Abnormal Cervical Smear - case Study And Management

A 28-year-old woman attends the colposcopy clinic after an abnormal smear test. She is very anxious as she thinks that she might have cervical cancer. The smear is reported as ‘severe dyskaryosis’. She had a previous normal result at age 25 years.
She has not had any postcoital or intermenstrual bleeding. Her first sexual relationship started at the age of 14 years and she has had several partners since then. She lives with her current partner who she has been with for 3 years. She was diagnosed with genital herpes several years ago but has not had any attacks for at least 3 years.
She smokes 15–20 cigarettes per day and drinks only at the weekends.
She has an intrauterine contraceptive device in situ.

On Examination
The cervix is macroscopically normal. At colposcopy, acetic acid is applied and an irregular white area is apparent to the left of the os. Lugol’s iodine is applied and the same area stains pale while the rest of the cervix stains dark brown. A biopsy is taken.

Cervical biopsy report: the sample received measures 4 mm x 2 mm and contains enlarged cells with irregular nuclei consistent with CIN 3.

Questions
• How should this patient be managed?

Answer And Discussion:

The colposcopy findings show an abnormal area on the left of the cervix. The abnormal tissue stains white with acetic acid because abnormal cells have high-density nuclei which take up the acetic acid more than normal cells. In contrast, abnormal cells have lower glycogen content than normal cells and stain less well, remaining pale when iodine is applied.
The diagnosis is of CIN 3 (cervical intraepithelial neoplasia). This is a tissue diagnosis as opposed to dyskryosis which is an observation of cells from a smear. The degree of dyskaryosis and CIN often correlate, but a dyskaryosis report is not a diagnosis.

Management
CIN needs to be treated to prevent progression over several years to cervical carcinoma.
The commonest treatment is large-loop excision of the transformation zone (LLETZ) – removal of abnormal cervical tissue with a diathermy loop. Most women tolerate this under local anaesthetic. The LLETZ sample needs to be examined histologically both to confirm removal of all the abnormal tissue, and to ensure that there is not a focus of carcinoma within the sample.
Follow-up smear should be performed in 6 months, and thereafter yearly smears for 10 years.

Advice after LLETZ procedure
• The patient may have light bleeding for several days.
• If heavy bleeding occurs she should return as secondary infection may occur and need treatment.
• She should avoid sexual intercourse and tampon use for 4 weeks, to allow healing of the cervix.
• Fertility is generally unaffected by the procedure, though cervical stenosis leading to infertility has been reported, and mid-trimester loss from cervical weakness is rare.

Points to Remember
• Dyskariosis refers to abnormality from a smear.
• Dysplasia or cervical intraepithelial neoplasia are histological terms from a biopsy sample.
• CIN should be treated to prevent long-term progression to cervical carcinoma.
• LLETZ is the usual treatment for CIN, with yearly follow-up for 10 years.