4  prof james bently management guidelines 2014
Upcoming SlideShare
Loading in...5
×
 

4 prof james bently management guidelines 2014

on

  • 174 views

all

all

Statistics

Views

Total Views
174
Views on SlideShare
124
Embed Views
50

Actions

Likes
0
Downloads
5
Comments
0

2 Embeds 50

http://cabwt.kau.edu.sa 36
http://marz.kau.edu.sa 14

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

4  prof james bently management guidelines 2014 4 prof james bently management guidelines 2014 Presentation Transcript

  • Colposcopy Management Guidelines IFCCP Jeddah Jan 2014 James Bentley Professor Dept. Obstetrics and Gynecology Dalhousie University Halifax, Canada
  • ASCCP Management Guidelines 2012 • Consensus meeting Sept 2012 • 47 experts, 23 societies, national and international organisations • Used available literature and data from the Kaiser Permanente Northern California health plan – Basis of recommendations was equal management for equal risk – Immediate colposcopy for >5% risk of CIN 3 over 5 years – 6 to 12 month return for a CIN 3 risk of 2-5% – 3 year return for an CIN 3 risk of 0.1-2% – 5 year return interval for a risk comparable to women without a history of abnormality or 0.1% Massad et al. JLGTD Vol 17, 5, 2013, S1-27
  • SOGC SCC Colposcopy Guidelines 2012 Colposcopic Exam • The new IFCPC terminology should be used • Biopsy: take 2 – ALTS trial 2 Bx’s detected 81.8% of CIN2 or> vs. 68.3%1 • Biopsy a lesion: even if you think its just metaplastic • Random Biopsy generally not indicated • ECC: – Calgary review 99 ECC’s needed to detect one additional case of CIN 2 or > – Largest benefit in older women with high-grade cytological abnormalities2 • HPV testing for all cases: NO 1Gage et al Obs Gyn 2006 Aug;108(2):264-272. 2Gage et al. Am J Obstet Gynecol 2010 Nov 203 (5) 481. 1-9
  • Abnormal cytology in the woman < 21 years old • Should not be screened < 21 years old • Controversial issues if screened: – ASCUS or LSIL; repeat vs. refer for colp vs. do not repeat till after 21 years old – Refer to provincial guidelines • ASC-H, HSIL, AGC should be colposcoped
  • Wait Times – Suggested time receipt of referral to visit: – ASC-H or AGC: 6 weeks – HSIL: 4 weeks – Carcinoma: 2 weeks – ASCUS/LSIL 12 weeks
  • Unsatisfactory Cytology HPV negative (age ≥30) HPV unknown (any age) ColposcopyRepeat Cytology after 2-4 months Manage per ASCCP Guideline Abnormal Negative Unsatisfactory Routine screening(HPV-/unknown) or Cotesting @ 1 year (HPV+) © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. HPV positive (age ≥30)
  • Cytology NILM* but EC/TZ Absent/Insufficient Ages 21-29+ HPV negative HPV positive HPV testing (Preferred) Routine screening HPV unknown Manage per ASCCP Guideline Cytology + HPV test in 1 year Genotyping Repeat cytology in 3 years (Acceptable) or Age ≥30 years © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. *Negative for intraepithelial lesion or malignancy +HPV testing is unacceptable for screening women ages 21-29 years
  • Abnormal HPV test and Normal Cytology Bentley J et al. J Obstet Gynecol Can 2012;34(12)1188-1202 http://www.sogc.org/scc/guidelines/index.html www.colposcopycanada.org
  • HR#HPV#+ve# Cytology#nega1ve## <#30#yrs# ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • HR#HPV#+ve# Cytology#nega1ve#>#30#yrs#
  • Management of Women ≥ Age 30, who are Cytology Negative, but HPV Positive Cytology Negative and HPV Negative ≥ASC or HPV positive Repeat Cotesting @ 1 year Acceptable Repeat cotesting @ 3 years HPV DNA Typing HPV 16 or 18 Positive Colposcopy Acceptable Repeat Cotesting @ 1 year HPV 16 and 18 Negative © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Manage per ASCCP Guideline Manage per ASCCP Guideline 5 year risk of CIN3+ ~10%
  • Management of LSIL/ ASCUS • Referral for low grade lesion varies across the country – Repeat cytology – Reflex HPV testing for ASCUS • Colposcopy done to rule out CIN 2/3 (potentially pre- malignant changes) • CIN 2+: 10% with ASCUS, 17% with LSIL1 • CIN 3+: 6% with ASCUS, 12% with LSIL1 • Biopsy any lesion and consider random Biopsy at TZ • If negative colp/Bx/ECC with any TZ type discharge to annual cytology for 3 yrs then per provincial guidelines 1 Arbyn M JNCI 2004, GynecolOncology 2005, Vaccine 2006
