4 prof walter managmet of cin
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Transcript of 4 prof walter managmet of cin
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FOGSI / FIGO
2013
Hydrabad
THE MANAGEMENT OF CIN
wprendiville
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The management of CIN
• Should read The management of women with CIN
• Should never be dictated by an
individual test result, even histology
• Should incorporate all the case
characteristics
• Is a balance of benefit vs harm
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How to safely treat CIN3
• Safely means
– Reducing the risk of cervical cancer to
almost zero
– Reducing the side effects of treatment to
as low as possible
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The management of CIN3
• Will always include
– Pre-treatment counselling
• Need for Rx, risks of Rx, need for follow up
monitoring by cytology/HPV/Colposcopy
– Assessment of all the case characteristics
• Age, parity, future fertility, likelihood of default,
cytology, histology, HPV status and other
biomarkers where known.
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Safe treatment of CIN3
• Will always mean
– A preliminary colposcopic examination
• By a trained colposcopist
• Documenting specific findings
– If excisional, Rx will be colposcopically
guided
– Eradication of the entire TZ
– Sufficient tissue for histology to rule out
invasive or associated GIN
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Safe treatment of CIN3
• Will sometimes mean
– That excision is necessary
– Removal of a relatively large amount of
cervical tissue
– An associated increased risk of pre-term
labour
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Safe treatment of CIN3
• May sometimes
– Be performed at the first / assessment visit
– Be performed using a destructive method
– Be performed under general anaesthesia
– Be deferred
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Choice of treatment for CIN
EXCISIONAL DESTRUCTIVE
Hysterectomy Radical diathermy
Cone biopsy (Variety of techniques ) Cryocautery
LLETZ type 1
LLETZ type 2
LLETZ type 3
Cold (or thermal) coagulat ion
Laser excision Laser ablation
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Destructive methods of
treatmentAdvantages
Simple, cheap,
Equipment widely
available
Very effective in expert
hands,
No expense of
histology of TZ
Disadvantages
No histological
examination of TZ.
Concern about the
margins, the true
diagnosis and the
depth of excision
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Preconditions for ablative
therapy for CIN
The TZ must be fully visible
There must be no cytological or colposcopic
suspicion of invasive disease
There must be no cytological or colposcopic
suspicion of glandular disease
There should be no disparity between
cytological and histological diagnosis
The patient must not have had previous
therapy for CIN
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Indications for treatment
As ever, a balance of risks
1. Risk of not treating the conditionProgression to cancer
ie ; 50% for CIN 3, perhaps 1% for CIN 1
2. Risk of treating the conditionShort term morbidity, uncommon
Long term complications in particular pregnancy related, if large type 2 or 3 TZ
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Threshold for treatment
• High grade disease
– Virtually all CIN 3
– Most CIN 2
• High risk patient with persistent low grade
disease
– Smoker
– Older
– High default risk
– Anxious
– HPV and other biomarker test results
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EXCISION OF THE TZ
• Hysterectomy is rarely appropriate
– Genuine risk of inadequately treating
invasive disease
– Unnecessary risk of general anaesthesia
and major surgery and no benefit to patient
– May miss VAIN
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EXCISION OF THE TZ
• Laser excision is entirely reasonable
– Expensive
– Useful for vaginal disease
– Similar success and complications profile to LLETZ, with perhaps an increased risk of subsequent perinatal mortality
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EXCISION OF THE TZ
• LLETZ
– Usually an outpatient procedure
– Relatively inexpensive
– Simple to perform
– Accommodates all cases of CIN and Microinvasive disease and glandular disease
– Needs modification according to presentation
If performed inexpertly may be associated with excess morbidity
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Optimising the treatment
experience
• Informed, comfortable, relaxed
• TZ has adequately analgesia
• Privacy, support, confidence
• Appropriately sized suction-
speculum
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Excision of the TZ
LLETZ
• Under binocular colposcopic vision
• Thoroughly anaesthetised TZ
• After full colposcopic exam
• Low magnification
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Full colposcopic exam
• Size and Type of TZ
