4 prof walter managmet of cin

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4 prof walter managmet of cin

  1. 1. FOGSI / FIGO 2013 Hydrabad THE MANAGEMENT OF CIN wprendiville
  2. 2. The management of CIN • Should read The management of women with CIN • Should never be dictated by an individual test result, even histology • Should incorporate all the case characteristics • Is a balance of benefit vs harm
  3. 3. How to safely treat CIN3 • Safely means – Reducing the risk of cervical cancer to almost zero – Reducing the side effects of treatment to as low as possible
  4. 4. The management of CIN3 • Will always include – Pre-treatment counselling • Need for Rx, risks of Rx, need for follow up monitoring by cytology/HPV/Colposcopy – Assessment of all the case characteristics • Age, parity, future fertility, likelihood of default, cytology, histology, HPV status and other biomarkers where known.
  5. 5. Safe treatment of CIN3 • Will always mean – A preliminary colposcopic examination • By a trained colposcopist • Documenting specific findings – If excisional, Rx will be colposcopically guided – Eradication of the entire TZ – Sufficient tissue for histology to rule out invasive or associated GIN
  6. 6. Safe treatment of CIN3 • Will sometimes mean – That excision is necessary – Removal of a relatively large amount of cervical tissue – An associated increased risk of pre-term labour
  7. 7. Safe treatment of CIN3 • May sometimes – Be performed at the first / assessment visit – Be performed using a destructive method – Be performed under general anaesthesia – Be deferred
  8. 8. Choice of treatment for CIN EXCISIONAL DESTRUCTIVE Hysterectomy Radical diathermy Conebiopsy(Varietyoftechniques) Cryocautery LLETZ type1 LLETZ type2 LLETZ type3 Cold (orthermal)coagulation Laser excision Laser ablation
  9. 9. Destructive methods of treatment Advantages Simple, cheap, Equipment widely available Very effective in expert hands, No expense of histology of TZ Disadvantages No histological examination of TZ. Concern about the margins, the true diagnosis and the depth of excision
  10. 10. Preconditions for ablative therapy for CIN The TZ must be fully visible There must be no cytological or colposcopic suspicion of invasive disease There must be no cytological or colposcopic suspicion of glandular disease There should be no disparity between cytological and histological diagnosis The patient must not have had previous therapy for CIN
  11. 11. Indications for treatment As ever, a balance of risks 1. Risk of not treating the condition Progression to cancer ie ; 50% for CIN 3, perhaps 1% for CIN 1 2. Risk of treating the condition Short term morbidity, uncommon Long term complications in particular pregnancy related, if large type 2 or 3 TZ
  12. 12. Threshold for treatment • High grade disease – Virtually all CIN 3 – Most CIN 2 • High risk patient with persistent low grade disease – Smoker – Older – High default risk – Anxious – HPV and other biomarker test results
  13. 13. EXCISION OF THE TZ • Hysterectomy is rarely appropriate – Genuine risk of inadequately treating invasive disease – Unnecessary risk of general anaesthesia and major surgery and no benefit to patient – May miss VAIN
  14. 14. EXCISION OF THE TZ • Laser excision is entirely reasonable – Expensive – Useful for vaginal disease – Similar success and complications profile to LLETZ, with perhaps an increased risk of subsequent perinatal mortality
  15. 15. EXCISION OF THE TZ • LLETZ – Usually an outpatient procedure – Relatively inexpensive – Simple to perform – Accommodates all cases of CIN and Microinvasive disease and glandular disease – Needs modification according to presentation If performed inexpertly may be associated with excess morbidity
  16. 16. Optimising the treatment experience • Informed, comfortable, relaxed • TZ has adequately analgesia • Privacy, support, confidence • Appropriately sized suction- speculum
  17. 17. Excision of the TZ LLETZ • Under binocular colposcopic vision • Thoroughly anaesthetised TZ • After full colposcopic exam • Low magnification
  18. 18. Full colposcopic exam • Size and Type of TZ • SWEDE score • Diagnostic impression of worst lesion • Documented using ifcpc nomenclature
  19. 19. LLETZ LLETZ using a Tan Loop 2 x 2.5cms Applicable to wider type 1 TZs Dental syringe systemused for all LLETZ procedures Octapressin and citanest with a 2.2m. Vial and a 27 gauge needle
  20. 20. Excision: Principles of treatment • Treat the entire TZ • Excise only the TZ • Miminise the artefactual damage – Fulguration not dessication – Paint the wound with electrosurgery – Always have monsel’s paste available
  21. 21. Excision: Principles of treatment • Always, always treat under binocular colposcopic vision • Always ensure full vision of : – the entire TZ – the entire loop – and the adjacent vaginal wall • Pass the loop slowly from left to right
  22. 22. Principles of treatment • Choose the appropriate loop for the specific TZ • Modify the technique according to the TZ type • Ensure excision of the scj • Beware the type 3 TZ
  23. 23. Type I • Completely ectocervical • Fully visible • small or large Transformation Zone Classification
  24. 24. Type II • has endocervical component • Fully visible • may have ectocervial component which may be small or large Transformation Zone Classification
  25. 25. Transformation Zone Classification Type III • has endocervical component • is not fully visible • may have ectocervical component which may be small or large
