Excisional & Ablative Proceduresin Premalign Cervical Lesions

Haberal Ali, MD

Resim şu anda görüntülenemiyor.

How can we decide about the choiceof therapy for CIN

Cytologic and colposcopic findingsCytologic and colposcopic findings

The patient’s age and further desire for fertilityThe patient’s age and further desire for fertility

The type of TZThe type of TZ

The experience of the physicianThe experience of the physician

Excisional Procedures

Cold knife conization Cold knife conization 

Laser conizationLaser conization

HF‐needle conizationHF‐needle conization

LEEP (LLETZ)LEEP (LLETZ)

HisterektomiHisterektomi

Indications for Excisional Treatment

Inconsistency between cytologic, colposcopic and histologic findings

Unsatisfactory colposcopy

Glandular lesion on cytology or colposcopic biopsy

Suspicion of invasive cancer

Endocervical canal involvement (ECC+)

Recurrence after ablative treatment

Excisional Treatment of CIN

The goal is to remove the entire TZ

The size and shape of the cone biopsy should be tailored with colposcopy according to the type of TZ• Direct colposcopic vision just before cone biopsy may be helpful

Type of T‐Zone

The complete TZ is located ectocervix

The cutting depth from the external orifice must be 8mm, whereas 5mm may be sufficient for periphery of the TZ

Type 1 TZ

Type 2 TZ• The TZ extends into the EC but the upper border (SJ) is visible on colposcopy

• TZ extends 7‐10mm into EC, a second resection of the adjacent canal with a smaller square loop is performed to achieve clear endocervical margins(cowboy‐hat)

Type 3 TZ

• The TZ extends into the EC and the upper border is not visibleon colposcopy

• The shape of removed sample with loop resembles cilindricalshape with HF needle

• Type 2 and 3 excisions are associated with an increased risk of incomplete excision and subsequent pregnancy relatedmorbidity

Cold Knife Conization

AISAIS

Suspicion of invasive CC on colposcopic biopsySuspicion of invasive CC on colposcopic biopsy

Technique

Resim şu anda görüntülenemiyor.

Definition

LEEP

•Loop•Electrosurgical•Excision•Procedure

LLETZ

•Large Loop•Excision of the•Transformation•Zone

• The cutting wire loop• High‐frequency electrosurgical unit• Non‐conductive speculum with a smokeevacuator

• Ball electrode• Solutions

– Local anestetic with a vasospastic agent–Monsel’s solution– Lugol’s solution

LEEP Conization‐ Equipment

Equipment

LEEP

• Proper adjustments should be made to reducethe degree of thermal injury

• For cutting– 1.5x0.5cm     30w– 1x1cm            35w– 2x0.8cm         40w– 2x1.2cm         50w

• For coagulation– 3mm top     30w– 5mm top     50w

Advantages of LEEP

• Simple procedure with an easier learningcurve

• Can be used in all cases of CIN, microinvasivedisease and glandular disease

• Cost effective and usually does not requiregeneral anesthesia (out‐patient)

• Less complication rate than the others• Chance to both diagnose and treat the lesionin sametime (see and treat)

See and Treat

Popular

Can protect loss of patients for a second clinic attendance

But, the risk of over‐treatment does exist in young women

Problems associated with LEEP

Burn‐necrosis at the margins (Thermal injury)Burn‐necrosis at the margins (Thermal injury)

Unable to remove the tissue in one‐pieceUnable to remove the tissue in one‐piece

Contraindications

Relative• Bleeding diathesis• Patient exposed in utero DES• Patient fewer than 12 wks

after delivery• Equivocal cervical

abnormalities• Heavy menses• A preexisting short cx• Patients with pacemakers• Severe cervitis

Absolute• Pregnancy• Clinically apparent invasive

carcinoma of the cx• Lack of expertise to control

potential severe cervicalbleeding

Complications

Bleeding (4%‐6%)

Pain

İnfection

Damage to the vaginal sidewalls

Postoperative Instructions

• The patient is informed for complications andblack or brown vaginal discharge for the next 2 to4 weeks

• The patient is advised to avoid for intercause forthe next 4 to 6 weeks

• İs seen six weeks later to be sure the cervix is healing and the endocervical canal is patent

