2 prof james bently differentiating high and low grade

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2 prof james bently differentiating high and low grade

  1. 1. COLPOSCOPY OF CIN; DIFFERENTIATING HIGH GRADE FROM LOW GRADE LESIONS James Bentley , Professor Department of Obstetrics and Gynecology, Dalhousie University, Halifax NS, Canada
  2. 2. Normal CIN 1 CIN 2 CIN 3 Cancer
  3. 3. Progression/Regression of CIN Regress Persist Progress to CIS Progress to invasion Months to CIS from baseline CIN 1 57% 32% 11% 1% 58 CIN 2 43% 35% 22% 5% 38 CIN 3 32% <56% - >12% 12 OsterAG. Int J Gynecol Pathol 1993;12:86 Richart RM, Barron BA. A follow-up studyof patientswith cervical dysplasia.Am J Obstet 1969;105:386–393 Resolution of CIN 1 in adolescent is 90% CIN 3/ CIS progression to cancer in 31% of cases treated by Bx; McCredie et al Lancet Oncology 2008 9(5) 425-34
  4. 4. ASCUS LSIL Images downloaded from http://nih.techriver.net/bethesdaTable.php
  5. 5. Results: hc2 +ve Pap smear history Number of cases HybridCapture 2 +ve 1 95%Confidence intervals ASCUS/ASCUS 87 58 (67%) 56% to 76% ASCUS/LSIL 33 23 (74%) 52% to 82% LSIL/ASCUS 19 18 (95%) 73% to 100% LSIL/LSIL 21 15 (71%) 49% to 86% All cases 160 114 (72%) 64% to 78% 1 note 10 specimens had insufficient sample •No significant difference between groups for hc2 Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC 2008
  6. 6. Results: CIN2 + on Bx Pap smear history Number of cases CIN 2 or greater 95%CI ASCUS/ASCUS 87 23 (26%) 18% to 37% ASCUS/LSIL 33 7 (21%) 10% to 38% LSIL/ASCUS 19 2 (10.5%) 1.7% to 32% LSIL/LSIL 21 3 (14%) 4% to 35% All cases 160 35 (22%) 16% to 29% •No significant difference between groups for histology Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC 2008
  7. 7. CIN2 and 3 after low grade cytology  ALTS trial:  Progression to CIN2 or 3 in 13% of women referred for the evaluation of LSIL or ASCUS HPV +ve smear  NS Data:  2ASCUS, 2 LSIL, or combination  HR HPV +ve 72 %  CIN2 or > 22%
  8. 8. ASC-H Images downloaded from http://nih.techriver.net/bethesdaTable.php
  9. 9. CIN2 or > after ASC-H  Significant pathology seen in the majority of cases  Barreth et al.:  CIN2 or > in 70% of cases  2.9% invasive disease  1.7%AIS
  10. 10. HSIL
  11. 11. CIN2 or > after HSIL  WrightASCCP:  CIN2 or > 53%-66% with Biopsy  90% if policy of immediate colposcopy
  12. 12. AGC cytology Pathology finding1 CIN 1 7% CIN 2 or 3 36% Adenocarcinoma in situ 20% Cervical Cancer 9% Endometrial Pathology 29% 1Daniel A Int.J.Gynaecol.Obstet 2005; 91(3)238-242 2 Wright T Emerging Issues on HPV infections 2006 p 140-146 Cytology2 Any high-grade lesion High grade glandular AGC-NOS 9-14% 0-15% AGC-N 27-96% 10-93%
  13. 13. ASC-H Colposcopy NoCIN Manage as per SCC guidelines CIN1 or > Colposcopy, cytology, at 6 months x 2 (HPV testing at 6 or 12 months ideally) Return to screening protocol CIN 1 or > No CIN HPV +ve follow in colposcopy clinic
  14. 14. HSIL Colposcopy (Bx, +/- ECC) NoCIN 2, 3 Manage as per SCC guidelines CIN 2 or greater Satisfactory Colposcopy Unsatisfactory Colposcopy Observe with Colposcopy and cytology Q 6/12 x2* Return to screening protocol Diagnostic Excision procedure * Consider HPV testing Cytology/histolo gy review disagreeagree
