Pathology · Year 2 · from Pathology

Case 3: Cervical Dysplasia with Metaplasia and Cellular Adaptation

Patient Demographics

  • Age: 32 years old
  • Sex: Female
  • Occupation: Marketing manager

Chief Complaint

"Abnormal Pap smear result"

History of Present Illness

A 32-year-old female presents after receiving notification of an abnormal Pap smear showing "HSIL" (high-grade squamous intraepithelial lesion). She is a current smoker (10 pack-years) and has had multiple sexual partners. She received the HPV vaccine at age 26 (after becoming sexually active). Her last Pap smear 3 years ago was normal. She denies abnormal vaginal bleeding or discharge.

Physical Examination

  • Vital Signs: Within normal limits
  • Pelvic exam: Normal external genitalia
  • Speculum exam: Cervix with white area visible after acetic acid application (acetowhite lesion)
  • Bimanual exam: No cervical motion tenderness, normal uterine size

Diagnostic Workup

Colposcopy Findings:

  • Large acetowhite lesion extending into the endocervical canal
  • Coarse punctation pattern
  • Mosaic pattern present
  • Lesion covers approximately 40% of cervix

Cervical Biopsy:

  • High-grade squamous intraepithelial lesion (CIN 3/carcinoma in situ)
  • Dysplastic cells involving full thickness of epithelium
  • Intact basement membrane (no invasion)
  • Strong p16 immunohistochemistry positivity

HPV Testing:

  • Positive for HPV-16 (high-risk type)

Pathology Correlation

This case demonstrates multiple cellular adaptations:

  1. Squamous Metaplasia:
  • Normal columnar epithelium of transformation zone replaced by squamous epithelium
  • Adaptive response to vaginal acidic environment
  • Predisposes to HPV infection
  1. Dysplasia:
  • Disordered epithelial growth with loss of maturation
  • HPV E6 protein degrades p53 (tumor suppressor)
  • HPV E7 protein inactivates Rb (tumor suppressor)
  • p16 overexpression is a surrogate marker for HPV infection
  1. Progression to Neoplasia:
  • Represents cellular adaptation gone wrong
  • If untreated, may progress to invasive squamous cell carcinoma

Clinical Image

Histopathology of cervical intraepithelial neoplasia grade 3 (CIN 3). Note the full-thickness dysplasia with loss of normal epithelial maturation, nuclear pleomorphism, and increased mitotic figures. The basement membrane remains intact.

Image Source: Wikimedia Commons - "CIN pathology" License: Public Domain URL: https://commons.wikimedia.org/wiki/File:CIN_III.jpg

Diagnosis

Cervical Intraepithelial Neoplasia Grade 3 (CIN 3) / Carcinoma in situ

Treatment

  1. Loop electrosurgical excision procedure (LEEP) or cold knife conization
  2. Close follow-up with Pap smear and HPV testing at 6 months
  3. Smoking cessation counseling
  4. Education about HPV and cervical cancer prevention

Teaching Points

  1. Metaplasia is a reversible change where one cell type replaces another
  2. Squamous metaplasia in the cervix creates the transformation zone vulnerable to HPV
  3. Dysplasia represents disordered growth that may progress to cancer
  4. HPV oncoproteins (E6, E7) inactivate key tumor suppressors (p53, Rb)
  5. CIN 3/CIS represents pre-invasive neoplasia - a critical window for intervention
  6. These adaptations demonstrate the continuum from normal adaptation to neoplasia

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