• Follow‐up cytology should not be obtained beforefor to six months postoperatively– Because specimens are frequently contamined withdebris, metaplastic cells and leukocytes

Ablative Procedures

Laser ablationLaser ablation

CryotherapyCryotherapy

Cold coagulationCold coagulation

Electrocoagulation diathermyElectrocoagulation diathermy

Photodynamic therapyPhotodynamic therapy

5‐FU5‐FU

Indications for Ablative Treatment

• Colposcopy must be sufficient• Lesion must be completely visiable on ectocervix

• ECC (‐)• No suspicion of invasion• Adenocarcinoma in situ must be exist• Consistency between cytology, histology andcolposcopy

Cryotherapy

• Cryotherapy uses a refrigerent gas (carbondioxide or nitrous oxide to cool the ectocervixwith metal cryoprobe

• The ectocervix must be cooled to ‐20˚C tocause crystallization of intracellular water anddestroy the lesion

• This can be achieved by forming an ice ball in the cervical tissue that is at least 5mm fromthe tip of the prob

Cryotherapy Triage Rules

• Entire squamocolumnar juction must be visualized

• Entire extent of lesion must be seen• CIN diagnosed by biopsy• Endocervical canal disease has been ruled out• Colposcopic impression, cytology, and histologycorrelate

• Invasive disease is not present• Cryotherapy prob must cover lesion

Contraindications• Invasive cervical cancer• Pregnancy• In utero DES exposure• Acut cervicitis• Cryoglobulinemia• Positive ECC• Unsatisfactory colposcopy• Lesions larger than 75% of the cx• Lesions that extend more than 5mm into the endocervical canal• Exophytic, nodular, or papillary lesions or an obstetric scar that

hinders proper application of the cryoprobe to the cx andtransformation zone

Cryotherapy equipment

• Cryogun• Large nitrogen oxide or carbon dioxide tank with a 

pressure gauge and at least 20 psi pressure in the tank• Vaginal speculum• Vaginal wall retractors• Various sizes and shapes of cryotips• Water‐soluble lubricating gel• Colposcope• Acetic acid or vinegar (3% or 5%)• Disinfectant for cryoprobes

Cryotherapy

• Cryotherapy is completed using cycles of freeze‐thaw‐freeze

• The WHO recommends a cycle of 3‐minute freeze, 5‐minute thaw, and 3‐ minute freeze

• The probe must have thawed completelybefore removal, central part of the freeze zoneis friable and is a source of bleeding ifdisturbed

Reepithelization

47% of patientsby 6 weeks

İn all patientsby 3 months

Side effects

Menstrual‐like cramps

Flushing and light‐headness

Vasovagal syncope

Complications

• Vaginal mucosal injury• Pain and cramping• Profuse watery discharge• Cervisitis• PID• Cervical stenosis (very rare)

Cryotherapy & CIN

CIN 1 for94%

CIN 1 for94%

CIN 2 for92%

CIN 2 for92%

CIN 3 for85%

CIN 3 for85%

Sauvaget C, Int J Gynaecol Obstet, 2013

• Among 4569 CIN patients treated with coldcoagulation

• Summary proportion cured of 96% CI(92‐98%) were obtained for CIN 1 and CIN 2‐3 disease

• Cold coagulation CIN cure rates comparable tothose of other excisional and ablativemethods

• Cold coagulation is indicated for all grades of CIN

Dolman L, BJOG, 2014

Santesso N, Int J Gynaecol Obstet, 2015

Santesso N, Int J Gynaecol Obstet, 2015

Summary

• Excisional treatments are preferable• Treatment should be performed undercolposcopic vision

• The technique and configuration of the coneshould be individualized, depending on the TZ

• TZ should be excised entirely• The most significant perioperativecomplication of cone biopsy is bleeding, whichis generally managed with local measures

Summary

• The excisional treatment of CIN do not compromise future fertility, but is associatedwith an increased risk of preterm labouraccording to type of excision

• The excisional treatment of AIS is regarded tobe appropriate if fertility is desired. But closefollow‐up is mandatory

Thank you for your attention !