Obgyn · Year 3 · from Obgyn
Case 1: Cervical Intraepithelial Neoplasia Progressing to Early Invasive Cervical Cancer
Patient Demographics
- Age: 38 years
- Sex: Female
- Occupation: Office manager
Chief Complaint
"My Pap smear was abnormal and my doctor said I need more tests."
History of Present Illness
The patient presents for colposcopy after her routine cervical cancer screening showed abnormal results. She has had normal Pap smears in the past and is surprised by the abnormal result. She denies any vaginal bleeding, discharge, or pelvic pain. She has been sexually active since age 17 and reports multiple lifetime partners (estimated 8-10). She was not vaccinated against HPV as it was not available during her adolescence.
Gynecologic History
- Menarche: Age 12
- Menstrual cycles: Regular, 28 days
- LMP: 2 weeks ago
- Prior Pap smears: Normal at ages 25, 28, 31, 34 (q3 years with HPV co-testing)
- HPV co-test at age 34: Negative
- Contraception: Tubal ligation after third child
- Prior pregnancies: G3P3
- STI history: Chlamydia at age 21 (treated)
Past Medical History
- Hypothyroidism (on levothyroxine)
- Former smoker: 1 pack per day x 10 years, quit 3 years ago
Current Screening Results
- Pap smear cytology: High-grade squamous intraepithelial lesion (HSIL)
- HPV testing: Positive for high-risk HPV type 16
Risk Factors for Cervical Dysplasia/Cancer
- HPV 16 positive: Present (highest risk type)
- Multiple sexual partners: Present
- Early sexual debut (age 17): Present
- Smoking history: Present (quit 3 years ago)
- Prior STI (chlamydia): Present
- No HPV vaccination: Present
- Immunocompromise: Absent
Colposcopy Procedure
Visualization:
- Transformation zone fully visible (adequate colposcopy)
- Squamocolumnar junction visible
After Acetic Acid Application:
- Large area of dense acetowhite epithelium from 10 o'clock to 3 o'clock
- Sharp, raised borders
- Coarse punctation pattern
- Coarse mosaicism at 12 o'clock
- Atypical vessels noted at 1 o'clock - concerning for possible invasion
Schiller's Iodine Test:
- Non-staining area corresponding to acetowhite lesion (iodine-negative)
Impression: High-grade lesion with features concerning for possible early invasion
Biopsies Obtained
- Directed cervical biopsies x 4 (from most abnormal areas, including atypical vessels)
- Endocervical curettage (ECC)
Pathology Results
Cervical Biopsies:
- 10 o'clock: CIN 3
- 12 o'clock: CIN 3
- 1 o'clock: Microinvasive squamous cell carcinoma (invasion 2 mm depth, 4 mm width)
- 2 o'clock: CIN 3
ECC: CIN 2
Diagnosis
Microinvasive Cervical Cancer (FIGO Stage IA1)
- Squamous cell carcinoma
- Depth of invasion: 2 mm (Stage IA1 = less than 3 mm depth)
- Width: 4 mm (less than 7 mm)
- HPV 16 associated
Staging Workup
FIGO Staging (Clinical):
- Stage IA1: Stromal invasion ≤3 mm depth and ≤7 mm width
- No lymphovascular space invasion reported on biopsy
Additional Evaluation:
- Pelvic examination: No gross lesion, cervix appears normal grossly
- No parametrial involvement
- Chest X-ray: Normal
Multidisciplinary Discussion
Key Questions:
- Is there lymphovascular space invasion (LVSI)?
- Does the patient desire fertility preservation?
Patient Discussion:
- Patient has completed childbearing (3 children, tubal ligation)
- Does not desire fertility preservation
- Prefers definitive treatment
Treatment Options for Stage IA1
If No LVSI:
- Simple hysterectomy (standard treatment for non-fertility desiring patients)
- Or conization with negative margins if fertility desired
If LVSI Present:
- Modified radical hysterectomy with pelvic lymph node assessment
- Or radical trachelectomy with lymphadenectomy if fertility desired
Treatment Plan
Procedure: Cold Knife Conization (Diagnostic Excision)
Rationale:
- Need to assess margins and LVSI status
- Biopsy cannot evaluate complete lesion
- Will guide definitive treatment
Conization Pathology:
- CIN 3 and microinvasive squamous cell carcinoma
- Depth of invasion: 2.5 mm
- Width: 5 mm
- No lymphovascular space invasion
- Endocervical margin: Positive for CIN 3 (not invasive cancer)
- Ectocervical margin: Negative
Definitive Treatment
Given:
- Stage IA1 without LVSI
- Positive endocervical margin for CIN 3
- No fertility desires
Recommendation: Simple Total Hysterectomy
Surgical Procedure:
- Total laparoscopic hysterectomy
- Ovaries preserved (age 38)
- No lymphadenectomy required (Stage IA1 without LVSI has <1% nodal metastasis risk)
Final Pathology:
- Residual CIN 3 in cervix
- No residual invasive carcinoma
- All margins negative
Prognosis
- Stage IA1 without LVSI: >99% cure rate
- Excellent prognosis
- No adjuvant therapy required
Surveillance
- Vaginal cytology (Pap) annually x 5 years
- History and physical examination every 6 months x 2 years, then annually
- Patient education on symptoms of recurrence
Patient Counseling
- Discussed HPV transmission and vaccination for her children
- HPV vaccination recommended for her 12-year-old daughter and 14-year-old son
- Partner does not require treatment (HPV likely already shared)
Teaching Points
- HPV 16 is responsible for approximately 50% of cervical cancers
- Atypical vessels on colposcopy are the most concerning finding for invasion
- Microinvasive cervical cancer (Stage IA1 without LVSI) can be treated with simple hysterectomy
- LVSI status determines need for lymph node assessment
- Conization provides definitive diagnosis and may be adequate treatment if fertility desired
- Post-treatment surveillance with vaginal cytology is essential
Clinical Image
Image Description: Colposcopic image of the cervix after acetic acid application demonstrating a large high-grade lesion with dense acetowhite epithelium, sharp borders, coarse punctation, and atypical vessels. The presence of atypical vessels (irregular, branching vessels that do not conform to normal patterns) raises concern for invasive disease.
Attribution: Educational illustration. Adapted from colposcopy teaching resources.