Difference between revisions of "Squamous intraepithelial lesion of the uterine cervix"

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Squamous intraepithelial lesion of the uterine cervix (view source)

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===High-grade squamous intraepithelial lesion===
===High-grade squamous intraepithelial lesion===
Features - CIN II:<ref name=Ref_PBoD1075-6>{{Ref PBoD|1075-6}}</ref>
{{Main|High-grade squamous intraepithelial lesion}}
*Increased nuclear-cytoplasmic ratio, loss of polarity, incr. mitoses, hyperchromasia.
**If there are large nuclei... you should seen 'em on low power, i.e. 25x.
 
Notes:
#Hyperchromasia is a very useful feature for identifying CIN (particularly at low power, i.e. 25x).
#Koilocytes are the key feature of CIN I.
#Koilocytes are ''not'' considered to be part of a CIN II lesion or CIN III lesion.
#Large irregular nuclei are not required for CIN II... but you should think about it.
#Some mild changes at the squamo-columnar junction are expected.
#Look for the location of mitoses...
#* If there is a mitosis in the inner third (of the epithelial layer) = think CIN I. 
#* If there is a mitosis in the middle third (of the epithelial layer) = think CIN II.
#* If there is a mitosis in the outer third = think CIN III.
#Prominent [[nucleoli]] are ''not'' present in CIN.<ref name=Ref_GP146>{{Ref GP|146}}</ref>
#*Nucleoli are common in reactive changes.<ref>STC. January 2009.</ref>
#The most probably place for CIN is the posterior cervix (6 o'clock position) - risk is marginally increased.<ref name=pmid16378031>{{Cite journal  | last1 = Pretorius | first1 = RG. | last2 = Zhang | first2 = X. | last3 = Belinson | first3 = JL. | last4 = Zhang | first4 = WH. | last5 = Ren | first5 = SD. | last6 = Bao | first6 = YP. | last7 = Qiao | first7 = YL. | title = Distribution of cervical intraepithelial neoplasia 2, 3 and cancer on the uterine cervix. | journal = J Low Genit Tract Dis | volume = 10 | issue = 1 | pages = 45-50 | month = Jan | year = 2006 | doi =  | PMID = 16378031 }}
</ref>
*The difference between CIN II (moderate dysplasia) and CIN III (severe dysplasia) is: changes as in CIN II + outer third (or full thickness).<ref name=Ref_PBoD1075-6>{{Ref PBoD|1075-6}}</ref>
 
DDx:
*[[CIN II]].
*[[Squamous cell carcinoma of the uterine cervix]].
 
====Images====
Image:
<gallery>
Image:Cervical intraepithelial neoplasia (3) CIN2.jpg| CIN II. (WC/KGH)
Image:Cervical_intraepithelial_neoplasia_(4)_CIN3.jpg| CIN III. (WC/KGH)
</gallery>
<gallery>
Image: High-grade squamous intraepithelial lesion -- intermed mag.jpg | HSIL - intermed. mag.
Image: High-grade sqaumous intraepithelial lesion -- high mag.jpg | HSIL - high mag.
Image: High-grade squamous intraepithelial lesion - p16 -- high mag.jpg | HSIL - p16 - high mag.
</gallery>
www:
*[http://www.flickr.com/photos/euthman/6076642630/in/pool-labmed CIN III (flickr.com/euthman)].
*[http://www.flickr.com/photos/euthman/3995927827/in/pool-labmed CIN III (flickr.com/euthman)].
*[http://www.flickriver.com/photos/euthman/tags/hsil/ CIN III - several images (flickriver.com)].


