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3  prof walter colposcopic
 

3 prof walter colposcopic

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    3  prof walter colposcopic 3 prof walter colposcopic Presentation Transcript

    • ColposcopicNomenclature 22. JahrestagungderArbeitsgem einschaft fürZervixpathologie und Kolposkopie AG CPC walterprendiville IFCPC
    • Evolution of terminology  Progress evolves from clear understanding of existing research and experience and clarity of terminology is fundamental to this  It is not possible to compare apples with oranges or to understand precisely published evidence where terminology is unclear  cone biopsy (UK) with cone biopsy (US),  Height  Depth  atypia
    • Practice variation in OB/GYN  C Section, 3rd stage of labour  Antenatal V/E  Hysteroscopy  Management of Endometrial Cancer  Colposcopy
    • Evolution of colposcopy  First colposcope :: Hamburg  Early colposcopic skills  image recognition,  diagnosis of HSIL,  recognition of microinvasion  Late colposcopic skills =  discriminating between normal and abnormal  facilitating precise treatment
    • MODERN COLPOSCOPY Objective and easily achieved skills through structured training as part of a QA service Risk assessment using biomarkers and patient characteristics Modified treatment techniques
    • Variation in colposcopy and treatment  Colposcopy is not a defined entity and performs differently in different settings  Treatment is not a defined entity and produces different results and complications in different settings  Nomenclature varies in interpretation and we therefore can not easily compare practice
    • Colposcopy is not a defined entity and performs differently in different settings Colposcopy performed by variably trained colposcopists who do not adhere to strict quality assured practice or self audit is completely different to colposcopy in a region where QA, adherence to best evidence guidelines and CME are the norm’
    • Why is there such a difference in colposcopic reward ALTS 11.5% CIN 2+ after a normal colposcopy 72.3% of CIN2+ found at original colposcopy UK NHS study 5.3% CIN2+ after a normal colposcopy 94.6% of CIN2+ found at original colposcopy
    • Why is there such a difference in colposcopic reward In the UK NHS CSP colposcopy setting the risk of missing high grade disease appears to be much lo than in the equivalent US setting Why is this?
    • Why is there such a difference in colposcopic reward In the UK there exists A comprehensive training programme Preceptor based Strict number of cases under supervision and subsequently unsupervised Ongoing assessment during training Exit exam (OSCE) 30% failure rate
    • Why is there such a difference in colposcopic reward In the UK Colposcopy practice Devoted colposcopy clinics All women referred with a suspected abnormality Rate of CIN relatively high Not rewarded according to procedures performed Comprehensive audit of practice
    • Treatment is not a defined entity and produces different results and complications in different settings  The resection of a small type 1 TZ is easy and associated with minimal morbidity  The resection of a large Type 3 TZ is difficult and associated with significant short and long term morbidity
    • 13 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)
    • RiskofpretermlabourafterLLETZDoessizematter, Aretrospectivestudy Khalid S, Dimitriou E &Prendiville W BSCCP (poster) 2009
    • Excision dimensions and preterm labour Khalid S, Dimitriou E & Prendiville W2009  1999 - 2002  Obstetric &Colpo databases  353 pregnancies in women after LLETZ
