Cancer

Diagnostic tests for women with abnormal cervical cytology (Pap) results

A Pap test is intended to screen for changes in cervical cells. In other words, it is a screening test, rather than a diagnostic test. If your Pap test shows an abnormal result, you will need to have additional tests such as a colposcopy and biopsy—and perhaps also an endocervical scraping—to find out whether a precancerous change or cervical cancer is present. One or more of these tests is nearly always recommended for women whose Pap test results show squamous intraepithelial lesions (SIL) or atypical glandular cells.

Because doctors are sometimes unclear about what to do when the result reveals atypical squamous cells, some may recommend colposcopy and biopsy while others may recommend a repeat Pap test after several months. When deciding about follow up, your doctor should take into consideration your past Pap results, your risk factors for cervical cancer, and whether you've had Pap tests done in the past.

Some doctors have now started an intermediate step of testing women for human papillomavirus, or HPV. If a high-risk HPV is found in women with atypical squamous cells—particularly in middle-aged or older women—doctors are more inclined to perform a colposcopy. Colposcopy is generally performed on women with squamous intraepithelial lesions (SIL). If a biopsy reveals SIL or dysplasia, your doctor will take necessary measures to prevent these conditions from progressing to actual cancer.

Colposcopy

A colposcopy is a painless procedure performed when certain symptoms suggest cervical cancer or when the results of a Pap test reveal abnormal cervical cells. Using a colposcope, an instrument with magnifying lenses, the doctor views the cervix and is able to examine its surface more closely. If any abnormal areas are seen, a small sample of tissue is removed (biopsy) and sent to a laboratory for analysis by a pathologist. A biopsy is the only way to tell for certain whether an abnormal area is precancer, a true cancer, or neither.

Cervical biopsies

There are several different types of cervical biopsies that may be performed to diagnose cervical cancers and precancers. In cases of precancers and early cancers, biopsies involving the complete removal of the abnormal tissue may be the only treatment necessary. In other situations, however, additional treatment of precancers is needed.

Colposcopic biopsy

While the patient is under a local anesthetic, a doctor uses a colposcope to find the abnormal area. Once it is found, he or she will then use biopsy forceps to remove a small (1/8 inch or 3 millimetre) section of the abnormal area from the surface of the cervix.

Endocervical curettage/endocervical scraping

Usually performed at the same time as a colposcopic biopsy, an endocervical scraping uses an instrument called a curette inserted into the endocervical canal to remove (scrape) the tissue lining the endocervical canal. This tissue sample is then sent to a laboratory for analysis.

Endocervical scraping is used by doctors to find out whether the endocervix is affected by precancer or cancer. This is because the colposcope only allows them to view the outer part of the cervix and not into the endocervix itself.

Cone biopsy/conization

This procedure involves the removal of a small, cone-shaped piece of tissue from the cervix. The base of the cone is formed by the ectocervix, while the apex (point) of the cone comes from the endocervical canal. The transformation zone—that area between the ectocervix and the endocervix—is contained within the cone. It is within the transformation zone that precancers and cancers are most likely to develop. Also a treatment, a cone biopsy can be used to completely remove many precancers and early cancers.

Cone biopsies may be performed using one of two methods: the loop electrosurgical excision procedure (LEEP) and the cold knife cone biopsy.

Loop electrosurgical excision procedure (LEEP)

A ten-minute procedure performed while the patient is under a local anesthetic, LEEP uses a wire heated with an electrical current to remove tissue from the cervix.

Cold knife cone biopsy

Performed as day surgery with the patient under a general anesthetic, a cold knife cone biopsy uses a surgical scalpel or a laser, rather than a wire, to remove tissue.

You may be wondering how biopsy results are reported. Biopsy reports use the terms cervical intraepithelial neoplasia (CIN) and dysplasia, to refer to precancerous changes. The terms squamous cell carcinoma and adenocarcinoma are used for reporting cancer.

If an area of squamous intraepithelial neoplasia is seen during a colposcopy, the abnormal area is removed using biopsy techniques such as LEEP or a cold knife cone biopsy. Abnormal cells may be destroyed through outpatient techniques such as cryosurgery or laser surgery, each of which can be performed in a doctor's office or clinic. Cryosurgery involves killing the abnormal cells by freezing them. This is accomplished through the use of a metal probe cooled with liquid nitrogen. In laser surgery, the doctor uses a focused beam of high-energy light to vaporize the abnormal tissue.

Almost always effective in destroying precancers and in keeping them from developing into actual cancers, these treatments require follow up to ensure cervical abnormalities do not recur. If they do, treatments can be repeated.

Cystoscopy, proctoscopy, and examination under anesthesia

If a biopsy shows cancer—and particularly if that cancer appears advanced—cystoscopy, proctoscopy, and examination under anesthesia will be performed.

Cystoscopy involves checking the bladder and urethra to ensure cancer hasn't invaded these structures. In cystoscopy, a slender tube equipped with a lens and a light is inserted into the bladder through the urethra. Small tissue samples are removed for examination under a microscope. Although cystoscopy is usually performed with the patient under local anesthetic, some patients may require a general anesthetic. Your doctor will let you know what to expect before the procedure.

Proctoscopy uses a lighted tube to visually inspect the rectum to determine whether cervical cancer has spread to this structure. While you are under anesthetic, your doctor may perform a pelvic exam to determine whether cancer has spread beyond the cervix.

If your doctor determines you have cervical cancer, he or she may recommend imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scans to show whether the cancer has spread beyond the cervix. A chest x-ray will be done to determine whether the cancer has spread to your lungs.

Also be sure to read…

Cervical cancer
How can I avoid or prevent cervical cancer?
Diagnostic tests for women with abnormal cervical cytology results
Treating cervical cancer
Pap test
Chlamydia
Human papilloma virus (HPV)