  • 1Any colposcopic lesion identified should be biopsied. If no lesion is identified biopsies of the TZ should be considered. LSIL/ASCUS x 2 or ASCUS HPV+ve Colposcopy1 Return to screening protocol Manage as per SCC guidelines No CIN CIN 1 or > ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Management of Women with Atypical Squamous Cells of Undetermined Significance (ASC-US) on Cytology* Negative > ASC Repeat Cytology @ 1 year Acceptable HPV Testing HPV Positive (managed the same as women with LSIL) Colposcopy Endocervical sampling preferred in women with no lesions, and those with inadequate colposcopy; it is acceptable for others Preferred Repeat Cotesting @ 3 years HPV Negative Manage per ASCCP Guideline © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. *Management options may vary if the woman is pregnant or ages 21-24 +Cytology at 3 year intervals Routine Screening+ 5 year risk of CIN3+ ~0.54%
  • Management of Women Ages 21-24 years with either Atypical Squamous Cells of Undetermined Significance (ASC-US) or Low-grade Squamous Intraepithelial Lesion (LSIL) Negative, ASC-US or LSIL ASC-H, AGC, HSIL Reflex HPV Testing Acceptable for ASC-US only Negative x 2 > ASC Routine Screening Repeat Cytology @ 12 months Women ages 21-24 years with ASC-US or LSIL Colposcopy Repeat Cytology @ 12 months Preferred HPV Positive Routine Screening HPV Negative © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved.
  • Management of Women with Low-grade Squamous Intraepithelial Lesions (LSIL)* Non-pregnant and no lesion identified Endocervical sampling “preferred” Inadequate colposcopic examination Endocervical sampling “preferred" Adequate colposcopy and lesion identified Endocervical sampling “acceptable” Colposcopy CIN2,3No CIN2,3 Repeat Cotesting @ 3 years * Management options may vary if the woman is pregnant, postmenopausal, or ages 21-24 years (see text) Manage per ASCCP Guideline LSIL with no HPV test LSIL with positive HPV testLSIL with negative HPV test Repeat Cotesting @ 1 year Preferred Acceptable ≥ASC or HPV positive Cytology Negative and HPV Negative © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Manage per ASCCP Guideline
  • Management of Pregnant Women with Low-grade Squamous Intraepithelial Lesion (LSIL) CIN2,3 Colposcopy Preferred Pregnant Women with LSIL Defer Colposcopy (Until at least 6 weeks postpartum) Acceptable ^ In women with no cytological, histological, or colposcopically suspected CIN2,3 or cancer No CIN2,3^ Postpartum follow-up © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Manage per ASCCP Guideline
  • Management of ASC-H • Bareth et al. 517 cases ASC-H CIN2 + in 70%, Carcinoma in 2.9% • Women need colpscopy and liberal biopsy
  • ASC-H Colposcopy1 No CIN Manage as per SCC guidelines CIN1 or > Colposcopy, cytology, at 6 months x 2 ( +/- HR HPV testing) Return to screening protocol CIN 1 or >No CIN HR-HPV +ve follow in colposcopy clinic 1 Biopsies should be taken of any lesion identified at colposcopy ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Colposcopy Regardless of HPV status CIN2,3 Management of Women with Atypical Squamous Cells: Cannot Exclude High-grade SIL (ASC-H)* Manage per ASCCP Guideline No CIN2,3 Manage per ASCCP Guideline © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. *Management options may vary if the woman is pregnant or ages 21-24 years.
  • Management of Women Ages 21-24 yrs with Atypical Squamous Cells, Cannot Rule Out High Grade SIL (ASC-H) and High-grade Squamous Intraepithelial Lesion (HSIL) No CIN2,3 CIN2,3 Two Consecutive Cytology Negative Results and No High-grade Colposcopic Abnormality High-grade colposcopic lesion or HSIL Persists for 1 year Routine Screening Observation with colposcopy & cytology* @ 6 month intervals for up to 2 years Manage per ASCCP Guideline for young women with CIN2,3 Colposcopy (Immediate loop electrosurgical excision is unacceptable) Biopsy CIN2,3 (If no CIN2,3, continue observation) HSIL Persists for 24 months with no CIN2,3 identified Diagnostic Excisional Procedure+ Other results © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Manage per ASCCP Guideline *If colposcopy is adequate and endocervical sampling is negative. Otherwise a diagnostic excisional procedure is indicated. +Not if patient is pregnant