  15. 15. Colposcopic Approach  Examine whole lower genital tract  Use acetic acid liberally  Beware the small lesion  Take >1 biopsy  Liberal use of ECC  Always do ECC with unsatisfactory colposcopy
  16. 16. High grade features: Snow white epithelium
  17. 17. Low grade colposcopic features: colour  The acetowhite reaction is slower in onset and more transient than high grade lesions  Semi-transparent  Snow-white colour  Gray-white colour higher grade
  18. 18. Low grade: colour
  19. 19. Low grade Colposcopic features: size / position  Peripheral lesions  Often smaller
  20. 20. Low grade Colposcopic features: size / position
  21. 21. Low grade Colposcopic features: margins  Feathered  Geographic  Flat with indistinct margins  Satellite lesions
  22. 22. Colposcopic features: margins
  23. 23. Low grade Colposcopic features: margins
  24. 24. Low grade Colposcopic features: margins
  25. 25. Colposcopic features: iodine staining
  26. 26. Colposcopic features: iodine staining
  27. 27. Colposcopic features: iodine staining
  28. 28. Colposcopic features: iodine staining
  29. 29. High grade features: Coarse Mosaicism
  30. 30. Low grade Colposcopic features: vessels  Ill defined areas of fine punctation or mosaicism
  31. 31. Colposcopic features: vessels
  32. 32. High grade features: Irregular vessels vascularity Hair pin vessels from cancer Punctation from CIN2
  33. 33. High grade features: Thick keratosis
  34. 34. High grade features: inner border sign
  35. 35. High grade features: ridge sign
  36. 36. High grade features: papillary lesion; sharp border
  37. 37. CIN3
  38. 38. CIN 3 in pregnancy
  39. 39. Colposcopic mimics of CIN 1
  40. 40. CIN 2 Photo courtesy of Dr LGeldenhuys Histology of CIN 2
  41. 41. CIN 3 Photo courtesy of Dr LGeldenhuys Histology of CIN 3
  42. 42. CIN 1 on Biopsy or ECC SatisfactoryColposcopy Observe with Colposcopy and cytology Q 6/12 x2 Return to screening protocol Unsatisfactory Colposcopy Observe with Colposcopy and cytology at 24 months2 Treatment1 1 consider ablative therapy for persistent CIN1 2 if cytology persists continue FU in colposcopy Colposcopy and cytology -ve CIN persists or progresses Observe with Colposcopy and cytology 12 months persisten t
  43. 43. CIN 2,3 on Biopsy Return to screening protocol Diagnostic Excision procedure CIN 2,3 Treatment1 SatisfactoryColposcopy Unsatisfactory Colposcopy Follow-upat 6 and 12 months with colposcopy and cytology Follow-upat 6 months with colposcopyand cytologyand HPV2 OR Treat per guidelines CINNegative 1 LEEP or excision preferred for CIN 3 2 HPV testing for high risk HPV
  44. 44. CIN 2,3 on Biopsy in women < 25 yrs old CIN 2 Return to screening protocol Diagnostic Excision procedure CIN 3 Observe with Colposcopy and cytology Q 6/12 x2 yrs Treatment SatisfactoryColposcopy Unsatisfactory Colposcopy CIN persists or progresses CIN Resolves
  45. 45. CIN 3 with AIS (on final LEEP)
  46. 46. HSIL pap: colposcopic view after acetic acid
  47. 47. 21 yr old G0 P0 with LSIL pap, CIN 1 on Bx 20 yr old with ASC-H on pap andCIN 2 on Biopsy Adolescent
  48. 48. Conclusion  CIN 1 does not warrant therapy as most will resolve spontaneously  CIN 3 and CIN 2 are recognised cervical cancer precursors  They can be identified following both high grade and low grade cytology  The colposcopic features should allow differentiation between CIN 1 and CIN 2/3

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