Title Details

ALBERT SINGER, MB BS, PhD DPhil, FRCOG, Emeritus Professor of Gynecology and Consultant in Obstetrics and Gynecology, Whittington Hospital, London, UK; and Quality Assurance lead for colposcopy in London.

ASHFAQ KHAN, MB BS, FRCOG, Consultant Gynecologist at the Whittington Hospital, London, UK.

Preface to the Third Edition ix

Preface to the First Edition x

Acknowledgements xi

1 The Histopathology of Lower Genital Tract Neoplasia 1

1.1 Introduction 1

1.2 Terminology 1

1.3 Histopathologic features of cervical intraepithelial neoplasia or squamous intraepithelial lesion 3

1.4 Cervical glandular intraepithelial neoplasia and adenocarcinoma in situ 6

1.5 Early invasive carcinoma 7

1.6 Vaginal intraepithelial neoplasia 11

1.7 Vulval precancer 11

1.8 Related topics 12

1.9 Further reading 13

2 Human Papillomaviruses in the Pathogenesis of Lower Genital Tract Neoplasia 14

2.1 Introduction 14

2.2 Characteristics of human papillomaviruses 14

2.3 Manifestations of genital human papillomavirus infections 15

2.4 Prevalence of genital human papillomavirus infections 18

2.5 Transmission of genital human papillomavirus infections 19

2.6 Risk factors for genital human papillomavirus infections 19

2.7 Natural history of cervical human papillomavirus infections 19

2.8 Molecular pathways of human papillomavirus oncogenesis 19

2.9 The effect of human papillomavirus/host cell interaction: a prerequisite for neoplasia 21

2.10 The role of oncogenic human papillomavirus detection in the prevention of lower genital tract precancer 22

2.11 Further reading 23

3 Examination for Cervical Precancer: Use of colposcopy 24

3.1 Introduction 24

3.2 Tissue basis for colposcopy 24

3.3 The colposcopic examination 25

3.4 Video colposcopy 31

3.5 Image and electronic data management 31

3.6 Further reading 32

4 Colposcopy of the Normal Cervix: A prerequisite to establishing the diagnosis of cervical precancer 33

4.1 Introduction 33

4.2 Cervical epithelium: natural history 33

4.3 Cervical epithelium: topography 34

4.4 Cervical epithelium: colposcopic appearances 35

4.5 Squamous metaplastic epithelium 38

4.6 Colposcopy of the adolescent cervix 44

4.7 Cervical epithelium during pregnancy and puerperium 46

4.8 The effect of vaginal delivery on the cervical epithelium 48

4.9 The cervical epithelium during the menopause 50

4.10 The oral contraceptives and their effect on the cervix 52

4.11 The congenital transformation zone 53

4.12 Further reading 58

5 Cytology and Screening for Cervical Precancer 59

5.1 Introduction 59

5.2 Cytologic classifications 59

5.3 Cytologic reporting 60

5.4 Clinical referral 63

5.5 Cytodiagnosis of cervical glandular intraepithelial neoplasia/adenocarcinoma in situ 66

5.6 Cytologic features of adenocarcinoma 68

5.7 Screening for cervical cancer 68

5.8 Improvements to cervical screening 70

5.9 Cytologic interpretation 72

5.10 Role of human papillomavirus testing in the UK NHS Cervical Screening Programme 72

5.11 Primary screening with human papillomavirus testing 73

5.12 Human papillomavirus test as follow-up after treatment of cervical intraepithelial neoplasia 74

5.13 Human papillomavirus testing to triage minor cytologic lesions 74

5.14 Role of type-specific human papillomavirus tests 74

5.15 Further reading 75

6 Diagnosis of Cervical Precancer: Use of colposcopy 76

6.1 Introduction 76

6.2 Which cytologic abnormalities need further investigation? 76

6.3 Colposcopy: the initial clinical examination 76

6.4 The rationale for the use of colposcopy in the diagnosis of cervical precancer 77

6.5 Colposcopic appearance of the abnormal (atypical) cervical epithelium 78

6.6 The classification of colposcopically abnormal (atypical) cervical epithelium 87

6.7 Colposcopic examination of the precancerous/cancerous cervix 88

6.8 Benign condyloma of cervix 104

6.9 Correlation of diagnostic methods in the detection of cervical squamous precancer 111

6.10 Lack of correlation between diagnostic methods 116

6.11 The diagnosis of early invasion 117

6.12 Preclinical invasive carcinoma (colposcopically overt/suspect): colposcopy and pathology 122

6.13 Precancerous glandular lesions of the cervix 125

6.14 Colposcopic diagnosis of early adenocarcinoma of the cervix 128

6.15 Further reading 135

7 Management of Cervical Precancer 136

7.1 Introduction 136

7.2 Rationale behind treatment 136

7.3 Colposcopic and pathologic characteristics of cervical intraepithelial neoplasia lesions: a prerequisite to treatment 136

