To understand referral pathway for Colposcopy and treatment of precancerous lesion of cervical cancer. To provide facts that would be benefit for MRCOG exam.
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NHSCSP cervical screening program and treatment of CIN and CGIN
1. NHS cervical screening ( NHSCSP) and
treatment of CIN ( CBL )
Dr Wai Phyo
MBBS, MMedSc, MRCOG (UK)
Consultant Gynaecologist
2. Outline
Screening program policy
Management and referral guideline for colposcopy
Case base learning
Treatment of CIN
Treatment of CGIN
Management in special circumstances
HPV primary screening
6. Facts
Age 55 to 69, a negative screening result in the previous five years offers considerable
protection (83%)
women aged 40 to 54 need to have a negative screening result in the previous three years to
achieve a similar level of protection (84%).
For women under 25,
the prevalence of HPV infection after coitarche is high,
with the result that sexually active women in this age group are quite likely to have HPV-associated
cellular changes.
Because HPV infection is less likely to persist in younger women,
the majority of low-grade abnormalities detected in cytology samples taken from women will
regress spontaneously with time.
The incidence of cervical cancer in this age group is very low.
result in a large number of referrals to colposcopy for further investigation.
Unscheduled cervical screening does not form part of the NHSCSP with the exception of HIV
positive women.
7. Liquid-based cytology
Cost-effective
Offering improved sensitivity without any reduction in specificity
A reduction in the number of inadequate tests reported.
9. HPV triage and test of cure
borderline/low grade
dyskaryosis
HPV test
Negative
Positive Colposcopy
Routine Call
10. HPV triage and test of cure
Negative/Boderline/LGD HPV test
Negative
Positive Colposcopy
Recall in 3 years (
irrespective of age)
Return to Routine
Call if subsequence
LBC is normal
Six Months after treatment
11. HPV triage and test of cure
HGL Colposcopy
Without HPV test
16. Colposcopy
Biopsy Proven
CIN 1
No treatment
Cytology at 12 months
Cytology Negative
Repeat cytology at 12 months
Cytology negative
Routine Recall
LG/borderline
HPV test
HPV Negative
Routine Recall
HPV Positive
Colposcopy
HPV inadequate
Repeat at 3 months
HG
Colposcopy
Treatment
TOC guideline
If the lesion persists for longer than 24 months the treatment should be
discussed with the patient.
17. TOC
CIN
Cytology at 6 months
Negative/BL/LG
HPV positive
Colposcopy
HPV negative
3 years recall
(irrespective of age)
HG or Worse
Colposcopy
All women after treatment for CIN should be
discharged from colposcopy. Either complete
excision or not. Except in women over 50 years who
will need repeat excision when CIN 3 at lateral
margin.
18. CGIN
TOC
Completely excised
First or Re-excision
TOC
6 months after Rx
TOC
Cytology Negative, HPV inadequate
Repeat at 3 months
Cytology,HPV-Negative
Second TOC
12 months later(18 months after Rx)
Cytology,HPV- Negative
Recall in 3 years
Cytology abnormal
HPV Positive
Colposcopy
Colposcopy—Normal
19. CGIN
Incompletely excised / Declined re-excision
Cytology at 6 months
If Negative
2nd Cytology at 6
months later
Annually for 9 years
21. Follow-up of untreated women
Women referred with high-grade dyskaryosis (moderate or severe) with
Normal colposcopy? How to manage?
Women referred with high-grade dyskaryosis on their test result who have a
colposcopically low grade lesion, whose colposcopy is satisfactory. How to
manage?
23. Cytology – HG
Colposcopy - Normal
Multiple punch biopsy
No treatment
Cytology+Colposcopy
Every six months
Cytology – HG persist
Excisional treatment
24. Cytology – BL/LG
HPV positive
Colposcopy- LG and satifactory
NO need biopsy to confirm LG
12 months FU
25. Women referred with a result of low-grade dyskaryosis or less and HPV positive that have a
colposcopically low grade lesion may be followed up at 12 months in the colposcopy clinic or
the community. Colposcopic biopsy at initial assessment is not essential to confirm or exclude
low grade CIN. If the lesion has not resolved within two years of referral to colposcopy, at
least a biopsy is warranted (more than 90%).