    • Excision dimensions and preterm labour Khalid S, Dimitriou E & Prendiville W2009 Increased risk of preterm labour if specimens larger than 6 cubic cms RR 3.17, 95%CI 1.56 - 6.38
    • Excision dimensions and preterm labour Khalid S, Dimitriou E & Prendiville W2009 Increased risk of preterm labour if specimens thicker than 12 mms RR 3.05, 95%CI 1.37 - 7.08
    • 2011 IFCPC colposcopic terminology of the cervix(draft – May 2011) SCJ visualization: complete/partial/none Adequate/inadequate for the reason … (i.e.: cervix obscured by inflammation, bleeding, scar) Basic definitions Deciduosis in pregnancy, Atrophic epithelium, Nabothian cyst, Gland (crypt) openings Original squamous epithelium, Columnar epithelium including ectopy, Transformation zone types 1,2,3 Normal colposcopic findings Inside or outside the T-zone, Numberof cervical quadrantsthe l esioncovers , Size of the lesion in percentage of cervix, Lugol’s staining (Schiller’s test): stained/non-stained General principles Abnormal colposcopic findings Fine mosaic, Fine punctation Fine aceto-white epitheliumGrade 1 (Minor) Rapid appearance of acetowhitening, Cuffed gland (crypt) openings Sharp border, Exophytic lesion, Inner border sign, Ridge sign Dense aceto- white epithelium, Coarse mosaic, Coarse punctuation, Leukoplakia Grade 2 (Major) Atypical vessels, fragile vessels, Irregular surface, Necrosis, Ulceration (necrotic), tumor/gross neoplasm Suspicious for invasion Stenosis, Congenital anomaly, Post treatment consequence Endometriosis, Condyloma, Polyp (Ectocervical/ endocervical) Erosion (traumatic) Inflammation Miscellaneous finding
    • Nomenclature committee 2011  Jim Bentley - Canada  Jacob Bornstein – Israel (Chairman of the Committee)  Peter Bosze – Hungary  Frank Girardi – Austria  Hope Haefner - USA  Michael Menton – Germany  MyriamPerrota – Argentina  Walter Prendiville – Ireland  Peter Russell - Australia  Mario Sideri – Italy
    • ThenewIFCPCnomenclatureforcervix, (vaginaandvulva)WWW.IFCPC.ORG Bornstein et al Amer J Obstet Gynecol Vol 120 No 1 July 2012
    • 2011 committee considerations  Establish an evidence base  KeratosisvLeukoplakia  Inside/outside TZ  Size of lesion  Inner border and ridge signs  Treatment types
    • Abnormal vessel Coarse punctation
    • Colposcopic features suggestive of highgrade disease (major change)  A generally smooth surface with an sharp outer border.  Dense acetowhite change, that appears early and is slow to resolve; it may appear oyster white.  Iodine negativity, a yellow appearance in a previously densely white epithelium.  Coarse punctation and wide irregular mosaics of differing size.  Dense acetowhite change within columnar epithelium may indicate glandular disease.
    • New S C Junction Columnar Original squamous epithelium Crypt openings
    • Dr SC Quek Polyps
    • Size of cervical lesions  Kierkegaard 1995: lesion size has independent predictive value  Ferris 2005: Size of cervical lesions correlates directly with the severity of disease.  Hopman et al. 1995 reported an inter-observer agreement rate of 68% when evaluating colposcopic photographs for lesion size.  Hammes 2007: Lesions >50% of cervix had higher probability for high-grade lesion / carcinoma (OR, 3.45). Prof Jacob Bornstein
    • New colposcopic sign- Ridge sign An opaque acetowhite ridge at the squamocolumnar junction Prof Jacob Bornstein Scheungraber C, Koenig U, Fechtel B, Kuehne-Heid R, Duerst M, Schneider A. The colposcopic feature ridge sign is associated with the presence of cervical intraepithelial neoplasia 2/3 and human papillomavirus 16 in young women. J Low Genit Tract Dis. 2009;13(1):13- 16.
