1) Clinico-pathologic Considerations

Cervical cancer continues to be a major problem within the province. Although significant strides have been made in the reduction of both the incidence and mortality for clinical carcinoma of the cervix, a continued effort is necessary to maintain and improve these results. High risk groups identified in our province continue to be First Nation women, recent immigrants and those women who have never participated in screening programs. Regular Pap smear screening continues to be the most effective method to try and diagnose lesions which are in a pre-clinical and pre-invasive state where the opportunity for cure is uniformly high.

Investigation of Abnormal Pap Smears

Cervical Pap smears remain the most effective method of identifying the patient with possible preinvasive or preclinical cervical neoplasia. Pap smears taken in the presence of bleeding, spotting or discharge are often difficult to interpret and may be unreliable. It is recommended that women who have 3 consecutive negative smears and who have never had an abnormal Pap smear be screened every 2 years. Women who have a history of prior abnormal smears (CIN) should continue with annual smears. Refer to 4.3 above for Pap smear guidelines.

The optimum time for taking smears in the pre-menopausal women is in mid-cycle. However, for practical purposes this is not always possible, but if there is difficulty in obtaining good smears in these individuals then repeat smears should be scheduled for this interval. There is no single sampling device which is adequate for all cases, but in the vast majority of individuals the standard wooden Ayres spatula is satisfactory. Individuals who are post-menopausal or in whom the squamocolumnar junction may be placed within the endocervical canal because of previous surgery or other factors, may require sampling with an endocervical cytobrush or other devices to obtain specimens from this area. If a cytobrush is used immediate fixation with cytospray is required. Conversely, individuals who have a large area of columnar epithelium on the ectocervical surface need to have sampling from the peripheral margins of this transformation zone. If an endocervical specimen is taken as well as the standard scrape both specimens should be placed on the same slide using the opposite half of the glass slide.

Simple lack of endocervical cells in the Pap smear report does not necessarily mean that the smear in itself is inadequate. In older individuals where difficulties may be present in obtaining good quality smear, particularly in the post-menopausal women or women who have undergone radiation treatments to the pelvis, often a short course of topical or oral estrogen therapy will thicken the epithelium and produce a much better quality smear for evaluation.

It should be emphasized that an office punch biopsy should be taken of any clinically suspicious or so-called "target lesion" noted at the time of pelvic examination.

1. Patients presenting with positive, suspicious, markedly or moderately dyskaryotic smears in whom no target lesions are visible should have examination by this method.
2. Patients with an atypical smear of short duration and/or changes suggestive of a minimal atypia or dysplasia probably do not require routine colposcopic examination. Patients with persistent, mildly atypical Pap smears are also candidates for evaluation if the abnormality is present over an 18 month period.
3. Dyskaryotic or suspicious Pap smears in pregnancy: the objective with these patients is to rule out invasive cancer and avoid a cone biopsy in pregnancy.
4. Moderate dyskaryosis or worse on vaginal vault smears post-hysterectomy.

2) Classification Criteria

HISTOLOGICAL CLASSIFICATION OF INVASIVE CERVICAL CARCINOMAS

Squamous Cell Carcinomas

Adenocarcinomas

Mixed Adenosquamous Carcinomas

Small Cell Carcinomas

(synonyms: malignant carcinoid tumours, neuroendocrine carcinomas, arygyrophilic carcinomas, apudomas)

Rare Primary Cancers

Metastatic Carcinomas

*Most carcinomas referred to in the older literature as "small cell carcinomas" would, by current criteria, likely be placed in the category of small cell carcinoma.

Microscopic description for cervical tumours should include the following features: