Mr Ayman Ewies, consultant gynaecologist, is an invited speaker in national and international colposcopy courses.

1. Management Techniques
Ayman Ewies
Consultant Gynaecologist
The Ipswich Hospital
24th April 2009

2. Colposcopic Directed Biopsies?

3. 3
Is it important?
 Biopsy is mandatory if the planned intervention is
destructive.
 It may not be required if an excisional technique is to be
employed.
 The type of biopsy depends on:
1. The clinical situation.
2. The degree of abnormality.
3. The need to exclude invasive or glandular disease.

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Types of biopsy
 Punch
 Cone
 Endocervical curettage

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1- Punch Biopsy
 It is indicated when there is discrepancy between cytology and colopsopy in
grading.
 The lesion has to be fully visible i.e. satisfactory colposcopy.
 Multiple biopsies give greater diagnostic accuracy than a single biopsy.
 The most severe areas of the lesion should be included.
 Biopsy should include the stroma.
 Punch biopsy forceps is used to remove a piece of tissue (approximately 3.5
mm in diameter).
 Usually no anesthetic is required.
 Bleeding may require silver nitrate or Monsel’s solution.

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2- Cone Biopsy
 It may be used for diagnostic and therapeutic purposes.
 No further treatment may be needed in completely excised
early invasive disease, CIN, or CGIN.
 It may be indicated for diagnostic purposes in the
following situations:
1. Suspected malignancy
2. Glandular abnormality
3. Positive cytology with unsatisfactory colposcopy.
4. Persistently positive cytology with negative colposcopy.
5. Upper limit of an apparent lesion is not visible.

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2- Cone Biopsy
 It can be undertaken using different techniques:
1. Scalpel (needs GA).
2. Loop diathermy.
3. CO2 Laser.

8. 8Knife Cone Biopsy

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3- Endocervical Curettage (ECC)
 Its use and indications remain controversial.
 It may be useful in cases of unsatisfactory colposcopy
with:
1. Abnormal glandular cells on cytology.
2. Lesions extending into the canal.
 The problems:
1. Blind procedure.
2. The scrapings are too superficial and may miss disease in the
crypts.

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3- Endocervical Curettage (ECC)
 Studies showed that sampling with endocervical
brush to be equally or more informative.

11. Management Techniques

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Rational for Treatment
 Treatment is designed to prevent cervical cancer
development by eradicating the preinvasive process with
minimal morbidity.
 Regardless of treatment modality used, the aim should be
to remove the TZ.
 Depth of treatment should be to 7 mm since studies have
shown that gland crypts involved with CIN may extend up
to 5.2 mm into the cervical stroma.
 Depth of treatment should be to 10 mm for CGIN.

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Criteria for ideal techniques
1. Office based.
2. Cheap.
3. Quick.
4. With minimal or no discomfort.
5. Curative.
6. With little or no adverse effects.
7. Followed by good healing.
8. Allow for adequate cytology follow up.

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Techniques
Ablation (destruction) Excision*
Cryotherapy Diathermy Loop Excision
Thermal Ablation Laser Cone Biopsy
Cold coagulation Cold knife Cone Biopsy
CO2 laser ablation Hysterectomy
*Much more commonly used in the current practice.

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Advantages of excisional techniques
1. Allow using of “see & treat” policy.
2. Allow histological analysis of the excised specimens
(Punch biopsy may miss pathology).
3. Help recognizing incomplete treatment.
4. Excisional histology can be used in quality assurance of
the colposcopist.

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1- Diathermy Loop Excision
 The leading mode of treatment in most countries
because of :
1. Ease of performance
2. Very low associated morbidity
 In Europe  LLETZ = Large Loop Excision of
Transformation Zone.
 In North America  LEEP = Loop
Electrosurgical Excision Procedure.

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1- Diathermy Loop Excision
 Fulguration: occurs when the electrode is placed a millimeter or so
from the tissue to be treated.
– Using a blend of cutting and coagulation for the excision, the loop
should be transversed across slowly so that a fulgurative cutting
and coagulative effect ensues.
– If the loop is pushed or a hurried procedure is conducted, then
desiccation occurs and thermal damage occurs to the excised
specimen.
 Desiccation (literally means dehydration): occurs when the electrode
(loop ore ball) physically is touching the tissue and causes more
thermal damage.

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 CIN extending to margins at excision results in higher
incidence of recurrence but does not justify routine repeat
excision as long as:
– No glandular abnormality.
– No invasive disease.
– <50 years of age.
 Women >50 years who have CIN 2/3 at the endocervical
margin and in whom satisfactory cytology and colposcopy
cannot be guaranteed  repeat excision to obtain clear
margins.
 Women with CGIN with incomplete excision at
endocervical margin  repeat excision to obtain clear
margins and exclude occult invasive disease.
1- Diathermy Loop Excision

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Information given to patients following loop excision
 Not to use tampons.
 To abstain from intercourse for 4 weeks.
 A single loop excision is associated with small but significant increase
incidence of preterm labour (7% V 11%).
 There may be a change in the menstrual pattern.
 Not to swim for 2 weeks.
 Normal activities including light exercise can continue as normal.
1- Diathermy Loop Excision

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23. Video Clip 4 - 10:34 min
LLETZ
..VideosClip 4 - LLETZ -
10.34.flv

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2- Laser
 The CO2 laser is most widely used.
 It can be used for either ablative or excisional techniques.
 It is a precise tool that can be focused to a specific spot
0.2-2mm diameter.
1. It allows good control of depth of destruction & good
haemostasis.
2. It allows excellent healing because there is minimal
thermal damage to the adjacent tissues.