26. Swede score 0 1 2
Aceto uptake Nil or
transparent
Thin, milky Distinct, stearin
Margins Nil or diffuse
Sharp but
irregular, jagged,
satellites
Sharp and even,
difference in
level
Vessels Fine, regular Absent
Coarse or
atypical vessels
Lesion size < 5 mm
5-15 mm or 2
quadrants
>15 mm, 3-4
quadrants, or
endocervically
undefined
Iodine uptake Brown
Faintly or patchy
yellow
Distinctly yellow
Final Swede score: 1
Provitional diagnosis --- Type 1 TZ, Normal
Biopsy ----- Not done
Management ------ Routine screen
27. Swede score 0 1 2
Aceto uptake
Nil or
transparent Thin, milky Distinct, stearin
Margins Nil or diffuse
Sharp but
irregular, jagged,
satellites
Sharp and even,
difference in
level
Vessels Fine, regular Absent
Coarse or
atypical vessels
Lesion size < 5 mm 5-15 mm or 2
quadrants
>15 mm, 3-4
quadrants, or
endocervically
undefined
Iodine uptake Brown Faintly or patchy
yellow
Distinctly yellow
Provisional diagnosis: Type 1 transformation zone; normal.
Management: Routine screening after 5 years.
Histopathology: Normal.
Comment:
Thin acetowhite areas with centripetal tongue-like projection that are faintly yellow after Lugol’s iodine are
characteristic of immature metaplasia.
28. Swede score 0 1 2
Aceto uptake
Nil or
transparent Thin, milky Distinct, stearin
Margins Nil or diffuse
Sharp but
irregular, jagged,
satellites
Sharp and even,
difference in
level
Vessels Fine, regular Absent
Coarse or
atypical vessels
Lesion size < 5 mm 5-15 mm or 2
quadrants
>15 mm, 3-4
quadrants, or
endocervically
undefined
Iodine uptake Brown Faintly or patchy
yellow
Distinctly yellow
Provisional diagnosis: Type 1 transformation zone; CIN1 with SPI.
Management: Punch biopsy from the lesion on the posterior lip.
Histopathology: LSIL-CIN1.
Comment:
Colposcopy should be repeated after 1 year. The lesion should be treated if the lesion is persistent after 2 years or
increases in size or severity at any time.
29. Swede 0 1 2
Aceto uptake
Nil or
transparent
Thin, milky Distinct, stearin
Margins Nil or diffuse
Sharp but
irregular, jagged,
satellites
Sharp and even,
difference in
level
Vessels Fine, regular Absent
Coarse or
atypical vessels
Lesion size < 5 mm 5-15 mm or 2
quadrants
>15 mm, 3-4
quadrants, or
endocervically
undefined
Iodine uptake Brown
Faintly or patchy
yellow Distinctly
Provisional
diagnosis:
Type 1 transformation zone; high-grade squamous intraepithelial lesion (HSIL).
Management: LLETZ (type 1 excision).
Histopathology: HSIL-CIN2.
Comment: TOC followup
30. Swede score 0 1 2
Aceto uptake
Nil or
transparent
Thin, milky Distinct, stearin
Margins Nil or diffuse
Sharp but
irregular, jagged,
satellites
Sharp and even,
difference in
level
Vessels Fine, regular Absent
Coarse or
atypical vessels
Lesion size < 5 mm
5-15 mm or 2
quadrants
>15 mm, 3-4
quadrants, or
endocervically
undefined
Iodine uptake Brown
Faintly or patchy
yellow Distinctly yellow
Provisional
diagnosis:
Type 1 transformation zone; high-grade squamous intraepithelial lesion (HSIL).
