about preventative strategy for ca cervix

1. “Prevention is better than cure”
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Dr Anuj Sharma

2. Preventative strategy – Ca Cervix
Dr Anuj Sharma
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Dr Anuj Sharma

3. Preventative strategy
• Preventable Ca
• Known etiology
• Long natural course of disease
• Preventative strategy
– Social and behavioral changes
– Life style / hygiene
– Vaccination
– Screening
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Dr Anuj Sharma

4. Social and behavioral changes
• Avoid child marriage / early coitarche
• Avoid polygamy
• Barrier contraception
• Personal hygiene
• Proper nutrition/ social uplifting
• Avoid substance abuse
• Immune surveillance management
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Dr Anuj Sharma

5. HPV Vaccines
Types
• HPV 16 & 18 (Cervarix,GSK)
• HPV 16,18,6,11 (Gardasil, Merk,FDA June
2006, Males in 2009)
• HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58
(Nonavalent, Merk, Dec 2014) …….still not
available in India !
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Dr Anuj Sharma

6. Recommended number of
doses
Recommended dosing
schedule
Population
2 0, 6–12 months Persons initiating
vaccination at ages 9
through 14 years, except
immunocompromised
persons
3 0, 1–2, 6 months
(0-2-6 m)
Persons initiating
vaccination at ages 15
through 26 years, and
immunocompromised
persons initiating
vaccination at ages 9
through 26 years
HPV Vaccines
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7. Screening – Ca Cervix
• Down Staging
• Pap Smear & Liquid Based Cytology (LBC)
• HPV DNA
• Colposcopy
– VIA & VILI
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8. Down Staging
• Detection of the disease in an earlier , curable
stage in asymptomatic women ,using simple
speculum examination.
• ASHA/ Aanganwari worker/ ANM
• Trained to diagnosed unhealthy cervix and
refer them to higher health center..
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9. Pap Smear
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10. PAPA OF PAP
Georgios Papanikolaou
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11. Screening of Ca Cervix
• Who should undergo ?
• When should it begin ?
• Why not early screening ?
• Co testing ?
• Exceptions
• Does early intercourse or Vaccination alter the
approach for screening ?
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12. Who Should Undergo
• All Females at the age of 25 yrs onwards
• Discontinue at 65 yrs Provided 3 samples are
negative in last 10 yrs
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14. Why Not Early Screening
• Increase anxiety, morbidity, and expense
• The emotional effect of labeling an
adolescent with a sexually transmitted
infection and potential pre-cancer must be
considered because adolescence is a time of
heightened concern for self-image and
emerging sexuality.
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Dr Anuj Sharma

15. Co Testing
• Preferred
• Performed every 5 yrs
- HPV + Cytology
• cytology alone every 3 y is a acceptable
option
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Dr Anuj Sharma

16. Exceptions
• Women who are infected with HIV (annualy)
• Women who are immunocompromised (such as
those who have received solid organ transplants)
• Women who were exposed to diethylstilbestrol
in utero
• Women previously treated for CIN 2, CIN 3, or
cancer
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17. Commonest Query
Early intercourse and vaccination does not alter
the approach.
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18. Conventional

19. LBC

20. Which One Is Better
• Both are same
• Advantage of LBC – Reflex HPV testing can be
done
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21. Interpretation Of Results
• Bethesda System (1 to 7)
• Dysplasia/CIN System (CIN 1,2,3, CIS, SCC)
• Papanicolaou System ( I to V )
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Dr Anuj Sharma

22. • Develops following HPV
infection.
• Clear zone around
nucleus (peri-nuclear
halo)
• Enlarged nucleus
• Increased staining of
nucleus
• Irregularity of nuclear
membrane
• High HPV DNA & Caspid
Antigen
Koilocytosis
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Dr Anuj Sharma

23. Normal Ectocervical Epithelium
Nonkeratinizing, stratified
squamous epithelium.
Mitoses are normally
confined to the lower layers,
namely, the basal and
parabasal epithelial layers.
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24. Low-grade Squamous Intraepithelial Lesion(LSIL)
Disordered proliferation of
squamous cells and increased
mitotic activity confined to the
basal one third of the epithelium.
Koilocytotic atypia, which is
indicative of proliferative HPV
infection, involves the more
superficial epithelium.
Koilocytosis Is nuclear enlargement,
coarse chromatin, nuclear
“wrinkling,” and perinuclear halos
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25. Disordered, highly
atypical squamous cells
and increased mitotic
activity involving the
full thickness of the
epithelium.
Note the mitotic figure
located close to
epithelial surface
(yellow arrow).
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High-grade Squamous Intraepithelial Lesion (HSIL)

