A 55- years old lady presenting to out patient depament with postmenopausal bleeding for 3 months has a 1 x 1 cm nodule on the anterior lip of cervix. The most appropriate investigation to be done subsequently is :
Ans. is b i.e. Punch Biopsy A 55 year old lady presenting to OPD with Post menopausal bleeding with a 1 x 1 cm nodule on the anterior lip of cervix- obviously we suspect carcinoma cervix in this case. Investigation Protocol for Diagnosis of Carcinoma Cervix / CIN : Post coital bleeding / Irregular bleeding/Abnormal cervical cytology smear Do perspeculum examination If lesion is visible No visible lesion & cervical cytology shows Biopsy ASUS* C/N I-C/N Ill Frankly malignant If Negative, go for colpo- Repeat Pap Smear Colposcopy & Colposcopy & scopy & directed biopsies every 6 months X 1 directed biopsies Directed biopsies year, if normal; if abnormal do colposcopy. * ASUS - Atypical squamous cells of unknown significance. Here in the case since leison is visible we can go for direct biopsy i.e., Punch biopsy. Also know : Details of Diagnostic modalities in Cervical intraepithelial neoplasia and Carcinoma cervix : A. Pap smear : It is a screening procedure. The primary goal of cervical cytologic screening is to identify women in whom fuher evaluation by coloposcopy is required to detect the presence of true cancer precursor. A speculum is introduced in vagina without lubricant and material from cervix is collected using Ayre's spatula. Whole of squamo-columnar junction has to be scrapped i.e. rotate the spatula through 360deg (Ist slide) and another slide is made from posterior fornix which acts as control. For more details, about Pap smear, see Chapter no. 2 B. Schiller Test : Principle : * Normal mature squamous epithelium of cervix contains Glycogen, which combines with Lugol's iodine to produce a deep mahogany colour. Abnormal squamous / dysplastic epithelium does not stain and constitutes a positive schiller test. C. Colposcopy associated with biopsy remains the gold standard for diagnosis of cervical precancer. Ideally all patients undergoing treatment for abnormal cervical smears should be colposcoped. The aim of colposcopy is to identify the extent of the lesion and eradicate it by destruction or excision. The whole of the transformation zone needs to be visualize, as this area is believed to be the site of neoplastic change. Indications : Abnormal Pap smear cytology To locate abnormal areasdeg To obtain directed biopsiesdeg Conservative therapy under colposcopy guidancedeg For follow up of cases treated conservativelydeg In case of a lesion grossly suggestive of invasive carcinoma, cone biopsy is not indicated as it predisposes the patient to serious pelvic infection and bleeding. The diagnosis of such lesion can be confirmed by colposcopic directed simple biopsy. Colposocopy is safe in pregnancy. D. Endocervical Curettage : Transformation zone also extends into the endocervical canal. By colposcopy upper 2/3 of endocervix is not visualised. Therefore evaluation of the non visualised pa of the endocervical canal should be done by Endocervical curettage. Endocervical curettage should be performed in every case. - In which colposcopy is unsatisfactory. - where the lesion is extending into the endocervical canal. - Where the colposcopic impression does not explain the cervical cytology findings. E. Cone E'iopsy is both a diagnostic and a therapeutic procedure. Indications (Diagnostic) : When limits of the lesion cannot be visualised with colposcopy.deg The squamo-columnar junction is not seen at colposcopy.deg In Endocervical curettage-histological findings are positive for CIN II or CIN III.deg There is a lack of correlation between cytology biopsy and colposcopy results.deg Microinvasive carcinoma or Adenocarcinoma in situ on colposcopy or cytology results.deg Therapeutic - In case of CIN III
Pap smear
Punch biopsy
Endocervical curettage
Colposcopy