Managament of Abnormal Cervical Cytology And Histology

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Managament of Abnormal Cervical Cytology And
Histology
Ali Ayhan, MD Baskent University School of
Medicine Department of Obstetrics and
Gynecology Head of Division of Gynecologic
Oncology
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Globocan 2008
Cervical Cancer Case (n) Death (n)
Worldwide 529.000 274.000
Developed countries 76.000 33.000
Developing countries 452.000 241.000
Turkey 1.443 556
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HPV - Cervical Cancer
decads
years
months
Normal epithelium
HPV infection coilocytosis
CIN1
CIN2
CIN3
Carsinoma
HSIL
ASC-US/LSIL
SIL Squamous Intraepithelial Lesion / CIN
Cervical Intraepithelial Neoplasia
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• AS cells
• ASC US
• ASC H
• LSIL
  
• HSIL
• AG cells
• AGC NOS
• AGC favor neoplasia
• AIS
• Invasive Cancer

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Abnormal Cervical Cytology in Turkey A Turkish
Gynecologic Oncology Group (TGOG) Study
Ayhan et al, Int J Gyn Obst, 2009
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• Abnormal Cytology(2481/140334) 1.76
• ASC (n2341) 1.66
• ASC-US rate (n1510) 1.07
• ASC-H rate (n100) 0.07
• LSIL rate (n429) 0.3
• HSIL rate (n243) 0.17
• AGC (n111) 0.07
• Cytologic Ca (SCCAdeno, n88)
  0.062

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Abnormal Cytology
USA ()
TR ()

• ASC-US 4.3 1.07
• LSIL 1.6 0.33
• HSIL 0.2 0.17
• AGC 0.3 0.07

2012
ASCCP Modern Colposcopy 2012
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Abnormal Cytology-ASC
Abnormality Biopsy
ASCS ASC-US 5-12 CIN 2-3 0.1-0.2 InvC
ASC-H 24-94 CIN 2-3
LSIL 15-30 CIN 2-3
HSIL 26-68 CIN 2-3 1-2 InvC
Immunosupresyon, HPV ?
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Risk for detection of CIN 2 at Colposcopy
ASCUS HPV 17-20
ASCUS HPV - 0,74-1,2
ASCUS Total Risk 6,4-11,9
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Abnormal Cytology-AGC
Abnormality Biopsy
AGC 9-54 CINs 0-8 AIS lt1-9 InvC
AGC-NOS 9-41 (CIN2-3, AIS, InvC)
AGC-Favor neoplasia 27-96 (CIN2-3, AIS, InvC)
AIS 48-69 AIS 38 InvC
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Risks of CIN 2-3 and ICC
Pap/HPV Risk of CIN2-3 Risk of ICC
Pap(-) HPV() 4
ASC-US 6-12 0.1-0.2
ASCUS HPV() 17-20
ASCUS HPV(-) lt2
ASC-H 27-51
LSIL 15-30 lt0.1
HSIL gt70 1-2
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Management of Abnormal Cervical Cytology

• Patients age
• Type of abnormality (Sq. vs. Glanduler)
• Grade
• Available tests (HPV,Colposcopy)
• Special situations (Menopause,pregnancy,adeloscent
  , immunosupression)

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Management of Pregnant women LSIL
Colposcopy (preferred approach for non-adolescent)
Defer Colposcopy (until at least 6 weeks
postpartum
OR
Manage per ASCCP guideline
CIN 2,3
No CIN2,3
Postpartum Follow-up
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HSIL in Pregnancy

• Colposcopy is recommended
• Biopsy of suspicious lesions for CIN2/3 or cancer
  is preferred
• ECC is unacceptable
• Diagnostic exicion is unacceptable unless
  invasive cancer
• Reevaluation with cytology and colposcopy is
  recommended no sooner than 6-wk postpartum(with
  HSIL in whom CIN 2/3 is not diagnosed)

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New Terminology

• LGL (CIN1 HPV)
• HGL (CIN2, CIN3)

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Incidence of Preinvasive Lesions
27 / 100000 (1980) 54 /
100000 (1990) 1.5 6 of
all cytologic spesimens
SEER
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Pre-invasive 100 Early localized
92 Regional spread 49 Distant met. 14.9
Am J Obstet Gynecol, 13-20, 188, 2003 (SEER)
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Fundamental Objectives of Managing Preinvasive
Lesions