• SWEDE score
• Diagnostic impression of worst lesion
• Documented using ifcpc nomenclature
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LLETZLLETZ using a Tan Loop
2 x 2.5cms
Applicable to wider type 1 TZs
Dental syringe system used for all LLETZ
procedures
Octapressin and citanest with a 2.2m. Vial and a 27 gauge needle
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Excision: Principles of
treatment
• Treat the entire TZ
• Excise only the TZ
• Miminise the artefactual damage
– Fulguration not dessication
– Paint the wound with electrosurgery
– Always have monsel’s paste available
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Excision: Principles of
treatment
• Always, always treat under binocular
colposcopic vision
• Always ensure full vision of :
– the entire TZ
– the entire loop
– and the adjacent vaginal wall
• Pass the loop slowly from left to right
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Principles of treatment
• Choose the appropriate loop for the
specific TZ
• Modify the technique according to the
TZ type
• Ensure excision of the scj
• Beware the type 3 TZ
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Type I
• Completely
ectocervical
• Fully visible
• small or large
Transformation Zone
Classification
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Type II
• has endocervical
component
• Fully visible
• may have
ectocervial
component which
may be small or
large
Transformation Zone
Classification
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Transformation Zone
Classification
Type III
• has endocervical
component
• is not fully visible
• may have ectocervical
component which may
be small or large
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Excision Types
new IFCPC proposal• Type 1 Excision
– Resection of a type 1 TZ
• Type 2 Excision
– Resection of a type 2 TZ
• Type 3 Excision
– Resection of a type 3 TZ
– Glandular disease
– Suspected microinvasion
– Repeat treatment
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Cases which require a type 3
excision
• CIN with a type 3 transformation zone
• Suspected microinvasive disease
• Suspected glandular disease
• Residual disease, ie previous treatment
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Long loop or straight wire for
electro-surgicaltype 3 transformation
zone
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Type 3 TZ
Type 3 excision =
approximately to a
Cone biopsy
LLETZ using a
single large (blue)
loop
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Excision of a type 3 TZ
• Using a long loop
• Loop dimensions
dictated by
– TZ size
– cervical size
– patient future
– pregnancy
expections
– anticipated grade of
disease
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Type 3 TZ
Type 3 Excision
approximates to a
Type 3 TZ
Using a straight wire
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Type 3 TZ
Type 3 Excision
approximates to a
Cone biopsy
Using a straight wire
ie SWETZ
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Type 3 Excision
• Parous woman, family complete,
• V large type 3 TZ, suspicion of CIN3
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Success of treatment
Martin-Hirsch PL, Paraskevaidis E, Kitchener H.,
Surgery for cervical intraepithelial neoplasia.
Cochrane Database Syst Rev. 2000;(2):CD001318.
• Published cure rates are very high no
matter which technique is examined
• Success is measured in surrogate ways
• Cure ultimately means the woman will
not develop cancer
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Laser Ablation Com pared With Loop Excision
Residual Disease: All Grades of CIN
Graph of Relative Risks
Alvarez (375)Dey (285)
Gunasekera (199)Mitchel (251)
Meta-analysis
.
0 0.1 1 10 100
favours favours
Loop Excision Laser Ablation
NO SIGNIFICANT DIFFERENCE FOR ALL METHODS
FOR ALL GRADES OF DISEASE
CRYOTHERAPY SHOULD NOT BE USED FOR HIGH GRADE DISEASE
Meta-analysis
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Success of treatment
• Surprisingly few large RCTs
– No difference between techniques in terms
of success
– except cryocautery
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Excision
• Margin Status
• Volume excised
• TZ type
• These three aspects of excision will
inform both doctor and patient in terms
of prediction of success and morbidity
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Margin Status
• Marker for risk of residual disease
– Cytological suspicion 5 - 51%
– Histologically proven 3 - 7%
• Negative margins don’t preclude risk of
residual disease
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Margin status at excision
• Ghaem-Maghami et al
• Meta-analysis 35,109 subjects
• Recurrence rate, high grade
– Complete excision 3%
– Incomplete excision 18%
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The relation of type of excision and clear
histopathological margins after LLETZ
Dimitriou E., Martin M., Farrar K & Prendiville W.
