Second Opinion on Precancerous diseases in gynecological oncology

Normal cells do not turn malignant all of a sudden. Usually they undergo a stepwise transformation. The identification and management of the so-called precancerous lesions is one of the major issues in preventing gynecologic cancers. The borderline between insignificant changes and a disease-threatening alteration is sometimes very subtle, so external expert advice is needed to identify a problem and find the correct strategy.

Women’s cancer precursors: what are they?

In medicine, a precancerous condition is a tissue change that is associated with a statistically increased risk of malignant degeneration. A precancerous condition can be congenital (for example, familial adenomatous polyposis) or acquired. According to the probability of cancer development, they can be divided into facultative (less than 30% risk of turning malignant in over 5 years) and obligate (over 30% in less than 5 years) precancers.

Gynecological premalignant lesions can develop from stratified squamous epithelium (vulva and vagina) and single-row cylindrical epithelium of the endometrium.

Their most common types are:

• dysplasia of the cervix;
• endometrial hyperplasia;
• vulvo-vaginal dysplasia.

How are female precancers diagnosed?

Premalignancies develop over a long period of time, during which the cells undergo increasingly abnormal changes. These transformations can be detected by preventive examinations.

For example, in Germany, every woman over the age of 20 is entitled to an annual gynecological cancer screening. Among other studies, it includes the so-called PAP test. In this exam, cells from the mucous membrane of the cervix and the uterine cervix are "swabbed" with a cotton swab or a small brush (hence the name "swab smear") and examined microscopically. The assessment of the cells (cytological examination) provides information on whether and to what extent the cells are abnormal. Depending on the degree of cell alteration, the findings are classified from PAP I to PAP V. Pap I means normal healthy cells, while a Pap V result proves the presence of a malignant tumor. The PAP test is painless, uncomplicated - and very effective: suspicious cell changes may help to detect around 80 percent of all precancerous lesions at an early stage.

Depending on how pronounced the cell change detected in the PAP test is, further examinations may follow. The PAP I or II results are normal and only require follow-up screening. All women with other PAP findings such as PAP III, IIID, IVa, IVb or V are encouraged to undergo an examination by a dysplasia expert. The aim is to rule out a precancerous condition.

While the PAP test provides information on whether single cells are altered, the biopsy takes a look at the tissue - i.e. a group of cells. The examination can determine how far the cell change has already spread in the epithelium of the cervix. To do this, pathologists examine the tissue taken from the suspicious area under a microscope, which is called a histological examination.

Its results are classified according to the CIN scale (CIN I to CIN III), CIN standing for “cervical intraepithelial neoplasia”. Very often the changes are also described as mild, moderatItse and severe dysplasia.

Management of gynecological incipient cancers

Depending on how advanced the tissue changes are, a distinction is made between different stages. It is important to note that dysplasia at its various CIN stages is a precancerous lesion, but it does not mean cancer, and the woman having it is not seriously ill. Premalignancies are confined to the surface of the cervix and have not yet grown into the deeper connective tissue and are therefore not dangerous at the moment of diagnosis. However, detection of precancerous lesions and their careful control and treatment are important, as it can prevent future development of cancer. Mild dysplasia (CIN I) and moderate dysplasia (CIN II) often heal on their own. CIN I findings regress spontaneously in 50 to 70 percent of cases. To avoid surgical overtreatment, quarterly cytological (PAP test) and colposcopic (vaginal endoscopy) monitoring of mild and moderate changes are recommended. If the change persists over a longer period of time or progresses to a CIN III, excision should be performed. If there is a CIN III finding meaning a severe dysplasia (also called "a carcinoma in situ"), an excision (called conization) should usually be performed without delay.

Do I need a second opinion on dysplasia?

Knowing or suspecting that you have a lesion that may lead to a life-threatening disease is always troublesome. So it seems quite reasonable to get additional proof that what you are doing about it is just right, or probably learn about a better strategy before it is too late. Thus, seeking advice from a gynecologist with a sub-specialty in dysplasia will help relieve your anxiety and provide for the best outcome.