Cervix biopsy - Large Biopsy 3-6 cm

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Large cervical tissue biopsy.

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Cervix Biopsy - Large Biopsy 3-6 cm

Why is it done?
- Diagnostic Tool for Cervical Pathology: A large cervical biopsy measuring 3-6 cm is performed to obtain tissue specimens from the cervix for histopathological examination when abnormalities are detected on visual inspection or colposcopy.
- Detection of Cervical Cancer: Primary indication is to diagnose cervical cancer or precancerous lesions (CIN I, II, or III - cervical intraepithelial neoplasia) that require definitive tissue confirmation.
- Evaluation of Colposcopic Findings: Performed when colposcopic examination reveals suspicious lesions, areas of abnormal vascular patterns, or acetowhite epithelium requiring tissue diagnosis.
- Investigation of Abnormal Pap Test Results: When cytology (Pap test) shows ASCUS (atypical squamous cells of undetermined significance), LSIL (low-grade squamous intraepithelial lesion), HSIL (high-grade squamous intraepithelial lesion), or AGC (atypical glandular cells).
- Assessment of Visible Cervical Lesions: Used when there are grossly visible lesions, ulcerations, masses, or suspicious areas on the cervix that require tissue characterization.
- Evaluation of Other Cervical Conditions: Assessment of chronic inflammation, cervicitis, HPV-related changes, or other benign and malignant conditions affecting the cervix.
- Timing: Typically performed in a gynecologist's office or ambulatory surgery setting during a colposcopy procedure or after visual abnormalities have been identified.
Normal Range
- Normal Result: Benign cervical epithelium with no evidence of malignancy, significant dysplasia, or concerning pathology. Histology shows normal stratified squamous epithelium with appropriate maturation and organization.
- Negative for Malignancy: The tissue shows no cancer cells. This is the desired outcome and indicates no evidence of cervical carcinoma or invasive disease.
- Benign Findings Include:
  - Normal squamous epithelium
  - Chronic cervicitis or inflammation
  - Metaplasia or repair
  - Polyps
- Interpretation Scale for Dysplasia:
  - CIN I (Low-Grade Dysplasia): Abnormal cells limited to lower third of epithelium
  - CIN II (Moderate Dysplasia): Abnormal cells extend to middle third of epithelium
  - CIN III (Severe Dysplasia/Carcinoma In Situ): Abnormal cells extend to upper third or full thickness of epithelium without stromal invasion
  - Invasive Carcinoma: Malignant cells breach the basement membrane and invade underlying stroma
Interpretation
- Negative for Dysplasia/Normal: No premalignant or malignant changes identified. Patient may return to routine screening. However, if colposcopy was indicated, clinical follow-up may still be warranted based on cytologic results and HPV status.
- CIN I (Low-Grade Lesion): Early dysplastic changes present. May regress spontaneously (especially in younger women), persist, or progress to higher grade lesions. Management depends on patient age, HPV status, and patient preference. Options include observation with repeat cytology/colposcopy or excisional treatment.
- CIN II: Moderate dysplasia with significant risk of progression to cancer if untreated. Typically requires excisional treatment (LEEP/cone biopsy) to remove the lesion and obtain clear margins. Histologic findings at excision margins are critical for treatment adequacy assessment.
- CIN III: Severe dysplasia with high risk of malignant transformation. Requires excisional treatment with adequate margin evaluation. Close follow-up with repeat cytology and HPV testing is essential to detect recurrent disease.
- Invasive Carcinoma: Cancer is present. Additional staging investigations (imaging, tumor markers) are required. Oncology consultation and comprehensive treatment planning including surgery, radiation, chemotherapy, or combination therapy is indicated. Prognosis depends on tumor stage, histologic type, and grade.
- Factors Affecting Interpretation:
  - HPV Status: HPV-positive results generally carry higher risk for progression. HPV type (16/18 vs. other types) affects management decisions.
  - Patient Age: Younger women (under 25) with CIN I may be observed as lesions often regress. Women over 25 typically require treatment for CIN II or higher.
  - Immunosuppression: HIV-positive or immunocompromised patients have higher progression rates and require more aggressive management.
  - Specimen Quality: Adequate tissue sampling and specimen preservation are essential for accurate diagnosis. Specimens should be placed in formalin and properly labeled.
  - Margin Assessment: For excisional biopsies, margins must be evaluated. Positive or involved margins suggest incomplete lesion removal and higher recurrence risk.
  - Glandular Involvement: If dysplasia extends into cervical glands/endocervix, risk of residual disease is higher.
- Clinical Significance:
  - This biopsy is critical for confirming diagnosis and guiding treatment decisions that can prevent progression to invasive cancer.
  - Results directly influence follow-up surveillance intervals and treatment intensity.
  - Accurate grading is essential as treatment thresholds differ between CIN I and CIN II/III.
Associated Organs
- Primary Organ: Cervix (lower portion of uterus)
- Organ System: Female reproductive system/genital tract
- Related Structures:
  - Uterus (endometrium)
  - Vagina
  - Pelvic lymph nodes (in cases of invasive disease)
- Diseases and Conditions Diagnosed/Monitored:
  - Cervical intraepithelial neoplasia (CIN I, II, III)
  - Cervical cancer (squamous cell carcinoma, adenocarcinoma)
  - Human papillomavirus (HPV) infection and associated lesions
  - Cervicitis (acute or chronic inflammation)
  - Cervical polyps and other benign lesions
  - Metaplasia and repair processes
  - Atypical glandular cells of undetermined significance (AGUS)
  - Suspected adenocarcinoma in situ (AIS)
- Potential Complications and Risks of Abnormal Results:
