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Practical tips colposcopic treatment modalities
This document provides an overview of colposcopy techniques and procedures for diagnosing and treating cervical lesions. It discusses the use of colposcopy for examination of the cervix using magnification and acetic acid to identify abnormalities. Various treatment modalities are described including cryotherapy, laser therapy, LEEP, and cone biopsy. Guidelines are presented for managing low-grade versus high-grade cervical intraepithelial neoplasia. The document emphasizes the importance of accurate diagnosis and avoiding overtreatment. It concludes that a simplified approach can reduce costs while still effectively investigating and managing patients.
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Practical tips colposcopic treatment modalities
- 1. Practical tips colposcopic treatment modalities incervical 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!! • Newoptical lenses • fiber optic light cables • video cameras • Computer technology • with digital computer enhancement
- 6. Screening colposcopy • Feasibleprocedure • More sensitive • Cost effective than cytological screening. • When access to cytopathology difficult • an alternative (Cecchini et al,1997).
- 7. Current indications ofcolposcopy • 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 AbnormalPap 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 cervicalabnormalities 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 ofCervical 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 ofCervical Pathology & Colposcopy(1991) Unsatisfactory: SCJ not visible severe inflammation atrophy invisible cervix • Miscellaneous: Nonacetowhite micropapillary surface exophytic condyloma inflammation atrophy ulcer
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- 16. Eligibility criteria forLEEP • 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 One Day hysterectomy
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- 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
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- 21. Removal of polyp OneDay hysterectomy
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- 27. Ablative Techniques Cryotherapy • Freezingto 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 diseasedtissue 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 ElectrocauteryExcision 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. • • One Day hysterectomy
- 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 usuallygives 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
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- 33. Low-grade CIN • acetowhitelesions Thin smooth well-demarcated • margins irregular, feathery digitating angular. High-grade CIN • acetowhite areas thick, Dense dull, opaque • .
- 34. • The characteristicsof 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 mostcommon indication of referral for colposcopy is positive screening tests (e.g., positive cytology, positive on visual inspection with acetic acid (VIA) etc.).
- 36. • The colourchanges 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 observationof 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 treatlesions Height of cost cutting One Day hysterectomy
- 40. One Day hysterectomy Sufficiently advanced technology is indis>nguishable from magic Thankyou
- 41. Take Care • Caremust be taken to avoid exploitation of patients with expensive unnecessary tests
- 42. Concept to keepin mind A simplified approach will lead to a significant reduction in both the time and cost of investigating patients (Strandell 2000)