• 1071 women who
underwent LLETZ
between January 2004
and October 2008
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The relation of type of excision and clear
histopathological margins after LLETZ
Dimitriou E., Martin M., Farrar K & Prendiville W.
Small type 1 vs large type 2 RR=1.92 95%CI 1.19-3.08
Small type 1 vs large type 3 RR=3.41 95%CI 1.83-6.37
0%
20%
40%
60%
80%
100%
Small
TZ1
Large
TZ2
Large
TZ3
complet
epos
ectopos
endo
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The relation of type of excision and clear
histopathological margins after LLETZ
Dimitriou E., Martin M., Farrar K
& Prendiville W 2009.
• Large type 2 or 3 TZ excisions are
associated with an increased risk of
incomplete excision margin status
• Perform larger TZ excisions in these
circumstances and counsel
appropriately
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Complications after LLETZ
• Short term morbidity low
• Recent reviews have examined long
term complications, specifically
pregnancy related morbidity
– Kyrgiou et al,Lancet 2006
– Arbyn et al BMJ, 2008
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Risk of perinatal death by
technique of excision
• Estimate of one perinatal death for
every 70 pregnancies in women treated
by CKC, laser cone or RD compared to
one in 500 for women treated by LLETZ
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Severe pregnancy related
outcomes Arbyn et al 2008
• The current meta-analysis demonstrates that
CKC and probably also LC and radical
diathermy place women at increased risk of
PM and other serious pregnancy outcomes.
LLETZ and Laser ablation do not.
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Morphological damage after excision
• Biologically plausible
• Perhaps related to extent or amount of excision
• Applies largely to cases where ablation would be inappropriate
– Large type 2 or 3 TZ,
– Previously treated patients,
– Glandular or suspected Microinvasion
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48
Preterm delivery (<37W): Excision vs no treatment ~heigth
Height < 10mm
Risk ratio
.1 .2 .5 1 2 5 10
Risk ratio (95% CI)
Raio, 1997 0.52 ( 0.06, 4.83)
Sadler, 2004 0.99 ( 0.57, 1.72)
Samson, 2005 3.02 ( 1.65, 5.53)
Nohr, 2007 0.83 ( 0.21, 3.25)
Overall 1.32 ( 0.59, 2.95)
Risk ratio
.1 .2 .5 1 2 5 10
Raio, 1997 4.64 ( 1.20, 17.88)
Sadler, 2004 1.64 ( 1.13, 2.37)
Samson, 2004 3.84 ( 1.66, 8.88)
Nohr, 2007 2.46 ( 1.45, 4.16)
Overall 2.39 ( 1.55, 3.69)
Height >= 10mm
Risk ratio (95% CI)
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Risk of preterm labour after
LLETZ
Does size matter?
A retrospective study
Khalid S, Dimitriou E & Prendiville W
BSCCP (poster) 2009
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Excision dimensions and preterm labour
Khalid S, Dimitriou E & Prendiville W 2009
• 1999 - 2002
• Obstetric & Colpo
databases
• 353 pregnancies in
women after LLETZ
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Excision dimensions and preterm labour
Khalid S, Dimitriou E & Prendiville W 2009
Increased risk of
preterm labour if
specimens larger
than 6 cubic cms
RR 3.17, 95%CI 1.56 -
6.38
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Excision dimensions and preterm labour
Khalid S, Dimitriou E & Prendiville W 2009
Increased risk of
preterm labour if
specimens thicker
than 12 mms
RR 3.05, 95%CI 1.37 -
7.08
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Choices in treatment
• Depends on the case characteristics
– Age, parity, contraception
• Nulliparous 27yr old, minimum risk of default
with a moderate cytological and colposcopic
abnormality
• Sterilised parous 24 yr old with a moderate
cytological and colposcopic abnormality
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In summary
• Define your treatment threshold
• Always treat under colposcopic vision
• Excise the entire TZ preferably as one
piece
• Minimise the excision of normal tissue
• Minimise morbidity of wound
managment
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The BSCCP
invites you to the
15th World
Congress
On behalf of
IFCPC
In London
26-30th May 2014
www.IFCPC2014.c
om