8
Benign Proliferative Reactions, Intraepithelial Neoplasia, and Invasive cancer of the Uterine cervix
A
B
Fig. 8.70 Severe dysplasia of metaplastic type. (A) Extension of the
epithelial abnormality into the stromal invagination, with (B) replacement of
the lining columnar epithelium (H&E (A) x HIP and (B) x HP).
Fig. 8.71 Severe dysplasia. Cells of parabasal cell type with a small rim of
cytoplasm around a large, often irregularly shaped, hyperchromatic nucleus.
High nucleocytoplasmic ratio (Papanicolaou x OI).
and carcinomas in situ on the other hand was 4:1 at second
screening. It is often not understood that the ratio of precancer-
ous lesions to invasive cancer is probably on the order of 10:1,
possibly even higher.118
A suggestion of a fast transition time between normal epi-
thelium and severe dysplasia should be made only after the
more likely possibility of false-negative cytology because of
poor sampling has been precluded. In cases of severe epithelial
abnormalities, the number of unsatisfactory or less reliable
smears is much increased, owing to admixture of inflammatory
cells, cell debris, or blood.
The results of these studies strongly support a conservative
approach in the clinical treatment of patients diagnosed with
mild to moderately atypical epithelial abnormalities.
Rate o f Progression: Review o f the Literature
Richart and Barron monitored 557 patients with cervical dys-
plasia detected by cytologic and colposcopic examinations with-
out interference of punch biopsies or other treatment.89 They
estimated the time spent in each stage of dysplasia before its
progression to carcinoma in situ.
At the end of the follow-up period, transition probabilities
were calculated and transition times of mild, moderate, and
severe dysplasia to carcinoma in situ were computed. The tran-
sition times ranged from a median of 86 months for patients
with very mild dysplasia, 58 months for mild dysplasia, and
38 months for moderate dysplasia to 12 months for severe
dysplasia. The median transition time to carcinoma in situ for
all dysplasias was 44 months. In a 10-year period, moderate
dysplasia was calculated to progress to a more severe lesion in
about 90% of the cases. They reported the progression rates to
be relatively stable, and they concluded that almost all cases
of dysplasia would in time develop into carcinoma in situ if
left untreated. Although evolution from one smear class to
another might be an age-related phenomenon, no obvious
gradient in the ages was found. Similarly, there was no evi-
dence that progression from one class to another was solely
time dependent. During long-term follow-up, a substantial
proportion of cases remained in the stage in which they were
detected and did not progress to a higher stage disease dur-
ing a definite period. These data cannot be considered as
representative of true regression and persistence rates because
167
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