  • Management of HSIL • High rates of CIN 2 + have been reported, 56- 66% when biopsy is performed1 • Patients need prompt colposcopy and biopsy with an ECC if the TZ is not seen in its entirety • Areas of concern: – HSIL with no lesion in a young woman – HSIL in older woman when the TZ is not seen in its entirety: Should have an appropriate excision 1 Massad LS Gynecol Oncol 2001 sep 82(3) 516-522
  • 1 Consider HPV testing HSIL Colposcopy (Bx, +/- ECC) No CIN 2, 3 Manage as per SCC guidelines CIN 2 or greater Satisfactory Colposcopy (Type 1 or 2 TZ) Unsatisfactory Colposcopy (Type 3 TZ) Observe with Colposcopy and cytology Q 6/12 x21 Return to screening protocol Consider Diagnostic Excision procedure Cytology/histolog y review Concern re high grade findings Low grade CIN/Cytolog y ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Colposcopy (with endocervical assessment) * Management options may vary if the woman is pregnant, postmenopausal, or ages 21-24 + Not if patient is pregnant or ages 21-24 CIN2,3No CIN2,3 Management of Women with High-grade Squamous Intraepithelial Lesions (HSIL) * Immediate Loop Electrosurgical Excision + Or Manage per ASCCP Guideline © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved.
  • Management of AGC-NOS, AGC-N, AIS • Canadian review 456 cases of AGC – 7% CIN 1, – 36% CIN 2/3 – AIS in 20% – Ca Cx 9% – Endometrial pathology in 29 % • Need to adequately assess the patient • Appropriate ECC, endometrial biopsy, cervical Bx • AGC-NOS vs. AGC-N – AGC N has a much higher rate of abnormalities and requires an excisional procedure Daniel A Int J Gynecol Obstet 2005 91(3) 238- 242
  • AGC Colposcopy1 With ECC +/- endo Bx No CIN Manage as per SCC guidelines Invasive CancerSatisfactory Colposcopy (Type 1 or 2 TZ) Unsatisfactory Colposcopy (Type 3 TZ) Observe with Colposcopy cytology and HR- HPV testing Q 6/12 x2 2 Return to screening protocol Diagnostic Excision procedure AGC-NOS AGC-Neoplasia Colposcopy With ECC +/endo Bx AGC-endometrial Endometrial biopsy (all women over 35) Manage as per Gynecologic Oncology Guidelines CIN AIS Diagnostic Excision procedure 1Consider HR-HPV testing, n.b. not acceptable for initial triage 2 If HR-HPV testing not available repeat q 6/12 x 4 Manage endometrial pathology No endometrial pathology All negative AGC ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Initial Workup of Women with Atypical Glandular Cells (AGC) No Endometrial Pathology All subcategories (except atypical endometrial cells) Atypical Endometrial Cells Colposcopy (with endocervical sampling) and Endometrial sampling (if > 35 yrs or at risk for endometrial neoplasia *) Endometrial and Endocervical Sampling Colposcopy *Includes unexplained vaginal bleeding or conditions suggesting chronic anovulation. © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved.
  • Subsequent Management of Women with Atypical Glandular Cells (AGC) No CIN2+, AIS or Cancer Initial Cytology is AGC - NOS Manage per ASCCP Guideline Cotest At 12 and 24 months Any abnormality Colposcopy CIN2+ but no Glandular Neoplasia Initial Cytology is AGC (favor neoplasia) or AIS No Invasive Disease Diagnostic Excisional Procedure + +Should provide an intact specimen with interpretable margins. Concomitant endocervical sampling is preferred Both negative Cotest 3 years later © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved.
  • Managing Histological abnormalities
  • Managing CIN 1 • Seldom progresses • Regression occurs in 60%-80% with in 2-5 years1, up to 91% in younger women2 • So if you are not going to treat, where should these women be observed? – Screening Program vs. – Colopscopy Clinic – Favor return to annual screening with re-referral if have abnormal cytology
