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Dr. Sourav Chowdhury MBBS DGO &
Dr. Debraj Mondal MBBS MS
Senior Resident
IQ City Medical College, Durgapur
.
Cervical Histology:
Squamocolumnar Junction (SCJ):
The cervix is composed of columnar epithelium,
which lines the endocervical canal, and squamous
epithelium, which covers the exocervix. The point at
which they meet is called the squamocolumnar
junction.
Transformation Zone:
Transformation zone also called ectropion, an
area between original SC junction and new SC
junction due to regenerative metaplastic response.
Normal Transformation Zone:
1. The Basal Layer
2. The Parabasal Layer
3. The Intermediate layer
4. The superficial layer
Management of cin
Formation of TZ:
 SCJ is a dynamic point and it works in response to
puberty, pregnancy, Menopause and hormones.
 Neonates SCJ located at exocervix.
 In menarche, SCJ moves inwards and towards external
os resulting Transformation Zone.
 As metaplastic epi. Matures in TZ it resembles to
original squamous epithelium.
Age-wise Location of SCJ:
Columnar Epithelium:
 Columnar epithelium has a single layer of columnar cells
with mucus at the top and a round nucleus at the base.
 The glandular epithelium is composed of numerous ridges,
clefts, and infoldings and when covered by squamous,
metaplasia, leads to the appearance of gland openings.
 Technically, the endocervix is not a gland, but the term
gland opening often is used.
Metaplastic Epithelium
 Metaplasia originates at SCJ esp. at subcolumnar cells
 Begins at tip of columnar villi exposed to acidic pH
 Metaplastic cells replace columnar epithelium
 Deeper clefts, however, may not be completely
replaced, leaving them trapped below.
 Gland openings and nabothian cysts mark the original
SCJ
Satisfactory Colpscopy:
1. Adequate visualisation
2. Entire squamocolumnar junction to be visualized
3. Proximal and distal end of lesion
Jennifer E. Frank, MD (2008) The colposcopic examination, Available
Coarse punctationMosaic
Abnormal Vessels Acetowhite
Cervical Intraepithelial Neoplasia:
CIN I – Abnormal cells confined to lower third of sq. epi.
CIN II – Extending to middle third of sq. epi.
CIN III- Into upper third as severe dysplasia
CIS – Full thickness involvement
In contrast being only one cell thick, columnar cells
does not demonstrate similar analogous neoplastic
disease spectrum, histologic abnormalities limited to
AIS or Adenocarcinoma.
Why screen for cervical cancer?
1) It’s a highly prevalent condition in Indian population,
2) It has a long latent phase,
3) Its natural history of disease is well understood,
4) There are suitable test for screening,
5) These tests are easily available, cost-effective & well acceptable,
6) Treatment of screen positive patients will stop the disese
progression
Management of cin
Natural history of disease
Whom to screen?
ACOG or ACS recommendations
WHO recommendations
ACOG or ACS-
AGE Recommendations
Before 21 yr No screening (Irrespective of sexual
activity).
21 to 29 yrs Screen every 2 years with
conventional PAP smear or LBC
30 to 65 yr If 3 consecutive tests in last 10 yr are
negative then
Screen every 3 yrly with PAP/ LBC
Or
Every 5 yrly with CO-TESTING
(HPV-DNA + Cytology)
*ACOG has no upper age limit
ACOG & ACS
After 65 yr* If 3 consecutive tests in last 10 yr are negative
AND
There is no h/o CIN2+ in last 20 yr
Then
DISCONTINUE screening (even if the women report having
a new partner)
Post-
hysterectomised
If Cervix is removed
AND
Hysterectomy was done for benign indication
AND
There is no h/o CIN2+ in last 20 yr
Then
DISCONTINUE screening
*ACOG has no upper age limit
ACOG & ACS-
HPV vaccinated women:
 Women who have been vaccinated should continue to
be screened.
 Screening practices should not change on the basis
of HPV vaccination status.
*ACOG has no upper age limit
More frequent screening
1. History of CIN 2 or greater (screen annually for 20 yr)
2. HIV (Twice in 1st yr then annually after) or immune-
suppressed
3. Diethylstilbesterol(DES) daughters.
WHO-
AGE Recommendations
Before 30 yr New programmes should start
screening women aged 30 years or more
Before 25 yr Existing programmes should not
include women < 25 years of age
25−49 years Screen every 3 yrly with Cytology
>50 years Screen every 5 yrly with Cytology
>65 years Screening NOT necessary
provided the last two smears were
negative.