  - Progression to Invasive Cancer: Untreated CIN III has approximately 30-50% risk of progression to invasive cancer within 10-30 years. Even CIN II carries significant progression risk if not managed.
  - Metastasis Risk: Invasive carcinoma can metastasize to pelvic lymph nodes, distant organs (lungs, liver, bone), and peritoneal cavity, significantly reducing survival rates.
  - Pregnancy Complications: Cervical cancer or aggressive lesions may complicate pregnancy and delivery, requiring specialized obstetric management.
  - Recurrent Disease: Even after treatment, recurrence rates vary. CIN I has lower recurrence (5-10%), while CIN III may have higher recurrence (10-30%) depending on treatment adequacy.
  - Reduced Quality of Life: Both cancer diagnosis and aggressive treatments can impact sexual function, fertility, and emotional well-being.
Follow-up Tests
- For Normal/Benign Results:
  - Return to routine cervical cancer screening (Pap test or HPV testing) according to standard guidelines
  - Standard screening interval: Every 3-5 years depending on local guidelines and HPV status
- For CIN I Results:
  - Repeat cytology (Pap test) at 12 months to assess for regression or persistence
  - HPV reflex testing or HPV testing at baseline to guide management (HPV-positive may warrant treatment; HPV-negative may allow observation)
  - Colposcopy at 12 months if cytology abnormalities persist or patient is HPV-positive
  - Consider excisional treatment (LEEP) if patient preference or high-risk HPV type (16/18)
  - In patients under 25 years: Close observation preferred unless other risk factors present
- For CIN II Results:
  - Excisional treatment (Loop Electrosurgical Excision Procedure - LEEP or cold knife conization) for diagnostic and therapeutic purposes
  - Careful histologic evaluation of excision margins and endocervical margin status
  - Cytology at 3-6 months post-treatment
  - HPV reflex testing if available
  - Surveillance colposcopy at 6-12 months if margins involved or inadequate
  - Extended follow-up: Cytology and HPV testing for 25 years post-treatment per current guidelines
- For CIN III Results:
  - Urgent excisional treatment (LEEP or conization) is mandatory
  - Detailed margin analysis essential to rule out invasive disease
  - Repeat cytology at 3 months post-treatment
  - Immediate colposcopy if any cytologic abnormality detected post-treatment
  - Long-term surveillance: Annual cytology and HPV testing for at least 25 years
  - If margins positive or adenocarcinoma in situ (AIS) present, consideration for re-conization
- For Invasive Carcinoma Results:
  - Urgent Oncology consultation and referral
  - Staging imaging: Pelvic MRI or CT, chest imaging (X-ray or CT), and possibly PET-CT to determine tumor extent and metastatic disease
  - Tumor markers: Consider SCC (squamous cell carcinoma) antigen for monitoring
  - Pelvic lymph node assessment (sentinel node biopsy or lymphadenectomy may be considered)
  - Treatment planning: Surgery (hysterectomy, trachelectomy, pelvic exenteration depending on stage) and/or radiation therapy and/or chemotherapy
  - Regular surveillance after treatment with imaging and tumor marker monitoring
- Related Complementary Tests:
  - HPV DNA testing: Identifies high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68) associated with increased cancer risk
  - HPV mRNA testing: May provide prognostic information regarding lesion activity and progression risk
  - Cytology (Pap test): Follow-up screening tool for detecting recurrent or residual abnormalities
  - Liquid-based cytology: Improves specimen quality and reduces unsatisfactory rates compared to conventional Pap smears
  - Colposcopy: Visual examination under magnification to identify abnormal areas and guide directed biopsies
  - Immunohistochemistry: May include p16, Ki-67, or other markers to support CIN grade or rule out mimics of dysplasia
  - Endocervical curettage: May be performed during colposcopy if endocervical involvement is suspected
  - Pelvic imaging (MRI, CT, ultrasound): For staging invasive cancers and assessing treatment response
Fasting Required?
- Fasting Requirement: No
- Fasting is not required for cervical biopsy as it is a local tissue sampling procedure and does not involve systemic absorption of nutrients or medications.
- Patient Preparation Requirements:
  - Timing: Schedule biopsy during non-menstrual cycle days (preferably 7-21 days from start of menses) for better visualization and accurate assessment
  - Avoid intercourse, douching, tampons, and vaginal medications for 24 hours before the procedure
  - Empty bladder before the procedure for improved comfort
  - Light meal: Patient may eat and drink normally before the procedure
  - Medications: Continue all regular medications unless specifically instructed otherwise
  - Anticoagulants/Antiplatelet Agents: Discuss with physician regarding aspirin, warfarin, or other blood thinners, though biopsy can typically be performed while on these medications
  - Pain Management: Physician may offer pain medication (oral or intravenous sedation) depending on individual circumstances and patient preference. NSAID can be taken prior if not contraindicated
  - Informed Consent: Review procedure, benefits, risks, and alternatives prior to biopsy
  - Pregnancy Test: May be offered if pregnancy status uncertain, as biopsy during pregnancy requires special considerations
  - Post-procedure Care Instructions: Expect mild discomfort, spotting, or light vaginal bleeding for 1-2 weeks. Activity restrictions may apply. Avoid intercourse and tampons for 1-2 weeks post-biopsy
- Potential Procedure Risks (for information purposes):
  - Mild to moderate discomfort or cramping during procedure
  - Vaginal bleeding or spotting (usually resolves within 1-2 weeks)
  - Infection (rare, but may require antibiotics)
  - Significant hemorrhage (very rare)
  - Cervical stenosis (rare, more common with repeated aggressive biopsies)

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