  • CIN 1 on Biopsy or ECC Satisfactory Colposcopy (Type 1 or 2 TZ) Observe with Colposcopy and cytology Q 6/12 x2 Return to screening protocol Unsatisfactory Colposcopy (type 3 TZ) Treatment Colposcopy and cytology -ve CIN persists or progresses Observe with Cytology at 12 months (preferred) Manage according to cytology CIN 1 after HSIL/AGC Review cytology and histology (if available) If discrepancy remains consider excisional procedure ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • *“Lesser abnormalities” include ASC-US or LSIL Cytology, HPV 16+ or 18+, and persistent HPV ∞ Management options may vary if the woman is pregnant or ages 21-24 +Cytology if age <30 years, cotesting if age ≥30 years † Either ablative or excisional methods. Excision preferred if colposcopy inadequate, positive ECC, or previously treated. Management of Women with No Lesion or Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 1 (CIN1) Preceded by “Lesser Abnormalities”*∞ Manage per ASCCP Guideline Follow-up without Treatment Cotesting at 12 months > ASC or HPV (+) HPV (-) and Cytology Negative Colposcopy Age appropriate* retesting 3 years later No CIN CIN2,3 CIN1 If persists for at least 2 years © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Follow-up or Treatment † Cytology negative +/- HPV (-) Routine screening
  • Management of Women with No Lesion or Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 1 (CIN1) Preceded by ASC-H or HSIL Cytology Cotesting at 12 and 24 months* Age-specific Retesting in 3 years+ Colposcopy HPV(+) or Any cytology abnormality except HSIL *Only if colposcopy was adequate and endocervical sampling negative ^ Except in special populations (may include pregnant women and those ages 21-24) + Cytology if age <30; cotesting if age ≥30 years © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. HPV(-) and Cytology Negative at both visits HSIL at either visit Diagnostic Excision Procedure ^ Or Review of cytological, histological, and colposcopic findings Or Manage per ASCCP Guideline for revised diagnosis
  • Management of Women Ages 21-24 with No Lesion or Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 1 (CIN1) < ASC-H or HSIL > ASC-H or HSIL Repeat Cytology @ 12 months Negative > ASC Routine Screening Repeat Cytology @ 12 mos After ASC-US or LSIL After ASC-H or HSIL © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Colposcopy Manage per ASCCP Guideline for Women Ages 21-24 with ASC-H or HSIL using postcolposcopy path for No CIN2,3
  • Managing CIN 2/3 • Clarify if it is CIN 2 vs. CIN 3 • use p16 to help • Especially in the woman < 25
  • CIN 2/3 in women 25+ • CIN 3 when followed has a malignant potential of 31% over a 31 year period1 • Treatment, preferably with excision for CIN 3 Mc Credie et al. Lancet Oncol 2007 Nov 8(5):425- 434
  • CIN 2,3 on Biopsy (>25 yrs old) Diagnostic Excision procedure (Type 3 excision of TZ) CIN 2,3 Treatment Satisfactory Colposcopy (type 1 or 2 TZ) Unsatisfactory Colposcopy (Type 3 TZ) ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Management of Women with Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 2 and 3 (CIN2,3) * Either Excision† or Ablation of T-zone * Cotesting at 12 and 24 months 2x Negative Results Any test abnormal Diagnostic Excisional Procedure † Adequate Colposcopy Inadequate Colposcopy or Recurrent CIN2,3 or Endocervical sampling is CIN2,3 Colposcopy With endocervical sampling *Management options will vary in special circumstances or if the woman is pregnant or ages 21-24 †If CIN2,3 is identified at the margins of an excisional procedure or post-procedure ECC, cytology and ECC at 4-6mo is preferred, but repeat excision is acceptable and hysterectomy is acceptable if re- excision is not feasible. Repeat cotesting in 3 years © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Routine screening
  • CIN 2 in the woman < 25 years old • Regression occurs in >40 % • Study from NZ showed regression rate of 62% over 8 months1 • So: – Clarify CIN 2 vs. 3 (even for HSIL designation) – Observe in colposcopy clinic those with CIN 2 – Treat CIN 3 McAllum B AJOG 2011;205:478.e1-7
