of which is the condyloma acuminatum, a lesion often associated with low risk HPVs. The lesions can also be papular, also referred to as flat condyloma, and often associated with high risk HPVs.
On colposcopic examination HPV related lesions appear as white patches following application of acetic acid. The change in mucosal color that results from this application is known as “acetowhite change”. HPV infected lesions can also show distinct punctuate or mosaic vascular patterns
Mosaic vascular pattern

10. Mild Dysplasia (CIN I, Low grade SIL)
Acetowhite change
The superficial mucosa reveals cells with nuclear enlargement and hyperchromasia, raisin-like nuclei, cytoplasmic perinuclear halos (viral cytopathic effect, AKA: koilocytes or koilocytotic atypia), variable amounts of cytoplasm, and (maybe) multinucleation
Cells in the lower 1/3 of the full mucosal thickness may exhibit increased nuclear to cytoplasmic ratio
The superficial mucosa reveals cells with nuclear enlargement and hyperchromasia. Many of the virally infected cells have “raisin-like nuclei”. Cytoplasmic peri-nuclear halos are also present. Virally induced histologically evident cellular changes are known as “viral cytopathic effects”. Cells with these characteristics are known as “koilocytes” or cells with “koilocytotic atypia”. Variable amounts of cytoplasm and, maybe multinucleation, can be noted. The cells in the lower 1/3 of the full mucosal thickness may exhibit increased nuclear to cytoplasmic ratios.

11. Mild Dysplasia – Pap smear
koilocyte
binucleation
normal cell
These changes represent the effect of viral replication in mature cells (viral cytopathic effect), often containing abundant HPV nucleic acids
Hyperchromasia
Cytoplasmic perinuclear halos (viral cytopathic effect, koilocytes)
Variable amounts of cytoplasm, and (maybe) multinucleation
Do not progress directly to invasive cancer, but some can progress to high grade dysplasia (high grade SIL)
This is how the mildly dysplastic cells look on a Pap smear. The changes represent the effect of viral replication in mature cells, and we use the term “viral cytopathic effects” to describe them. These cells often contain abundant HPV nucleic acids. You can see the cytoplasmic peri-nuclear halos that are caused by the viral infection, resulting in the formation of the cell known as a “koilocyte”. The infected cells have variable amounts of cytoplasm and may be multinucleated. Mild dysplasia does not progress directly to invasive cancer, but can progress to high grade dysplasia.

12. Moderate dysplasia (CIN II, high grade SIL)
The superficial mucosa reveals features similar to those of the CIN I
However, the cells in the lower 2/3 of the full mucosal thickness exhibit increased nuclear to cytoplasmic ratio and increased mitotic figures (including abnormal forms)
The normal maturation pattern of the squamous epithelium is greatly altered
Acetowhite change
In cases of moderate dysplasia the superficial mucosa reveals histological features similar to those of the mild dysplasia. However, the cells in the lower 2/3 of the full mucosal thickness exhibit increased nuclear to cytoplasmic ratios and increased numbers of mitotic figures (including abnormal forms). The normal maturation pattern of the squamous epithelium is greatly altered. Note some “raisin-like nuclei” present on a Pap smear from a patient with moderated dysplasia.

13. Severe dysplasia/CIS (CIN III, High grade SIL)
The full epithelial thickness exhibits increased nuclear to cytoplasmic ratios, increased mitotic figures (including abnormal forms) and lacks an orderly pattern of cellular maturation
Carcinoma in situ (CIS)
In cases of severe dysplasia the full epithelial thickness exhibits increased nuclear to cytoplasmic ratios, increased numbers of mitotic figures (including abnormal forms) and lacks an orderly pattern of cellular maturation. Please note that the term “carcinoma in situ” refers to a dysplastic process that involves that full thickness of a mucosa, but is non invasive. Severe dysplasia and carcinoma in situ are sometimes difficult to distinguish histologically from each other, so it is not uncommon for the diagnosis to be submitted as severe dysplasia/carcinoma in situ.

14. Treatment for Cervical Intraepitelial Neoplasia
Not all lesions begin as CIN I, and some may start as CIN II or III (depending on the type of HPV and other host related factors)
CIN III is most frequently associated with invasive cancer when the latter is identified
If confirmed by biopsy, treatment depends on the stage of the process:
For CIN I: follow up Pap smear
For CIN II and CIN III: cryotherapy, loop electrical excision procedures (LEEP), cold knife cone biopsy, laser
Cryotherapy
LEEP procedure
Not all lesions begin as mild dysplasia, and some may start as moderate or severe dysplasia, depending on the type of HPV infection and other host related factors. Severe dysplasia is most frequently associated with invasive cancer when the latter is identified. If confirmed by biopsy, the type of treatment for cervical dysplasia depends on the stage of the process.
For cases of mild dysplasia, follow-up Pap smears are indicated. For cases of moderate and severe dysplasia there are several treatment options, including cryotherapy, the loop electrical excision procedure (also known as LEEP), the cold knife cone biopsy, and the laser treatment. Some of these treatments also result in tissue resection, providing a specimen that can be used to confirm diagnosis and evaluate the progression of the dysplasia.