Management: LLETZ (type 1 excision).
Histopathology: HSIL-CIN3.
Comment:
Although the acetowhite lesion is visible only in part of the posterior lip, all four quadrants are iodine-negative.
The entire iodine-negative area should be excised during LLETZ. The acetowhite area may not be visible in
of high-grade lesions, due to erosion.
31. Swede score 0 1 2
Aceto uptake
Nil or
transparent
Thin, milky Distinct, stearin
Margins Nil or diffuse
Sharp but
irregular, jagged,
satellites
Sharp and even,
difference in
level
Vessels Fine, regular Absent Coarse or
atypical vessels
Lesion size < 5 mm 5-15 mm or 2
quadrants
>15 mm, 3-4
quadrants, or
endocervically
undefined
Iodine uptake Brown
Faintly or patchy
yellow
Distinctly yellow
Provisional
diagnosis:
Type 3 transformation zone; high-grade squamous intraepithelial lesion (HSIL) of the cervix extending to the vagina.
Management: LLETZ (type 3 excision) with laser ablation of the residual vaginal lesion.
Histopathology: HSIL-CIN3.
Comment:
CIN3 lesions may extend to the vagina, especially in elderly women. In such cases, LLETZ is crucial to exclude invasive focus,
especially inside the endocervical canal. Hysterectomy with removal of adequate vaginal cuff may be performed after excluding
invasive cancer by LLETZ.
33. Colposcopic Excisional biopsy
An excisional form of biopsy is recommended in the following circumstances:
When most of the ectocervix is replaced with high-grade abnormality
When low-grade colposcopic change is associated with high-grade dyskaryosis (severe) or worse
When a lesion extends into the endocervical canal, sufficient cervical tissue should be excised to
remove the entire endocervical lesion ( Atypical transformation zone )
34. Colposcopically directed punch biopsy
Unless an excisional treatment is planned, biopsy should be carried out when the cytology
indicates high-grade dyskaryosis (moderate) or worse, and always when a recognizably atypical
transformation zone is present. Cases occurring in pregnancy are an exception.
Low-grade cytological abnormality (low-grade dyskaryosis or less) and a low-grade or negative
colposcopic examination do not require colposcopic biopsy if there is no atypical
transformation zone present.
In deciding on treatment (and especially if destructive methods are being considered)
associated cytological and colposcopic findings are as important as the result of directed
biopsy.
35. Surgical techniques
There is no obviously superior conservative surgical technique for treating and
eradicating CIN, however, ablative techniques are only suitable when:
The entire transformation zone is visualised (100%)
There is no evidence of glandular abnormality (100%)
There is no evidence of invasive disease (100%)
There is no major discrepancy between cytology and histology.
36. ‘See and Treat’ policy
Treatment at first visit to colposcopy for a referral of borderline or low-grade dyskaryosis
should not be offered.
All suspected CIN 2 and 3 must be treated
37. Local destruction
All women must have an established histological diagnosis before
undergoing destructive therapy
Cryocautery
Cryocautery should only be used for low-grade CIN and a double freeze-
thaw-freeze technique must be used
38. Excision
Removal of specimen
When excision is used, at least 80% of cases should have the specimen removed as a single sample.
Depth of excision
Type I cervical transformation zone
For treating ectocervical lesions, excisional techniques should remove tissue to a depth/length of more than
7mm , though the aim should be to remove <10mm in women of reproductive age
Type II cervical transformation zone:
Excisional techniques should remove tissue to depth/length of 10mm to 15mm
Type III cervical transformation zone:
Excisional techniques should remove tissue to a depth/length of 15mm to 25mm
Histological assessment of the depth of crypt involvement by CIN3 has shown a mean depth
of 1mm to 2mm with a maximum of 5.22mm
39. Excision and risk of preterm
Increased risk of preterm delivery after loop treatments >10mm in depth
Loop excisions greater than 12mm in depth are associated with a threefold increase in
preterm delivery
8% for excisions between 10mm and 14mm, rising to 18% for excisions over 20mm in
depth/length.