• Find the lesion
• R / O invasion
• Preserve fertility
• Employ cost-eff. and low morbid techniques

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The Aim of Therapy in Preinvasive Lesion

• Local control
• Prevention of ICC
• Decreased mortality

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CIN 1

• 60 Regression
• 30 Persistence
• 9 CIS
• 1 Invasive Cancer

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CIN 2

• 40 Regression
• 40 Persistence
• 15 Progression to CIS
• 5 Invasive Cancer

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CIN 3

• 56 Persistence
• 33 Regression
• 12 Invasive Cancer

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Which Lesions to Treat?

• all lesions selected
  lesions
• CIN 1...............1(ICC)
• CIN 2...............5(ICC)
• CIN 3.............12(ICC)

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Therapeutic Tools

• Ablation (destruction)
• Excision
• Photo dynamic therapy
• Non surgical
• Expectant management

Vidarabine, Podophylline (CINs HPV)
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Ablative or Local Destructive Methods

• Cryo surgery
• ECD
• Cold coagulator
• CO2 laser

No further histologic exam.
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Excisional Tools

• CONE
• CKC
• Laser
• LEEP
• Hysterectomy

in selected patients
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Indications for Excisional Therapy

• () ECC
• cyto histology discrepancy
• Microinvasion
• AIS
• unsatisfactory colposcopy

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Distribution of CIN Cases
n281 CIN 1-3 CIN1 68 CIN2 48 CIN3 162
Ayhan A et al., 2007
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Treatment Modalities used in Our Center
Ayhan A et al., 2007
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Results of Re-conization after Positive Surgical
Margins in CIN 2-3n56
Ayhan A et al., 2007 (under review)
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Cryotherapy
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Laser
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LEEP
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Cold-KnifeConization
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success rates of various methods
for the treatment of CIN
are similar (up to 97)
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• N28 randomized study
• The evidence suggests that there is no obviously
  superior surgical technique for treating CIN

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Reason of Treatment Failures

• poor techniques
• Glandular involvement
• grade of CIN
• size of lesion
• margin status

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AIS
AIS

• Incidence 1,25/100.000
• CIN 2-3 41.4/100.000
• Charareteristics of AIS
• -Multifocality
• -Colposcopic evaluation limited
• -Complete excision difficult
• -Skip lesions (Margin(-) Residu () )

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Management of CIN-2/3 in pregnant women

• Minimal invasive management
• High regression
• Repeat cytology/colposcopy (for every 12week)
• Repeat biopsy (colposcopic epithelial inv ca?)
• Reevaluation postpartum after 6weeks
• No treatment during pregnancy

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Posttreatment follow-up

• Why?
• Invasive Cx Ca increase 10 fold
• Non invasive 1-21
• Which tools?
• HPV (6-12 ms)
• Cytology only (6-12 ms)
• Cytology colposcopy (6-12 ms)

Grade, size, margin status , histology..
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New Cervical Cancer Screening ACS 2012

• Cervical cancer screening should begin at age 21
  years, regardless of the age of sexual initiation
  or other risk factors
• For women 21to 29 years of age cytology alone and
  every 3 years
• 21 to 29, 2 or more consecutive negatif
  cytology, screening interval longer than 3 years
• In this age group, HPV testing should not be used

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New Cervical Cancer Screening ACS 2012

• Age 30-65,
• HPV cytology every 5 years
• Cytology alone, every 3 years
• In this age group should not be screened with HPV
  testing alone
• gt65 years, negative prior screening and no
  history of CIN2 within the prior 20 years should
  not be screened
• Recommended screenin practice should not change
  on the basis of HPV vaccination status

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Cervical Cancer Screening in Turkey

• Cervical cancer screening begin at age 30 years
• Cervical cancer screening finish at age 65 years
  if negative 2 or more consecutive cytology
• Repeating every 5 years
• Screening in KETEM

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Conclusion

• Cervical cancer increasing in Turkey.
• Abnormal cytology is lower than western countries
  
• Cytology reduce invasive cancer and mortality
• Abnormal cytology is not enough for treatment
• Abnormal cytology- colposcopy -directed biopsy
  finally treatment

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Thank you for your attention...