Masaryk University Schol of Medicine
and Brno University Hospital
Department of Obstetrics and Gynecology
Head: Prof. Pavel Ventruba, DrSc.,MBA
General Medicine Obstetrics and Gynecology
Seminary 2017 – 2018 – Autumn Semester
Cervical dysplasia

•founded 150 types of HPV
•about 40 specific types of HPV - affinity the genitals (cervix, vulva, vagina, perianal area,
penis)
•500 000 new cases of invasive cervical cancer / year in the world (association with HR HPV
positivity)

Biology
ØDNA viruses (papovaviridae)
Øepiteliotrophia, proliferrative effect
Øaccording to the specificity of tissue
Ø   - skin
- mucosal
Øaccording to the oncogenic potential
Ø   - LR (low risk) - 6,11 (42,43,44)
Ø   - HR (high risk) - 16,18
                            (31,33,35,39,45,51)

Geographic distribution (cervical cancer)
ØEurope, N. America, N. Africa - type 16
ØAsia - type 18
ØSub-saharan Africa - type 45
ØM. and S. Amerika - type 31
ØCzech republic -  type 16(60-65%)
Ø         - type 18(15-20%)
Ø         - the others
Ø         - glandular precancerosis - type 18

The mechanism of action of oncogenic
• inactivation of tumor suppressor genes
• HPV genome encodes viral proteins E1- E7
   E6 - nuclear protein p53
   E7 - retinoblastom protein RB
• viral DNA - benign lesions, precancerosis
- episomal (extrachromosomal)
- malignancies - integration to the genome

Risk factors
• risky sexual behaviour, early start of sexual
  life (infection of unmature metaplastic
  epithelium „high malignant potential“)
• immunosuppression
• smoking, STD, multiple parity
• hormonal contraception (long term use) -
  persistence HPV, extensive TZ
  (transformation zone)

Transmission of infection
Ø: microtrauma, direct contact in places
Ø  transition epiteliums - cervix (nasopharynx,
Ø  epiglottis, anus..)
Ø
Øsexual intercourse (mostly)
Øindirect contamination
Øvertically (mother – fetus)
Ø(transplacental transmission)
Ø
Ø
Ø

The fate of infection – regresion, persistence, progression
: 70-80% of women - contact with HPV
  infection
: spontaneous clearance of the virus
  (excluding from the body in women with
  latent infection is to a certain age)
: 18-25 aged - 25% of women - HR HPV
  positive
: 35 aged - 3-5% of women with
  persistense HR HPV positivity -
  high risk of precancerosis and cancer

HPV in gynecology
Ø
Ø   Forms of infection :
Ø
ØCLINICAL (MANIFEST)
ØSUBCLINICAL
ØLATENT
Ø
Ø
Ø
Ø

A/ Clinical (manifest) form
- genital warts - HPV 6,11 - vulva (vagina,
  cervix, perianal area)
Morphology - condylomata accuminata
                    - smooth papular warts
                    - flat warts

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Diagnosis - macroscopic finding
                  - kolposcopy
                  - histology
NEED histological finding !!!
Therapy - elimination of virus very difficult, persistence of HPV pozitivity up to 45%

Conservative therapy
ØImiguimod (Aldara) - unguent
ØPhodophyllotoxin (Wartec) - unguent
ØPodophyllin - local solution
ØTrichloroacetic acid - local solution
ØInterferon alfa - injection
ØPhotodynamic therapy - sensitization
Ø   5-aminolevul acid and effect certain wave-
Ø   lengths of the visible spectrum

Surgical treatment
Øablation (spoon, curette)
Øexcision
Øelectrocoagulation
Ølaser

B/ Subclinical form
 in the cervix - separately or associated
 with CIN or cancer (up to 98%)
Dignosis:
1. COLPOSCOPY - a prominent JOD
negative lesions - papilary, fingerely,
flat (called brain-like area)

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2. PAP test – KOILOCYT
According to the BETHESDA system - SIL
: LG SIL/HPV – genital warts, CIN I
: HG SIL - CIN II, III
LBC (Liquid Based Cytology) - possibility
currently HR HPV testing
3.HISTOLOGY - acanthosis, hyperkeratosis,
parakeratosis, presence of koilocyts

C/ Latent form
- without clinical manifestations
- HPV DNA detection
: amplification methods (PCR) - research
: hybridization methods - qualitative
  determination of virus DNA, resoluton LR
  and HR (a smear of the cervix using the
  sampling kit)

Therapy
Øviral lesions separate or combined with
Ø   CIN I - 40-80% of spontanneous
Ø   regression
Ø   - observation
Ø   - destructive methods - electrocoagulation
Ø                                      - laser technology
Ø                                      - cryotherapy
Ø   INDICATION: exocervical lesions
Ø   HISTOLOGY FINDINGS ALWAYS
Ø   REQUIRED  !!!

Histological findings CIN II,III - excision
methods
- radio(electro)surgery
  : LETZ, LLETZ (disection of exocervix)
  : NETZ (dissection of endocervix)
  : SWETZ

LETZ



LETZ2



konizacejehlou



cyldisendocerv



Others excisional techniques
- „cold knife“ cone
- laser technology
- combination of excision and destructive
  techniques

Ø      Thank you for your attention !