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2- Laser
 The biologic effect is thermal.
– The tissue is vaporized at the speed of light.
 It requires local anesthetic and speculum with a smoke
extractor.
 Disadvantage: the initial cost and maintenance of the
machines.

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3- Cold Knife Cone Biopsy
 It is still used in cases where:
1. The TZ is not fully visualized.
2. There is suspected invasive disease or glandular
abnormality which requires histopathological
guarantee of the excision margins.

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4- Hysterectomy
 It may be indicated when:
1. CIN is present with other gynaecological condition e.g.
fibroids.
2. CIN is suspected or confirmed with no much cervix
left after multiple treatments.

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Requirements for ablative treatment
1. Satisfactory colposcopy i.e.
– TZ is fully visible.
– The lesion is completely visible.
2. Invasive disease ruled out by biopsy.
3. Concordance between cytology, colposcopy and
histology.
4. No evidence of a glandular lesion.
5. No evidence of endocervical involvement (Colposcopy ±
ECC).
6. No previous treatment to the cervix.

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1- Cryotherapy
 Principle: It refers to the application of a super-cooled
probe using refrigerant gases (nitrous oxide or carbon
dioxide) directly to the cervical lesion.
– The freezing point of nitrous oxide is -90oC and that of CO2 is
-60oC.
– Cell death occurs at -20oC.
 The biological effect: cryonecrosis (which occurs as a
result of formation of an iceball).
– Crystallization of intracellular water destroys the cells.
 The margin of the iceball should be at least 3-5 mm in
excess of the area to be destroyed.

30. 1- Cryotherapy
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A variety of probes are available of differing size and shape.

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1- Cryotherapy
 Indication: small low grade lesions.
 Duration of treatment: 2 minutes.
– if the lesion is large  multiple applications should be
employed.
– A freeze-thaw-freeze (double freeze) technique is
associated with improved efficacy and must be used.
– No anesthesia is required.
 Disadvantages:
1. Copious vaginal discharge for several weeks.
2. Cervical stenosis is commoner than other
modalities.

32. 1- Cryotherapy

33. Video Clip 5 - 4:26 min
Cryotherapy
..VideosClip 5 - Cryotherapy -
4.26.flv

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2- Cold Coagulation
 It employs heat applied to tissue using a Teflon-coated
thermosound.
 Treatment is conducted usually at 100-120oC for 30
seconds.
 The biological effect: desiccation.
 These temperatures are much lower as compared with
earlier electrocautery, hence the term cold.
 Advantages:
1. No anesthesia is required.
2. Following treatment, there is no need to place any restriction on
sexual intercourse or the use of tampons.

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3- Electro-diathermy = Thermal Ablation
 It destroys tissue by burning with high frequency
alternating current using ball diathermy.
 The biological effect: fulguration.
 It requires local anesthetic and speculum with a smoke
extractor.
 Fibrosis is commoner than other modalities of ablation,
but it does not appear to affect subsequent fertility or
obstetric outcome.

36. Complications of Treatment

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Complications - rare
 Morbidity is very low with all forms of treatment.
 Early:
– Bleeding
– Secondary infection
– Discharge (mainly with cryotherapy)
 Late: stenosis
– Commoner after cryotherapy and cold knife cone biopsy.
– Depends on the depth of treatment.
1. Difficulty in gaining adequate sample for cytology
2. Fertility problems
3. Menstrual dysfunction: amenorrhoea or dysmenorrhoea

38. Post-treatment Cervix

39. Post-treatment Cervix

40. Post-treatment Cervix

41. Post-treatment Cervix

42. Follow-up After Treatment

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Follow-up
 Objectives: To detect disease either:
1. Residual (within 12 months of treatment), or
2. Recurrent (after 12 months of treatment).
 It is believed that most second lesions are due to
progressive enlargement of small foci of residual disease
which has been missed on treatment.
 The risk of cervical cancer in women who underwent
treatment for CIN is 3-5 times the background rate for at
least 10 years.
 The risk of cervical cancer in women who develop
abnormal cytology following treatment for CIN is 25-30
times the background rate.

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How?
 The role of colposcopy is debatable in F/U of CIN:
– TZ may not be visible to its entirety.
– The regenerating epithelium is often misjudged as CIN.
 Colposcopy has no role in F/U of CGIN.
 Nonetheless, cytology can give false negative result:
– The residual disease may be very small.
– The residual disease may be covered by regenerated normal
epithelium.

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Risk factors for treatment failure
1. Large lesions (> 1cm2).
2. High grade lesions.
3. Older women > 50, since TZ is not always fully visualized.
4. Incompletely excised margins, particularly endocervical.
5. Smokers have 3-fold higher failure rate than non-smokers.
6. Technical reasons:
1. Inexperienced colposcopist.
2. Inappropriate choice of treatment method.
3. Operative difficulties e.g. poor access.

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Duration
 No CIN (previous abnormal cytology)  smear 6, 12 months.
 CIN 1  smear at 6, 12, 24 months.
 CIN 2 & 3 or CGIN*  smear at 6 (± colposcopy), 12 months, then
annually for further 9 years.
 CIN on hysterectomy:
– F/U as if cervix is in situ if concerned about excision margins.
– Vault smear 6, 12 months if margins are clear.
If all normal  routine recall cytology
*ensure the sample contains endocervical cells.

47. Management Techniques Require Skills