Evaluation of carcinoma

cervixTreatment

of dysplasias

George Papanicolaou

CERVICAL CYTOLOGY: PAP TEST

• AMERICAN CANCER SOCIETY

recommendation

Screening should begin at the age of 21

Or within 3 years of onset of sexual activity

Stop at age of 70,if no abnormal result in past

10 years

• AMERICAN COLLEGE OF OBSTETRICIANS AND

GYNECOLOGISTS recommendations states

Women younger than the age of 30 should

undergo screening yearly

Those older than the age of 30 can extend

screening their screening interval to 2 to 3

years

• US FOOD AND DRUG ADMINISTRATION approved

HPV DNA testing combined with cervical cytology as a screening technique for women older than age 30

When results of both tests are negative,does not have to be retested for 3 years

The negative predictive value of a double negative test exceeds 99%

How PAP test to be done???

• Patient in dorsal position• Labia minora parted• Speculum introduced• Cervix exposed• Squamocolumnar junction scraped with

spatula by rotating all around• Spread on slide and immediate fixation• Stained with papanicolaou• Presence of endocervical cells: satisfactory

NORMAL

Atypical Squamous Cells

• 10% to 20% incidence of CIN 1

• 3% to 5% risk for CIN 2 or 3

• Repeat pap test every 4 to 6 months with

referral for colposcopy

• Immediate colposcopy

• HPV testing

Low Grade Squamous Intraepithelial Lesions

• 75% of the patients have CIN,of these 20%

being CIN 2 or 3

• Colposcopy done to evaluate a single LSIL

result

LSIL

High Grade Squamous Intraepithelial Lesions

• Should undergo colposcopy and directed

biopsy

15-30% false negativity

Sensitivity 50-60% and specificity 95-98%

• Post menopausal women: indrawing of

SCJ,dry vagina,poor exfoliation

• Estrogen cream 10 days

HSIL

LIQUID BASED CTYOLOGY

• Plastic spatula placed in liquid fixative• Remove blood,mucus and inflammatory

cells

• HPV DNA: hybridization (HYBRID CAPTURE

II) or PCR, 88% sensitive

• ENDOCERVICAL CURETTAGE:

scraping of mucus membrane by endocervical

brush or curretage

COLPOSCOPY• Binocular stereoscope giving 10-20 times

magnificationTo study cervix when pap smear detect

abnormal cellsTo locate the abnormal areas and take biopsyConservative surgery under colposcopic

guidenceFollow up

HINSELMANN

• Visual inspection of acetowhite areas;

• Applying 5% acetic acid

• Acid coagulates protein of nucleus and

cytoplasm and makes the protein opaque

and white

• Dull white plaque with faint border: LSIL

• Thick plaque with sharp border: HSIL

Normal cervix Acetowhite areas

Abnormal areas

• Punctation: Dilated capillaries terminating on the surface appear from the ends as a collection of dots

• Mosaic: terminal capillaries surrounding roughly circular or polygonal shaped blocks of AW epithelium crowded together

• Leukoplakia:

• Atypical vascular pattern: looped vessels,branching vessels,reticular vessels

Cone biopsy• Diagnostic and therapeutic

• Large abnormalities,inner wall receded into

cervical canal,SCJ not visible

Cold knife technique under GA

Large loop excision of transformation zone

Laser excision

Treatment of dysplasia and CIN

CIN 1

• Evaluate every 6 months

• With pap test, HPV DNA

If lesion progress or persist for 2 years

Ablative treatment

CIN 2 and 3

• Require treatment

• Loop electrosurgical excision procedure

Ablative therapy is appropriate when

• No evidence of microinvasion or invasive

cancer

• Lesion located on ectocervix

• No involvement of the endocervix with high

grade dysplasia

CRYOTHERAPY• Destroy surface

epithelium by

crystallization of

intracellular fluid

• Freeze thaw freeze

technique over 9

minutes

• CO2(-65oc), nitrous oxide(-89oc)

Applicable only

• CIN 1 and 2

• Small lesion

• Ectocervical location

• Negative endocervical sample

• No endocervical gland involvement

Advantages:

• Least painful,cheap,best tolerated and safe

Disadvantages:

• Discharge,infection,bleeding,stenosis

• LASER ABLATION: expensive,special training required

LEEP• Low voltage diathermy

o Loop advanced lateral to lesion

o When required depth reached

o Loop taken across to opposite side

o Cone of tissue removed

• Cutting d/t steam envelope developing at the

interface b/w wire loop and tissue

• Disadvantages: hemorrhage,stenosis,preterm labour

Conization• Entire outer margin and endocervical lining

short of internal os Bleeding, Sepsis, Stenosis, Abortion,

Preterm labourIndications• Limits of lesion not visible• SCJ not seen• ECC finding positive for CIN 2 and 3• Lack of correlation• Microinvasion is suspected

Hysterectomy(not indicated)

• Older and parous women

• Poor compliance with follow up

• A/w fibroid, DUB, prolapse

• If micro invasion exist

• Recurrance

FIGO staging of carcinoma cervix based on:

• Biopsy• Colposcopy• Endocervical curettage• Conization• Hysteroscopy• Cystoscopy• Proctoscopy• Intravenous urography• Xray chest and skeleton

Thank you