  26. 26. Excision Types new IFCPC proposal • Type 1 Excision – Resection of a type 1 TZ • Type 2 Excision – Resection of a type 2 TZ • Type 3 Excision – Resection of a type 3 TZ – Glandular disease – Suspected microinvasion – Repeat treatment
  27. 27. Cases which require a type 3 excision • CIN with a type 3 transformation zone • Suspected microinvasive disease • Suspected glandular disease • Residual disease, ie previous treatment
  28. 28. Long loop or straight wire for electro-surgicaltype 3 transformation zone
  29. 29. Type 3 TZ Type 3 excision = approximately to a Cone biopsy LLETZ using a single large (blue) loop
  30. 30. Excision of a type 3 TZ • Using a long loop • Loop dimensions dictated by – TZ size – cervical size – patient future – pregnancy expections – anticipated grade of disease
  31. 31. Type 3 TZ Type 3 Excision approximates to a Type 3 TZ Using a straight wire
  32. 32. Type 3 TZ Type 3 Excision approximates to a Cone biopsy Using a straight wire ie SWETZ
  33. 33. Type 3 Excision • Parous woman, family complete, • V large type 3 TZ, suspicion of CIN3
  34. 34. Success of treatment Martin-Hirsch PL, Paraskevaidis E, Kitchener H., Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2000;(2):CD001318. • Published cure rates are very high no matter which technique is examined • Success is measured in surrogate ways • Cure ultimately means the woman will not develop cancer
  35. 35. Laser Ablation Com pared With Loop Excision Residual Disease: All Grades of CIN Graph of Relative Risks Alvarez (375) Dey (285) Gunasekera (199) Mitchel (251) Meta-analysis . 0 0.1 1 10 100 favours favours Loop Excision Laser Ablation NO SIGNIFICANT DIFFERENCE FOR ALL METHODS FOR ALL GRADES OF DISEASE CRYOTHERAPY SHOULD NOT BE USED FOR HIGH GRADE DISEASE Meta-analysis
  36. 36. Success of treatment • Surprisingly few large RCTs – No difference between techniques in terms of success – except cryocautery
  37. 37. Excision • Margin Status • Volume excised • TZ type • These three aspects of excision will inform both doctor and patient in terms of prediction of success and morbidity
  38. 38. Margin Status • Marker for risk of residual disease – Cytological suspicion 5 - 51% – Histologically proven 3 - 7% • Negative margins don’t preclude risk of residual disease
  39. 39. Margin status at excision • Ghaem-Maghami et al • Meta-analysis 35,109 subjects • Recurrence rate, high grade – Complete excision 3% – Incomplete excision 18%
  40. 40. The relation of type of excision and clear histopathological margins after LLETZ Dimitriou E., Martin M., Farrar K & Prendiville W. • 1071 women who underwent LLETZ between January 2004 and October 2008
  41. 41. The relation of type of excision and clear histopathological margins after LLETZ Dimitriou E., Martin M., Farrar K & Prendiville W. Small type 1 vs large type 2 RR=1.92 95%CI 1.19-3.08 Small type 1 vs large type 3 RR=3.41 95%CI 1.83-6.37 0% 20% 40% 60% 80% 100% Small TZ1 Large TZ2 Large TZ3 complet e pos ecto pos endo
  42. 42. The relation of type of excision and clear histopathological margins after LLETZ Dimitriou E., Martin M., Farrar K & Prendiville W 2009. • Large type 2 or 3 TZ excisions are associated with an increased risk of incomplete excision margin status • Perform larger TZ excisions in these circumstances and counsel appropriately
  43. 43. Complications after LLETZ • Short term morbidity low • Recent reviews have examined long term complications, specifically pregnancy related morbidity – Kyrgiou et al,Lancet 2006 – Arbyn et al BMJ, 2008
  44. 44. Risk of perinatal death by technique of excision • Estimate of one perinatal death for every 70 pregnancies in women treated by CKC, laser cone or RD compared to one in 500 for women treated by LLETZ
  45. 45. Severe pregnancy related outcomes Arbyn et al 2008 • The current meta-analysis demonstrates that CKC and probably also LC and radical diathermy place women at increased risk of PM and other serious pregnancy outcomes. LLETZ and Laser ablation do not.
  46. 46. Morphological damage after excision • Biologically plausible • Perhaps related to extent or amount of excision • Applies largely to cases where ablation would be inappropriate – Large type 2 or 3 TZ, – Previously treated patients, – Glandular or suspected Microinvasion
  47. 47. 48 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)
  48. 48. Risk of preterm labour after LLETZ Does size matter? A retrospective study Khalid S, Dimitriou E & Prendiville W BSCCP (poster) 2009
  49. 49. Excision dimensions and preterm labour Khalid S, Dimitriou E & Prendiville W 2009 • 1999 - 2002 • Obstetric & Colpo databases • 353 pregnancies in women after LLETZ
  50. 50. Excision dimensions and preterm labour Khalid S, Dimitriou E & Prendiville W 2009 Increased risk of preterm labour if specimens larger than 6 cubic cms RR 3.17, 95%CI 1.56 - 6.38
  51. 51. Excision dimensions and preterm labour Khalid S, Dimitriou E & Prendiville W 2009 Increased risk of preterm labour if specimens thicker than 12 mms RR 3.05, 95%CI 1.37 - 7.08
  52. 52. Choices in treatment • Depends on the case characteristics – Age, parity, contraception • Nulliparous 27yr old, minimum risk of default with a moderate cytological and colposcopic abnormality • Sterilised parous 24 yr old with a moderate cytological and colposcopic abnormality
  53. 53. In summary • Define your treatment threshold • Always treat under colposcopic vision • Excise the entire TZ preferably as one piece • Minimise the excision of normal tissue • Minimise morbidity of wound managment
  54. 54. The BSCCP invites you to the 15th World Congress On behalf of IFCPC In London 26-30th May 2014 www.IFCPC2014.c

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