    • A New Scoring System Strander et al 2005  Designed to evaluate a scoring system for high grade lesions  297 examinations of women referred for colposcopy, Department of Obstetrics and Gynecology, Göteborg, Sweden  First Scoring system to incorporate lesion size as a variable  Subsequently validated at the Royal Free
    • Aceto-white colour Iodine stainingVascular Pattern Peripheral Margins
    • 0 1 2 Score ACETO UPTAKE Zero or transparent Shady, Milky (not transparent not opaque) Distinct, opaque white MARGINS/ SURFACE Diffuse Sharp but irregular, jagged, “geographical” Satellites Sharp and even, difference in surface level incl “cuffing” VESSELS Fine, regular Absent Coarse or atypical LESION SIZE <5mm 5-15mm or 2 quadrants >15mm or 3-4 quadrants or endocervically undefined IODINE STAINING Brown Faintly or patchy yellow Distinct yellow Total score 10
    • The transformation zone  A Type 1 transformation zone is completely ectocervical and fully visible, and may be small or large  A Type 2 transformation zone has an endocervical component, is fully visible, and may have an ectocervical component that may be small or large  A Type 3 transformation zone has an endocervical component that is not fully visible and may have an ectocervical component that may be small or large
    • Type 1 • Completely ectocervical • Fully visible • small or large Transformation Zone Classification
    • SBX1739_3 Histology CIN1 Cytology LSIL,CIN 1;Atyp endocerv, neopl Carcinogenic HPV 16, 58, 66 Age 28 Category Mario Walter SCJ visibility Fully Visible Fully Visible TZ type Type 1 - Small Type 1 - Small TZ pattern Abnormal Grade 1 Abnormal Grade 2 Image quality Good Good Jim Usha Partially Visible Partially Visible Type 2 - Large Type 1 - Large Abnormal Grade 2 Normal Good Limited
    • SBX1759_3 Histology CIN3 Cytology LSIL,CIN 1;Atyp endocerv, neopl Carcinogenic HPV 16, 51 Age 25 Category Mario Walter SCJ visibility Partially Visible Fully Visible TZ type Type 2 - Small Type 1 - Small TZ pattern Abnormal Grade 2 Abnormal Grade 1 Image quality Good Limited Jim Usha Fully Visible Fully Visible Type 1 - Small Type 1 - Small Abnormal Grade 1 Normal Good Good
    • Type 2 • has endocervical component • Fully visible • may have ectocervial component which may be small or large Transformation Zone Classification
    • SBX1842_1 Histology CIN3 Cytology HSIL,CIN 3;Adeno, NOS Carcinogenic HPV 16, 18 Age 30 Category Mario Walter SCJ visibility Partially Visible Partially Visible TZ type Type 3 - Small Type 2 - Small TZ pattern Abnormal Grade 2 Suspicious for invasion Image quality Limited Limited Jim Usha Fully Visible Fully Visible Type 2 - Small Type 1 - Small Abnormal Grade 2 Abnormal Grade 2 Good Limited
    • Transformation Zone Classification Type 3 • has endocervical component • is not fully visible • may have ectocervial component which may be small or large
    • SBX1216_2 Histology CIN3 Cytology HSIL,CIN 2;Adeno in situ (AIS) Carcinogenic HPV 31 Age 21 Category Mario Walter SCJ visibility Not Visible Partially Visible TZ type Type 3 - Small Type 2 - Small TZ pattern Abnormal Grade 1 Abnormal Grade 2 Image quality Good Good Jim Usha Not Visible Fully Visible Type 3 - Small Type 1 - Large Abnormal Grade 2 Abnormal Grade 1 Good Good
    • SBX1774_1 Histology CIN3 Cytology HSIL,CIN 3;Adeno, NOS Carcinogenic HPV 16 Age 47 Category Mario Walter SCJ visibility Not Visible Partially Visible TZ type Type 3 - Small Type 2 - Small TZ pattern Abnormal Grade 2 Suspicious for invasion Image quality Good Good Jim Usha Not Visible Not Visible Type 3 - Small Type 3 - Large Suspicious for invasion Suspicious for invasion Good Good
    • SBX1928_1 Histology CIN3 Cytology HSIL,CIN 3;Adeno, NOS Carcinogenic HPV 16, 39 Age 30 Category Mario Walter SCJ visibility Not Visible Not Visible TZ type Type 3 - Small Type 3 - Small TZ pattern Abnormal Grade 2 Abnormal Grade 2 Image quality Good Good Jim Usha Partially Visible Fully Visible Type 3 - Small Type 1 - Small Abnormal Grade 1 Abnormal Grade 1 Good Good
    • The BSCCP invites you to the 15th World Congress On behalf of IFCPC In London 26-30th May 2014 www.IFCPC2014.
    • www.IFCPC2014.com Bemvindo a Londres al 26de30 de Mayo Queen Elizabeth II conference centre
    • Westminster Hall for the plenary sessions Up to 2160 delegates 2070 m2 exhibition space
    • ¡NosvemosemLondres ! 2014 St James’s Park – 5 minutes walk from venue
    • Shopping................... Covent Garden, London
    • National Institute of Medical Research- The biology of HPV and molecular markers Wolfson Institute of Preventive of Medicine- Screening across the world St Thomas’s Hospital – Improving Cytology Institute of Women’s Health Imperial College Post Congress Seminars
    • See you in London