Case 8: Abnormal cervical smear

 

Case 8: Abnormal cervical smear

CASE 8: ABNORMAL CERVICAL SMEAR

History

A 28-year-old woman attends the colposcopy clinic after an abnormal liquid-based cytology

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.

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.

INVESTIGATIONS

Cervical biopsy report: the sample received measures 4×2 mm and contains enlarged

cells with irregular nuclei consistent with CIN3.

Questions

• How should this patient be managed?100 Cases in Obstetrics and Gynaecology

20

ANSWER 8

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 CIN3 (cervical intraepithelial neoplasia). This is a tissue diagnosis as

opposed to dyskaryosis 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. After a smear

showing severe dyskaryosis she has an 80–90 per cent chance of CIN 2 or 3 being found histologically on biopsy at colposcopy.

Management

CIN3 needs to be treated to prevent progression possibly 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.

Assuming that all of the abnormal cells are excised, with clear margins, at the time of LLETZ

treatment, then six-month follow-up should be arranged where she should have a repeat

smear and human papilloma virus (HPV) screening. If both are negative then she can go

back to 3-yearly smear tests. If either is positive then annual smears remain necessary for 10

years.

She should be strongly advised to stop smoking as this is a significant modifiable risk factor

for cervical carcinoma.

! 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 midtrimester loss from cervical weakness is

rare.

KEY POINTS

• Dyskaryosis refers to abnormality from a smear.

• Dysplasia and cervical intraepithelial neoplasia are histological terms from a

biopsy sample.

• High-grade CIN should be treated to prevent long-term progression to cervical

carcinoma.

• Human papilloma virus (HPV) testing is a triage tool to identify women at high risk

of progression to more severe cervical pathology.