26. Bethesda System of Reporting
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Dr Anuj Sharma

27. Bethesda System CIN / Dysplasia Papanicolaou System
Within Normal Limits Normal I Absence of atypical cells
Infection with organism Inflammatory atypia II Atypical cytology
Atypical squamous cells of
undetermined significance
ASCUS-US
Squamous atypia, HPV
atypia, Exclude LSIL
Atypical squamous cells to
exclude high grade lesions
ASCUS-H
HPV atypia
Exclude HSIL
Low-grade squamous
intraepithelial lesion LSIL
Mild dysplasia CIN I
High-grade squamous
intraepithelial lesion HSIL
Moderate dysplasia CIN II III Cytology suggestive of
malignancy but not
conclusive of malignancy
Severe dysplasia CIN III
Carcinoma in-situ
IV Cytology strongly
suggestive of malignancy
Squamous cell carcinoma Squamous cell carcinoma V Cytology conclusive of
malignancy
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29. ASCUS/LSIL
Reflex HPV
Testing Negative
Routine Scrn
Positive
Repeat Cytology
2 X Negative
Routine Screening
Cytology Positive
Colposcopy
Every Year
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30. ASC-H/HSIL (21-24 yrs Age)
Colposcopy
NO CIN 2,3
Observation with Colposcopy
& Cytology @6 months
interval X 2 years
2
Consecutive
Cytology (-)
& NO High
Grade
Colposcopic
Abnormality
Routine
Screening
HSIL / High
Grade
Colposcopic
Lesion
Persists for
1
Year
BIOPSY
CIN
2,3
CIN 2,3
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31. Colposcopy
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32. Colposcopy
• Examination under magnified illumination of the
cervix, vagina and lower ano-genital tract
• Triage of abnormal cytologic, virologic or clinical
findings
• Diagnosing neoplasia in ano-genital tract
• Abnormal or Adjunct to Pap smear / HPV testing
• There should be 80% accuracy rate in colposcopy
& histologic correlation
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33. • No contraindications but may be differed in case of
periods, use of intravaginal products 24 hrs prior to
procedure
• After application of estrogen cream in postmenopausal
women
• Explanation & consent before the procedure
• Transformation Zone
Type 1 - SCJ completely visible
Type 2 – SCJ partly visible
Type 3 - SCJ completely not visible
Colposcopy
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35. Visual Inspection
• VIA – visual inspection with acetic acid
• VILI - visual inspection with lugol’s iodine
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36. VIA
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37. VILI
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38. Colposcopy Interpretation
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39. • ¼ Lugol’s Iodine (Schiller’s Test)
- Rule out allergy history
- Normal ectocervix/vaginal squamous epithelium
(contains glycogen) stains mahogany brown
- Normal columnar/immature or neoplastic
epithelium (no glycogen) stains mustard yellow
Colposcopy Interpretation
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40. Zero Point One Point Two Point
Margin Distinct
Feathery
Angular jagged shape
Regular smooth
Straight edges
Rolled or Peeling
edges
Color Shinny or semi-
transparent whitening
Shinny grey white Dull reflectance
Oyster white
Vessels Fine calibre
Poorly formed pattern
No surface
vessels
Definite coarse
punctation or
mosaic pattern
Iodine Mahogony brown Mottled pattern
or partial iodine
staining
Mustard yellow
staining
Reid’s Colposcopic Index
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Dr Anuj Sharma

41. RCI (overall score) Histology
0 - 2 Likely to be CIN 1
3 - 4 Overlapping lesion: likely to be CIN 1 or
CIN 2
5 - 8 Likely to be CIN 2-3
Reid’s Colposcopic Index
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42. Swede’s Score
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43. Swede’s Score
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44. Management Issues
• ASC-US: repeat cytology/HPV/colposcopy
• ASC-H: colposcopy
• LSIL: repeat cytology(<20Yrs)/ HPV /
colposcopy
• HSIL: colposcopy or excisional procedure
• AGC: colposcopy, endocervical sampling, HPV
DNA, endometrial sampling
• HPV DNA: repeat Pap & colposcopy
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45. Treatment Modalities
• Cryosurgery
• Electro-coagulation Diathermy
• CO2 Laser Excision
• Loop Electrosurgical Excision Procedure LEEP
• Conization
• Hysterectomy
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46. Cryosurgery
• N2O evaporation causes crystallisation of
intracellular water resulting in cellular death
(Freeze-Thaw)
• -65to -85 degree Celsius & 19-25 mm minicone
• 5 mm depth (Equivalent to 7 mm lateral spread)
• Smaller ectocervical lesions with 90 % cure rate
• Watery malodorous blood tinged discharge
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47. Cryosurgery
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48. LEEP
• Cartier, 1990 : Outpatient & Tissue specimen
• Loop Electrodes 1-2 cm width & 0.7-1.5 mm
rectangular thin wire loops & 35-55 W
• 2-3 mm lateral & depth of 5-7 mm of entire TZ
• Ideal specimen dome shaped 5-6mm base to 7-
10 mm center
• Good for lateral lesions & Cure rates 95%
• Complications: bleeding/stenosis/incompetence
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49. LEEP
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50. LEEP
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51. Sequelae
• Vaginal discharge upto 3 weeks
• Minor spotting & secondary bleeding
• Douching, tampon use, SI to be avoided for
next 3-4 weeks
• Repeat Pap & Colposcope at 6 & 12 months
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52. Indications Of Conization
• Unsatisfactory colposcopy
• Entire lesion is not visible
• Discrepancy between cytology & HPE
• ECC is (+) in HSIL
• Microinvasion is suspected
• HPE suspected the adenocarcinoma
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53. Excisional Cervical Conization
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54. • Cure rates for high grade CIN is 95%
• Haemorrhage within 24 Hrs or after 10-21
days
• Rates of stenosis (3%) & incompetence is high
• Persistence is related to lesion
size/grade/extension
Excisional Cervical Conization
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55. सा विद्या या विमुक्तये
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Dr Anuj Sharma