prevention of cervical cancer

1. Practical tips
colposcopic treatment
modalities
in cervical lesions
DR. KAWITA BAPAT
Bapat hospital
One Day hysterectomy

2.
Colposcopy
low-­‐power
stereoscopic
binocular
field
microscope
powerful
light
source
magnified
visual
examina9on
uterine
cervix
diagnosis
of
cervical
neoplasia.

3. Welcome
to
One
Centre
for
Gynaecological
Excellence

5. Technologic advances!!
• New optical lenses
• fiber optic light cables
• video cameras
• Computer technology
• with digital computer enhancement

6. Screening colposcopy
• Feasible procedure
• More sensitive
• Cost effective than cytological screening.
• When access to cytopathology difficult
• an alternative (Cecchini et al,1997).

7. Current indications of colposcopy
• Part of any gynecologic examination
• Primary screening for cervical cancer
• Clinically suspicious cervix
• Abnormal Pap smear
• Evaluation & treatment of CIN
• Follow up after conservative therapy of CIN
• Postcoital bleeding.
• Patients with external vulval warts
• Evaluation of sexual assault victims.
• Patients with history of DES exposure

8. The key ingredients
• colposcopic examination
Observation cervical epithelium after application of
1. normal saline
2. 3-5% dilute acetic acid
3. Lugol’s iodine solution in successive steps.

9. Assessment of colposcopy
1. Vascular pattern
2. Inercapillary distance
3. Contour
4. Color
5. Clarity of demarcation
6. Appearance of gland opening
7. Whiteness after acetic acid
8. Negativity after iodine test
9. Surface extent of the lesion

10. Management of Abnormal Pap Test
Cryotherapy
or
Laser therapy
Leep(ectocervix)
No suspicon of
invasion
Cone Biopsy
Cold-knife
laser cone
Leep(ecto-and endocervix
Suspicion of Invasion
Biopsy
ECC
Repeat Pap test
suspicious of CIN/SIL
Abnormal Pap Smear

11. CIN
• Most cervical abnormalities caused by HPV infection
are unlikely to progress to high-grade CIN or cervical
cancer.
• Most low-grade CIN regress within relatively short
periods or do not progress to high-grade lesions.
• High-grade CIN carries a much higher probability of
progressing to invasive cancer.

12.
Diagnosis
of
cervical
neoplasia
• four main features:
1. intensity (colour tone) of acetowhitening
2. margins and surface contour of acetowhite areas
3. vascular features
4. colour changes after iodine application

13. International Federation of Cervical Pathology & Colposcopy(1991)
• Normal: Original squamous epithelium
Columnar epithelium
Normal transformation zone
• Abnormal: Acetowhite epithelium
Punctation
Mosaicism
Leukoplakia
Iodine negative
Atypical vessels

14. International Federation of Cervical Pathology & Colposcopy(1991)
Unsatisfactory: SCJ not visible
severe inflammation
atrophy
invisible cervix
• Miscellaneous: Nonacetowhite micropapillary surface
exophytic condyloma
inflammation
atrophy
ulcer

15. One Day hysterectomy

16. Eligibility criteria for LEEP
• CIN confirmed cirvical bispsy
• Lesion involves and extents into endocervical
• There is no evidence of
PID ,cervicitis,vaginaltrichonomoniasis ,bacterial
vaginosis,angonitel ulcer or bleeding disorder
• If the women is recently delivered
• She should be leased 3 months postmortem
• Without hypertension
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17. One Day hysterectomy

18. One Day hysterectomy

19. Histologicaly
proved
CIN
1
CIN
2-­‐3
Adinocarcinoma
Invasive
cancer
Treatment
if
persists
aEer
2
follow
up
visits
at
9
month
apart
Treat
immediately
Cold-­‐knife
coniza9on
Treatment
with
surgery
Clinical
follow
up
LEEP

