Paul A. Younge

PUNCH BIOPSY OF THE CERVIX.

Abstract 1. 1. Three hundred and four consecutive patients with carcinoma in situ, carcinoma in situ with early stromal invasion and early invasive cancer of the cervix were studied for the purpose of evaluating the accuracy of cervical biopsy using a sharp punch and endocervical curette. 2. 2. The accuracy of punch biopsy in the detection of 159 cases of carcinoma in situ and carcinoma in situ with early stromal invasion was 96.9 per cent. 3. 3. The diagnostic accuracy of punch biopsy and endocervical curettage in 144 cases of carcinoma in situ alone and with early stromal invasion was 90 per cent. 4. 4. The necessity for diagnostic conization in patients with abnormal cervical cytology or preinvasive lesions has been exaggerated as has the fear of missing invasive cancer by the use of punch biopsy techniques. In only one patient in this series was invasive carcinoma not diagnosed preoperatively, a figure comparing quite favorably with reported series of conizations.

Management of benign cervical disease in the cervix of the nonpregnant patient.

There are three important aspects to consider in the management of benign cervical disease in the cervix of the nonpregnant patient. First, it is necessary to establish criteria and agree upon what is a normal cervix. This might seem absurd, but many physicians regard a clean erosion of the cervix as a normal condition, which it definitely is not. Also, many physicians consider it normal when the two lips of a lacerated cervix approximate one another or fall together upon withdrawal of the speculum; but this situation too is abnormal. Second, before treating any pelvic disease there must be an accurate evaluation of the cervix by cytologic and pathologic investigation in order to rule out premalignant and early malignant lesions. Such lesions do not produce symptoms nor are they evident clinically. Third, the correction of benign cervical disease eliminates or markedly reduces the incidence of cervical cancer.’ Apparently there is no universal agreement as to the definition of a normal cervix. Kaufmann and Ober2 in 1959 reported the condition of nearly 900 cervices of all ages obtained a t autopsy or from hysterectomy. They carefully measured the extent of columnar epithelium distal to the cervical canal. This study does not establish what is normal for each age group nor does it nqcessarily mean that the squamocolumnar junction migrates up and down or in and out. Their studies merely depict the average condition of the cervix in untreated women a t various ages. Elsewhere in this monograph Lang reports the condition of the cervical portio from the menarche on. Very few individuals have had the opportunity to observe and document one individual cervix from 14 to 50 or more years of age. I have been photographing cervices for well over 25 years and the longest documented case I have is only over a 13-year period (see FIGURES 1 to 5 ) . I t could be surmised that Lang’s cases are similar to those of Kaufmann and Ober, that is, they cover the average condition in the untreated cervix from the menarche to the menopause. A lacerated, everted, or so-called eroded cervix need not be normal, clean, and healthy just because some consider it so. A congenital erosion of the cervix in a nulliparous woman need not be normal because that is the way the cervix is in over 50 per cent of all untreated female patients. The so-called erosion, whether congenital or acquired, is abnormal. I t invariably shows histologic evidence of chronic inflammation and very frequently it harbors benign epithelial activity, such as epidermidalization, squamous metaplasia, and various healing processes. Most important of all, 90 per cent or more of the atypicalities less than carcinoma in situ and carcinoma in situ itself are found in such abnormal cervices. In general it is agreed that most atypical epithelia (dysplasia, anaplasia, etc.) and/or carcinoma in situ arise, begin, or are found a t or near the squamocolumnar junction. From this usual point of origin, the atypical or early malignant process spreads in all directions, along, distal to, and proximal to the squamo-