Vinoth

Module 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)


Vinoth
Module Task-Cervical Cancer



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
Vinoth
Module Task-Cervical Cancer

cancer or pre-cancer. Women who have had a hysterectomy without removal of the cervix
should continue to have Pap tests.
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
Vinoth
Module Task-Cervical Cancer

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.
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
endocervical
epithelium in the
transformation zone
Relocation of SCJ in
the endocervical canal
after the menopause
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.
Vinoth
Module Task-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
chemotherapy is the current standard of care. In patients with disseminated disease,
chemotherapy or radiation provides symptom palliation.