20. One Day hysterectomy

21. Removal of polyp
One Day hysterectomy

22. One Day hysterectomy

23. One Day hysterectomy

24. One Day hysterectomy

25. One Day hysterectomy

26. One Day hysterectomy

27. Ablative Techniques
Cryotherapy
• Freezing to about -60C to -80C
• depth of 4 to 5 millimeters
• With a liquid NO2 probe
• Use a three minute freeze
• Five minute thaw
• Another three minute freeze.
• Least expensive
• Easiest treatment to perform.
• Limited evidence suppress hpv.
• Local anesthetic not necesscary
• Less painful.
One Day hysterectomy

28. Laser
• removes diseased tissue with a CO2 laser.
• Energy is converted into light which is focused by mirrors and lenses on a
small area where it vaporizes the tissue.
• precise to the problem area,
• measured depth of about 6 to 7millimeters.
• possible to do a contoured conization
• rapid healing
• less disagreeable discharge,
• better visibility of the SCJ after the procedure.
• Laser is used for the vulva and vagina
• best for multifocal cervical disease,
• lesions wide on the cervix, or if the vagina is involved.
•
One Day hysterectomy

29. Excisional Techniques
Loop Electrocautery Excision Procedure (LEEP)
Large Loop Excision of the Transformation Zone (LLETZ),
• cuts off the surface of the cervix
• depth of six to ten millimeters
• with a low voltage,
• high frequency radio signal in a tungsten wire.
• blended cutting and coagulation,
• area is cauterized as well.
• all of the transformation zone is removed
• easier to learn,
• easier to perform
• faster than ablative laser therapy
• cold-knife or laser conization.
•
•
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30. See and treat
• expert colposcopists may diagnose
and treat HSIL at the same visit
• but there is a significant chance of over
treatment so this should be limited to
women with clear evidence of CIN-3.

31. • Conization usually gives a complete tissue sample for
microscopic analysis.
• The pathologic evaluation of the cone specimen is again
subjective and also subject to sampling error, since selected
blocks are taken from the specimen for pathological analysis.
• Both laser and LEEP cones have a significant risk of thermal
damage sufficient to impede the pathologic diagnosis.
• LEEP cone usually results in several pieces making it harder
to evaluate the margins for residual disease.
• The cure rate for HSIL and probably even microinvasive
cancer is as good or better than hysterectomy.
• Cold-knife cone has a better cure rate than LEEP and is
preferred for possible AIS, cancer, and adenocarcinoma.
However, no conization by any method (or other treatment)
will "cure" HPV infection.
One Day hysterectomy

32. One Day hysterectomy

33. Low-grade CIN
• acetowhite lesions
Thin
smooth
well-demarcated
• margins
irregular,
feathery
digitating
angular.
High-grade CIN
• acetowhite areas
thick,
Dense
dull, opaque
• .

34. • The characteristics of acetowhite
changes, if any, on the cervix following
the application of dilute acetic acid are
useful in colposcopic interpretation
and in directing biopsies.

35. • The most common indication of referral
for colposcopy is positive screening
tests (e.g., positive cytology, positive
on visual inspection with acetic acid
(VIA) etc.).

36. • The colour changes in the cervix
• following the application of Lugol’s iodine solution,
• depends on the presence or absence of glycogen in the
epithelial cells.
• Areas containing glycogen turn brown or black
• Areas lacking glycogen remain colourless
• Pale or turn mustard or saffron yellow.

38. • The observation of well-demarcated
• dense,
• opaque,
• acetowhite area(s) in the transformation zone
• close to or
• abutting the squamocolumnar junction
• is the hallmark of colposcopic diagnosis of CIN.

39. See and treat lesions
Height of cost cutting
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40. One Day hysterectomy
Sufficiently
advanced
technology
is
indis>nguishable
from
magic
Thankyou

41. Take Care
• Care must be taken to avoid
exploitation of patients with expensive
unnecessary tests

42. Concept to keep in mind
A simplified approach will lead to a
significant reduction in both the time
and cost of investigating patients
(Strandell 2000)