40. Repeat excision
CIN3 extending to margins
CIN3 extending to the lateral or deep margins of excision (or uncertain margin status)
results in a higher incidence of recurrence but does not justify routine repeat excision
provided:
there is no evidence of glandular abnormality
there is no evidence of invasive disease
the woman is under 50 years of age
42. CGIN
Young/ SCJ
visible
Cylindrical
excisional biopsy
Including TZ and 1 cm of endocervix above TZ
Older/SCJ not
visible
Cylindrical
excisional biopsy
Including visible TZ and 20 to 25 mm of
endocervical canal
Endometrial biopsy, +/-
pelvic imaging should be
considered.
After Tx, follow TOC
43. CGIN
TOC
Completely excised
First or Re-excision
TOC
6 months after Rx
TOC
Cytology Negative, HPV inadequate
Repeat at 3 months
Cytology,HPV-Negative
Second TOC
12 months later(18 months after Rx)
Cytology,HPV- Negative
Recall in 3 years
Cytology abnormal
HPV Positive
Colposcopy
Colposcopy—Normal
44. CGIN
Incompletely excised / Declined re-excision
Cytology at 6 months
If Negative
2nd Cytology at 6
months later
Annually for 9 years
45. Hysterectomy for cervical glandular neoplasia
Fertility is not required
Positive margins after an adequate excisional procedure
Treatment by cone biopsy is followed by further high grade cytological abnormality
The patient is unwilling to undergo conservative management
Adequate cytological follow up has not been possible, eg because of cervical stenosis
The patient has other clinical indications for the procedure
Invasive disease has been confidently excluded.
47. Pregnant women
Cervical screening during pregnancy
Should not be delayed
Previous Colposcopy was abnormal
After tx of CGIN,CIN 2 and 3 for TOC sample
During Pregnancy, Colposcopic examination
CIN 1 suspected ------ Three months following delivery
CIN 2/3 suspected -----
Repeat Colposcopy at end of 2nd trimester
Repeat Colposcopy 3 months following delivery
Invasive disease suspected----- Adequate biopsy
48. Contraception
No need to change COC pills if currently use
Not necessary to remove IUD to performe local treatment
Condom use for 3 months promote HPV clearence and CIN 1 regression
49. Women with renal failure requiring
dialysis
Must have cervical cytology at or shortly after diagnosis
All women undergo organ transplantation, should have cervical cytology
performed with previous year.
Five fold increase risk
40% women acquiring virus within 6 months of transplant
50. Women who are HIV positive
Intially Colposcopy examination
Annual cytology
Recurrent rate after treatment of CIN is 87% vs 10% in immunocompetent women
51. Women exposed in Utero to DES
Exposure to
DES
Colposcopy
Negative
Routine screening program
Positive
Annual Colposcopy of vagina,
cervix
52. Follow up after Stage Ia 2/Ib 1 conservative Tx
Stage Ia 2/ Ib 1
Only cytology
6 and 18 months after Tx
Annually * 9 years
NO HPV Test
53. Hysterectomy
Routine call + No CIN
NO further FU
No routine call +
NO CIN
6 months smear
No FU
Completely
excised CIN
6 & 18 months
No FU
Incompletely
excised CIN
CIN I
6,12 and 24
months after TX
CIN 2/3
Annually for nine year upto 65
years or 10 years after Surgery
56. HPV Primary screening
HPV-based screening offers a 60e70% greater protection against invasive
cervical cancer when compared to cytology.
Improved accuracy may permit the prolongation of screening intervals
from three to five years.
Sensitivity of 96.1% and specificity of 90.7% for HPV testing versus
cytology which had a sensitivity of 53% and specificity of 96.3%.
Disadv:
Many women testing positive will have just transient HPV infections.
Triage tests are required to better identify the women who would benefit most
from colposcopic referrals and minimise overload of colposcopy clinics