  • CIN 2,3 on Biopsy in woman < 25 yrs1 CIN 2 Return to screening protocol Diagnostic Excision procedure CIN 3 Observe with Colposcopy and cytology Q 6/12 x2 yrs Treatment2 Satisfactory Colposcopy (Type 1 or 2 TZ) Unsatisfactory Colposcopy (Type 3 TZ) 1 Pathologist should be asked to clarify whether the lesion is CIN 2 or 3 2 LEEP or excision preferred for CIN 3 Negative CIN persists or progresses CIN Resolves ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Management of Young Women with Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 2,3 (CIN2,3) in Special Circumstances Young Women with CIN2,3 Colposcopy worsens or High-grade Cytology or Colposcopy persists for 1 year 2x Cytology Negative and Normal Colposcopy Repeat Colposcopy/Biopsy Recommended Observation - Colposcopy & Cytology @ 6 month intervals for 12 months Treatment using Excision or Ablation of T-zone © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. CIN3 or CIN2,3 persists for 24 months Treatment Recommended Either treatment or observation is acceptable, provided colposcopy is adequate. When CIN2 is specified, observation is preferred. When CIN3 is specified, or colposcopy is inadequate, treatment is preferred. Cotest in 1 year Cotest in 3 years Both tests negative Either test abnormal
  • Excision types • Removal/ treatment of a lesion should be adjusted to the lesion type. – Type 1 TZ requires a shallower excision or type 1 excision – Type 3 TZ requires a full “cone” or type 3 excision • New nomenclature suggested so that confusion is less, particularly when describing complications
  • Transformation zone type Type I Type II Type III completely ectocervical fully visible small or large ectocervical component has an endocervical component fully visible may have ectocervical component which may be small or large has an endocervical component is not fully visible may have ectocervical component which may be small or large
  • Managing AIS • Need to perform an adequate excision: Type 3 (20 mm long) • Consider Hyst if child bearing is complete • When the lesion is diagnosed after a LEEP for CIN, with negative margins • Further surgery is unnecessary1 Bryson et al. Gynecol Oncol 2004 May;93(2) 465- 468
  • AIS on Biopsy Observe with Colposcopy, ECC & cytology for 5 years 2 Return to screening protocol Diagnostic Excisional procedure1 1 ECC after DEP preferred 2 consider HPV testing Margins +ve for AIS Hysterectomy if childbearing complete Repeat Excisional Procedure Conservative Management Preferred No CIN 2 or > Margins -ve for AIS Acceptable Consider Hysterectomy if childbearing complete ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Management of Women Diagnosed with Adenocarcinoma in-situ (AIS) during a Diagnostic Excisional Procedure Margins Involved or ECC Positive Re-excision Recommended Hysterectomy - Preferred Long-term Follow-up Conservative Management Acceptable if future fertility desired © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. Margins Negative * Using a combination of cotesting and colposcopy with endocervical sampling Re-evaluation* @ 6 months - acceptable
  • 1 HPV testing for high risk HPV Return to screening protocol Follow-up at 6 and 12 months with colposcopy and cytology Follow-up at 6 months with cytology and HR-HPV testing1 O R Treat per guidelines, Excision preferred for CIN 2,3 CINNegative Follow-up Post treatment for CIN ALGORITHMS BASED ON SOGC/SCC GUIDELINES J Obstet Gynaecol Can 2012;34(12):1188-1202
  • Interim Guidance for Managing Reports using the Lower Anogenital Squamous Terminology (LAST) Histopathology Diagnoses Manage like CIN1 Low Grade Squamous Intraepithelial Lesion (LSIL)* © Copyright, 2013, American Society for Colposcopy and Cervical Pathology. All rights reserved. *Histopathology Results only. Manage like CIN2,3 High Grade Squamous Intraepithelial Lesion (HSIL)*
  • ASCCP algorithms available for iphone and android phones
  • www.ifcpc.org www.colposcopycanada.org www.asccp.org
  • www.ifcpc2014.com