Methods of screening-
Down staging screening Recommended methods
Under The National Cancer
Control Program, Govt. of India
 VIA based screening & with
Lugol’s Iodine (VILI)
 Use of Magnascope
 Single visit approach
 Cryosurgery for VIA +ve
women
 Self collected samples for
cytology and (HPV)-DNA
testing
1. Cytology
Conventional PAP smear
Liquid Based Cytology
2. HPV DNA
3. Visual approach
VILI, VIA.
PAP smears
Sample collection
CONVENTIONAL LBC
 Ayre’s spatula-
predominantly samples the
ectocervix,
 The endocervical brush-
samples the endocervical
canal and is used in
combination with a spatula
 Samples are collected in
Koplik jar.
 The broom- samples both
endo and ectocervical
epithelia simultaneously.
 Samples are then collected in
a jar containing special
preservative solution.
HPV DNA testing
HPV DNA testing The Hybrid Capture 2, HC2, test is the most widely
used HPV-DNA test
 Has a very high negative predictive value (approx 99%)
 Currently tests for 13 high risk HPV types, It screens
for the presence of HPV 16, 18, 31, 33, 35, 39, 45, 51, 52,
56, 58, 59 and 68.
HPV DNA testing
Almost 80% women <30 yr show +ve
HPV HC-2.
Most women clears of the infection
within 10 yr.
Due to high prevalence of this
temporary infection this test has no
diagnostic value <30 yr.
so it should not be done <30 yr.
TRIAGE Screening It is done to reduce the load on the colposcopy centers.
 If PAP smear shows atypical cells
 HPV DNA testing by HC-2 method
Positive
Go for colposcopy
Negative
Repeat smear after 1 year
Management of CIN I preceeded by ASC-US or
LSIL-
Follow-up without treatment
Colposcopy
Routine
Screening
•Lesser abnormalities include ASC-US or LSIL
cytology. HPV16 or 18 +ve persistent HPV
•Management options would vary if pregnant
or age less than 21-24yrs
•Cytology if less than 30yrs and cotestinf if
age≥30yrs
Either ablative or excisional
Excisional if colposcopy inadequate or CIN II
Manage According
to ASCCP
Management of CIN I preceded by HSIL or
ASC-H -
Cotesting at 12 & 24 months
Diagnostic
Excisional
Procedure
Review of Cytological or
Histological or Colposcopic
findings
Colposcopy •Provided colposcopy is Adequate and EndoCx sampling is –ve
•Except in special population/pregnant women/age 21-24yrs
•Cytology if less than 30yrs, Cotesting if age ≥30yrs
Management of CIN I in Special Population
*
Cytology at
12 months
Repeat Cytology at
12months
Management of Women
with Biopsy confirmed CIN II or III
Adequate Colposcopy
Inadequate Colposcopy or Recurrent
CIN 2/3 EndoCx sampling CIN 2/3
Excision or Ablation of
the TZ
Diagnostic Excisional
Procedure
Cotesting at 12-24months
Any test Abnormal
Colposcopy
Two consequtive –ve
results
Repeat Cotesting at
3yrs
Routine Screening
Management of a Women with Biopsy-confirmed CIN
2or3 in special circumstances -
A young women with CIN 2 or 3
Observation-Cytology & Colposcopy
6month interval for 12months
Treatment using Excision
or Ablation
2x Cytology _ve &
Normal Colposcopy
Cotest in 1yr
Both tests -ve
Cotest in 3yrs
Colposcopy worsens or High-
grade Cytology or colposcopy
persists for 1yr
Repeat Biopsy or
colposcopy
If CIN 2 or 3
persists for
≥ 24months
Treatment
Required
Management of Women With AGC or Cytologic
AIS Initial Workup :
Management of cin
Treatment Modalities:
a. *
*
Excision Ablation
• LEEP • Laser Vapourization CO2
• Electrosurgical Needle Conisation • Cryotherapy
• Laser Conization CO2 • Cryopen
•Cold-Knife Conization • Cold Coagulation
• Hysterectomy • Electrocoagulation
• Electro-cautery
Cryotherapy-
 Criteria
 CIN I persisted for 2yrs or CIN II
 Lesion in EctoCx
 Negative EndoCx sampling
 Small lesion
 No EndoCx gland involvement
 Effective Temperature -20˚to -30˚C
 Iceball of 5mm from edge of probe=Effective
 Failure Rate
 Size
 EndoCx sample +ve
 EndoCx Gland +ve
*1
CO₂ Laser Vapourization :
 Outline of lesion are demarcated
 Vapourization to the depth 6-7mm.