==IHC==
==IHC==
Line 132: Line 94:
A cervical biopsy is suggested.
A cervical biopsy is suggested.
</pre>
</pre>
===LEEP===
<pre>
UTERINE CERVIX, LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP):
- CERVICAL INTRAEPITHELIAL NEOPLASIA 2 (MODERATE DYSPLASIA).
- DEEP, ENDOCERVICAL AND EXOCERVICAL MARGINS NEGATIVE FOR INTRAEPITHELIAL NEOPLASIA.
</pre>
<pre>
UTERINE CERVIX, LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP):
- CERVICAL INTRAEPITHELIAL NEOPLASIA 3 (SEVERE DYSPLASIA).
- DEEP, ENDOCERVICAL AND EXOCERVICAL MARGINS NEGATIVE FOR INTRAEPITHELIAL NEOPLASIA.
</pre>
<pre>
UTERINE CERVIX, LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP):
- CERVICAL INTRAEPITHELIAL NEOPLASIA 3 (SEVERE DYSPLASIA).
- DEEP, ENDOCERVICAL AND EXOCERVICAL MARGINS NEGATIVE FOR INTRAEPITHELIAL NEOPLASIA.
- NEGATIVE FOR MALIGNANCY.
COMMENT:
CIN 3 is seen in 2 of 5 blocks and has a total linear extent of 17 millimeters.
</pre>
<pre>
UTERINE CERVIX, LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP):
- HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (HSIL).
- DEEP, ENDOCERVICAL AND EXOCERVICAL MARGINS NEGATIVE FOR DYSPLASIA.
- NEGATIVE FOR MALIGNANCY.
COMMENT:
HSIL is seen in 3 of 4 blocks and has a total linear extent of approximately
12 millimeters.
The HSIL is in keeping with cervical intraepithelial neoplasia 3 (severe dysplasia).
</pre>
===Cervical biopsy===
====At least CIN 2====
<pre>
UTERINE CERVIX, BIOPSY:
- AT LEAST CERVICAL INTRAEPITHELIAL NEOPLASIA 2 (MODERATE DYSPLASIA).
- TRANSFORMATION ZONE PRESENT.
</pre>
<pre>
UTERINE ENDOCERVIX, CURETTAGE:
- HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (HSIL).
- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
COMMENT:
The HSIL is in keeping with CIN 2.
</pre>
<pre>
UTERINE CERVIX, BIOPSY:
- HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (HSIL).
- TRANSFORMATION ZONE PRESENT.
COMMENT:
A p16 immunostain is strong and within the limits of the tissue orientation appears to mark
the full thickness of squamous epithelium in the suspicious area. A Ki-67 immunostain marks
increased numbers of superficial epithelial cells.
The HSIL is in keeping with at least CIN 2.
</pre>
====CIN 2 surrounded by endocervical epithelium====
<pre>
UTERINE CERVIX, BIOPSY:
- HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (HSIL).
- ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
COMMENT:
A p16 stain marks the full thickness of the squamous epithelium and is strong.
A Ki-67 stain marks increased numbers of superficial epithelial cells.
The epithelium surrounding the lesion is endocervical. No normal exocervical epithelium is
apparent in the sampled tissue.
The HSIL is in keeping with CIN 2.
</pre>
====CIN 3====
<pre>
UTERINE CERVIX, BIOPSY:
- CERVICAL INTRAEPITHELIAL NEOPLASIA 3 (SEVERE DYSPLASIA).
</pre>
<pre>
COMMENT:
A p16 stain marks the full thickness of the squamous epithelium and is strong. 
A Ki-67 stain marks increased numbers of superficial epithelial cells.
</pre>
===Micro===
====CIN 2====
The sections show the transformation zone.
The squamous epithelium has a moderately increased nuclear-to-cytoplasmic ratio, and
nuclear hyperchromasia extending to the mid level of the epithelium. Binucleation
is present. A mid level mitoses is seen in one section.
A p16 immunostain, within the limits of the tissue orientation, focally marks (in the
suspicious area) weakly the full thickness of the squamous epithelium and strongly
marks up to the lower half of the epithelium. A Ki-67 immunostain marks increased numbers of
superficial epithelial cells.
====CIN 3====
The sections show the transformation zone.
The squamous epithelium has an increased nuclear-cytoplasmic ratio, loss of polarity, mitoses and nuclear hyperchromasia extending to the superficial third of the epithelium.  Mitoses are seen in the upper third of the epithelium.  No nucleoli are present. No invasion is identified.
The columnar epithelium has focal involvement by the squamous lesion.  There is no columnar dysplasia.  The margins are negative for dysplasia.
=====Biopsy=====
The sections show the transformation zone.
The squamous epithelium has an increased nuclear-cytoplasmic ratio, loss of polarity,
mitoses and nuclear hyperchromasia extending to the superficial third of the epithelium.
Mitoses are seen in the upper third of the epithelium. Nucleoli are not apparent.
No invasion is identified.
No columnar dysplasia is identified.
=====Alternate=====
The sections show fragments of transformation zone.
There is dysplastic squamous epithelium with coarse chromatin, nuclear hyperchromasia,
nuclear enlargement, irregular nuclear membranes, and an increase nuclear-to-cytoplasmic
ratio.  Mitotic activity is abundant focally (5 mitoses/0.2376 mm*mm).  The dysplastic
squamous epithelium does not show appreciable maturation toward the surface (CIN 3).
The dysplastic squamous epithelium is not associated with stroma; thus, the
presence/absence of invasion cannot be assessed.  Small nucleoli are seen rarely.
There is benign squamous epithelium. Scant benign stripped endocervical epithelium is
present.


==See also==
==See also==
Michael
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