7.4 Colposcopically directed biopsy 139

7.5 How to manage abnormal cytology? 140

7.6 Which lesions to treat 143

7.7 Prerequisites for treatment 144

7.8 Methods of treatment 145

7.9 Excision techniques for treating cervical intraepithelial neoplasia 153

7.10 Management of extension of the abnormal (atypical) transformation zone 163

7.11 Hysterectomy in the treatment of cervical intraepithelial neoplasia 166

7.12 Immediate complications of cervical intraepithelial neoplasia treatment 166

7.13 Long-term complications of cervical intraepithelial neoplasia treatment 168

7.14 Follow-up after treatment of cervical intraepithelial neoplasia 171

7.15 Treatment of suspected recurrence 174

7.16 Precancer in pregnancy 174

7.17 Precancer in the HIV-positive patient 178

7.18 Management of early invasive squamous carcinoma of the cervix (FIGO stage I) 180

7.19 Further reading 184

8 Vaginal Intraepithelial Neoplasia 185

8.1 Introduction 185

8.2 Natural history of vaginal intraepithelial neoplasia 185

8.3 Etiology 186

8.4 Clinical presentation 186

8.5 Vaginal intraepithelial neoplasia following hysterectomy 189

8.6 Biopsy of the vaginal intraepithelial neoplasia lesion 191

8.7 Pathology of vaginal intraepithelial neoplasia: is it a precancerous lesion? 193

8.8 Vaginal precancer and cancer: part of the lower genital tract neoplastic syndrome 194

8.9 Treatment of vaginal intraepithelial neoplasia 199

8.10 Further reading 204

9 Vulval Intraepithelial Neoplasia 205

9.1 Introduction 205

9.2 Epidemiology and pathogenesis 205

9.3 Natural history of vulval intraepithelial neoplasia: the rationale for treatment? 207

9.4 Pathology 209

9.5 The clinical examination in general 211

9.6 The clinical examination (specific) 215

9.7 Vulval intraepithelial neoplasia affecting the pilosebaceous unit 222

9.8 Superficially invasive carcinoma of the vulva 223

9.9 Lichen sclerosus 228

9.10 Paget’s disease (non-squamous intraepithelial neoplasia) 230

9.11 Vulval lesions masquerading as cancer or precancer 231

9.12 Skin and accessory appendages that are important for the management of vulval intraepithelial neoplasia 237

9.13 Management of vulval intraepithelial neoplasia 239

9.14 Treatment of superficial invasive vulval carcinoma 254

9.15 Further reading 255

10 Perianal and Anal Intraepithelial Neoplasia 256

10.1 Epidemiology 256

10.2 Etiology 256

10.3 Association with other genital intraepithelial neoplastic diseases 257

10.4 Examination 257

10.5 Presentation 258

10.6 Lesions masquerading as intraepithelial neoplasia 260

10.7 Anal canal involvement 261

10.8 Management and treatment 262

10.9 Further reading 267

11 Genital Tract Adenosis 268

11.1 Introduction 268

11.2 Developmental anatomy 268

11.3 Developmental anomalies caused by diethylstilbestrol 269

11.4 Present situation 272

11.5 Further reading 272

12 Infective and Other Conditions Causing Confusion in Diagnosis of Lower Genital Tract Precancer 273

12.1 Introduction 273

12.2 Trichomonas vaginalis 273

12.3 Bacterial vaginosis 273

12.4 Candidiasis 274

12.5 Herpes genitalis infection 275

12.6 Human papillomavirus infection 279

12.7 Cervical deciduosis in pregnancy 280

12.8 Polypoid lesions of the cervix 282

12.9 Further reading 285

Index 287