15. Squamous cell carcinoma: invasive cancer
Advanced disease (clinical manifestations):
flank pain due to pelvic sidewall involvement
leg pain due to sciatic nerve involvement
Local and distant lymph nodes can be involved
Distant metastases (lung, liver, other organs) can also occur
Patients usually die of renal failure due to involvement of the ureters by carcinoma (causing hydronephrosis)
When cervical dysplasia progresses to invasive squamous cell carcinoma several clinical manifestations can be expected based on the extent of disease. Advanced disease can present as flank pain due to pelvic sidewall involvement or as leg pain due to sciatic nerve involvement. Local and distant lymph nodes can be involved and distant metastasis can also occur. Patients with advanced disease usually die of renal failure due to the consequences of hydronephrosis caused by ureteral involvement by carcinoma.

16. Squamous cell carcinoma of the cervix: gross disease
In this slide you can appreciate examples of exophytic masses of invasive cancer involving the ectocervix. These patients likely presented clinically with vaginal bleeding.
fungating (exophytic,
polypoid mass)

17. Squamous cell carcinoma of the cervix: gross disease
Exophytic, ulcerative
Occult, infiltrative
To the left you have an example of an occult infiltrating squamous cell carcinoma. A tumor with this pattern of infiltration may remain clinically silent for a considerable period of time. To the right is an example of an exophytic squamous cell carcinoma with ulceration.

18. Microscopic: most tumors reveal nests of polygonal cells, typically with eosinophilic cytoplasm, keratinizing (forms squamous pearls) or non keratinizing
Upon microscopic evaluation most invasive squamous cell carcinomas are going to reveal the presence of nests of malignant polygonal cells, typically with eosinophilic (or pink) cytoplasm. Some tumors will produce keratin (these are known as keratinizing tumors) while others (usually less differentiated) will be non-keratinizing. Vascular space invasion is not uncommon.
Vascular space

19. Therapy and prognosis Therapy:
Depends on a number of factors including stage of disease and general health of the patient and includes surgery and radiation therapy
The role of adjuvant chemotherapy is being investigated
Surgery includes hysterectomy (simple, radical), and lymph node dissection
Prognosis:
Stage IA 95% 5 year survival rate
Stage IB % 5 year survival rate
Stage II 75% 5 year survival rate
Stage III and IV less than 50% 5 year survival rate
Therapy for cases of squamous cell carcinoma depends on a number of factors including the clinical stage of the disease and the general health of the patient. Currently used therapeutic approaches include surgery and radiation therapy. The role of adjuvant chemotherapy in this setting is being investigated.
The prognosis for these patients is related to the clinical stage at the time of diagnosis. As you can see, a patient with a low clinical stage (like a stage IA) has a better 5 year survival rate than a patient with a higher stage (like a stage III).

20. Other types of invasive cervical cancers
Adenocarcinomas of the cervix: (approx. 15%)
likely arise from the endocervical glandular epithelium
often preceded by an intraepithelial glandular neoplasm (precancer), termed adenocarcinoma in situ (AIS), a lesion 1/5 as common as its squamous counterpart
The adenosquamous carcinomas:
mixed glandular and squamous patterns
likely arise from the reserve endocervical basal cells
have a less favorable prognosis than SCC at the same stage
Other less common types: neuroendocrine carcinomas, undifferentiated carcinomas
In addition to squamous cell carcinomas, other types of invasive carcinomas can involve the uterine cervix. Adenocarcinomas comprise close to 15% of all invasive carcinomas of the cervix and likely arise from the endocervical glandular epithelium. An endocervical adenocarcinoma of this type is often preceded by a precancerous lesion termed adenocarcinoma-in-situ (referred to as AIS). AIS is 1/5 as common as its squamous counterpart.
Adenosquamous carcinomas are also important cervical lesions. These mixed carcinomas have glandular and squamous histological patterns and likely arise from the reserve endocervical basal cells. They have a less favorable prognosis than squamous cell carcinomas at the same clinical stage. Other less common types of carcinomas that can develop in the uterine cervix include neuroendocrine carcinomas and undifferentiated carcinomas.

21. Adenocarcinoma of the cervix
An invasive cervical adenocarcinoma looks grossly and behaves like an invasive squamous cell carcinoma. However, the microscopic features are different, and the adenocarcinoma is characterized by malignant invasive glands.
The invasive cervical adenocarcinoma
looks grossly and behaves like the
invasive squamous cell carcinoma

22. Cervical Pathology Quiz

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