Cervical Intraepithelial Neoplasm Speaker: Tseng Jen-Yu.

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Cervical Intraepithelial Neoplasm Speaker: Tseng Jen-Yu

Transcript of Cervical Intraepithelial Neoplasm Speaker: Tseng Jen-Yu.

Page 1: Cervical Intraepithelial Neoplasm Speaker: Tseng Jen-Yu.

Cervical IntraepithelialNeoplasm

Speaker: Tseng Jen-Yu

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Introduction

• Cervical cancer was the most common malignancy in both incidence and mortality among women prior to the 20th century

• Incidence fallen dramatically in developed nations due to implementation of population based screening, detection, and treatment programs for pre-invasive disease

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Epidemiology and Risk Factor

• 500,000 cases of cervical cancer diagnosed

• 2nd leading cause of cancer death• Risk factors

– Sexually transmitted disease– Human papilloma virus– Multiple sexual partners– Intercourse at early age– Poor personal hygine– Immunocompromise– Cigarette smoking

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Pathophysiology• Transformation zone

– Area where glandular epithelium undergoes squamous metaplasia

• Metaplasia– Occurs during fetal development / adolescence / and first pregnancy

– Columnar cells replaced by squamous cells

• Cells undergoing metaplasia are vulnerable to carcinogens

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Bethesda System

• LSIL– Low grade squamous epithelial lesion

• HSIL– High grade squamous epithelial lesion

• ASCUS– Atypical squamous cells of undetermined significance

• AGUS– Atypical glandular cells of undetermined significance

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Terminology and Definition

• CIN I– Mild dysplasia ( lower 1/3 of epithelium )

• CIN II– Moderate dysplasia ( 2/3 of epithelium )

• CIN III– Severe dysplasia ( upper 1/3 of epithelium / CIS )

• Dysplasia– Disorder maturation / Nuclear hyperchromatism– Increased N/C ratio / Pleomorphism / Mitosis

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CIN I

• Disease Profile– Self limited sexually transmitted HPV infection

– 60% regress spontaneously– 30% persistent– 10 ~ 15% progress to CIN II / III– 1% progress to invasive cancer

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• Treatment– Ablation ( cryotherapy / laser )– Excision ( LEEP / Knife conization )

• Follow up without treatment– Pregnant women– Immunosuppressed women– Adolescents

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CIN II / III

• Disease Profile– 43% untreated CIN II spontaneous regression– 32% untreated CIN III spontanenous regression

– 35% CIN II will persist– 56% CIN III will persist

– 22% CIN II progress to CIS or invasive cancer

– 14% CIN II progress to CIS or invasive cancer

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• Treatment– Ablation ( cryotherapy / laser )– Excision ( LEEP / Knife conization )

• Follow up without treatment– Pregnant women– Adolescents

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ASCUS

• Represent reactive / reparative changes secondary to inflammation

• 5% of routine Pap smears• Treatment

– Repeat Pap smear in 4 ~ 6 months– Colposcopy if repeat Pap shows ASCUS

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AGUS

• Suspected glandular lesion that can’t be classified as reactive or neoplastic

• Higher risk of neoplasia ( adenocarcinoma )

• 0.5 ~2.5% of routine Pap smear• Treatment

– Colposcopy– Conization + ECC

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Colposcopy• Acetic acid

– coagulation of nuclear protein preventing light to pass through the epithelium

– Higher nuclear density and higher concentration of protein => white intensity increase

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• Schiller / Lugol’s Iodine– Normal, mature squamou

s epithelium contains abundant glycogen

– Produce dark brown stain

– Abnormal epithelium contains relatively little or no glycogen

– Remain relative unstained

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Cryotherapy • Indication

– Cytology / Colposcopy / ECC => No microinvasion

– Lesion in ectocervix• Criteria

– CIN I / II– Small lesion– Ectocervix – ECC negative– No endocervical gland involvement

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Conization• Indication

– Unsatisfactory colposcopy – Evidence of premalignant or malignant glandular epithelium

– Microinvasion on biopsy / colposcopy / Pap smear

– HSIL ( CIN II / CIN III )– Uncertainty regarding presence of microinvsaion or invasion following direct biopsy for CIn

– Inconsistent Pap smear and colposcopy

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Cold Knife

• Indication– Lesion extend to endocervical canal and extent not possible to confirm

– Extent exceeds capability of LEEP ( 1.5 cm )– Cytology shows atypical glandular cells – Colposcopy suggest glandular dysplasia or adenocarcinoma

– Abnormal endocervical curretage

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Thank You for your attention