 Advantages-
 Precise
 Spare unnecessary damage
 Ability to destroy coexisting lesions
 Disadvantage-
 Increase preocedure time
 Very expensive
 Complications
 Minor discomfort
 Uterine cramps
Long Loop Excision of Transformation
Zone(LLETZ)-
 Tissue effects depends on
 Size of wire 0.5mm
 Power (watts) 35-55W
 Water content of tissue
 Steam envelope at tissue-wire interface =cutting
 Zone of 4-5mm beyond the affected area
 Advantage
 Specimen for Histopathological diagnosis
 Less expensive
 Complications
 Operative/post-operative haemorrhage
 Cervical stenosis
Conization
 Conization diagnostic/therapeutic
 Provides tissue for further evaluation
 Indications-
 Microinvasive Carcinoma present in EndoCx currettings
 Cytolopgy not consistent with tissue diagnosis
 Entire TZ not visualized
 Microinvasive Ca diagnosis by biopsy
 Cytology/Biopsy evidence of Premalignant or Malignant
glandular epithelium.
 Lesions with +ve margins more likely to recur
Hysterectomy-
Indications:
 Microinvasion
 CIN III at the EndoCx limits of conization specimens in
selected patients
 Poor compliance with follow-up
 Other gynaecologic problems requiring Hysterectomy
 Histologically confirmed recurrent high-grade CIN
Colposcopy-
Referrence
1. Jennifer E. Frank, MD (2008) The colposcopic examination,Available
at: http://www.medscape.com/viewarticle/579947_4(Accessed: 21st july 2014).
2. berek jonathan s., abaid s. lisa, anderson r. jean, aubuchon mira, baker l.
valerie, baram a. david, et el. Berek and Novak's Gynecology, 15th ed. united
states of america: wolters kluwers / lippincott william wilkins; 2011.
3. Connor P. Joseph, Hartenbach M. Ellen. Treatment of Cervical Intraepithelial
Neoplasia.
http://www.glowm.com/section_view/heading/Treatment%20of%20Cervical%2
0Intraepithelial%20Neoplasia/item/228#9151 (accessed 24th july 2014).
4. Massad Stewart L.,Einstein H. Mark, Huh k. Warner, Katki A. Hormuzd,
Kinney K. Walter, Schiffman Mark, et el. 2012 Updated Consensus Guidelines for
the Management of Abnormal Cervical Cancer Screening Tests and Cancer
Precursors. http://www.omniaeducation.com/images/hpv_resource2.pdf
(accessed 20th July 2014).
Thank you !

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Management of cin

  • 1. Dr. Sourav Chowdhury MBBS DGO & Dr. Debraj Mondal MBBS MS Senior Resident IQ City Medical College, Durgapur .
  • 2. Cervical Histology: Squamocolumnar Junction (SCJ): The cervix is composed of columnar epithelium, which lines the endocervical canal, and squamous epithelium, which covers the exocervix. The point at which they meet is called the squamocolumnar junction.
  • 3. Transformation Zone: Transformation zone also called ectropion, an area between original SC junction and new SC junction due to regenerative metaplastic response.
  • 4. Normal Transformation Zone: 1. The Basal Layer 2. The Parabasal Layer 3. The Intermediate layer 4. The superficial layer
  • 6. Formation of TZ:  SCJ is a dynamic point and it works in response to puberty, pregnancy, Menopause and hormones.  Neonates SCJ located at exocervix.  In menarche, SCJ moves inwards and towards external os resulting Transformation Zone.  As metaplastic epi. Matures in TZ it resembles to original squamous epithelium.
  • 8. Columnar Epithelium:  Columnar epithelium has a single layer of columnar cells with mucus at the top and a round nucleus at the base.  The glandular epithelium is composed of numerous ridges, clefts, and infoldings and when covered by squamous, metaplasia, leads to the appearance of gland openings.  Technically, the endocervix is not a gland, but the term gland opening often is used.
  • 9. Metaplastic Epithelium  Metaplasia originates at SCJ esp. at subcolumnar cells  Begins at tip of columnar villi exposed to acidic pH  Metaplastic cells replace columnar epithelium  Deeper clefts, however, may not be completely replaced, leaving them trapped below.  Gland openings and nabothian cysts mark the original SCJ
  • 10. Satisfactory Colpscopy: 1. Adequate visualisation 2. Entire squamocolumnar junction to be visualized 3. Proximal and distal end of lesion Jennifer E. Frank, MD (2008) The colposcopic examination, Available
  • 12. Cervical Intraepithelial Neoplasia: CIN I – Abnormal cells confined to lower third of sq. epi. CIN II – Extending to middle third of sq. epi. CIN III- Into upper third as severe dysplasia CIS – Full thickness involvement In contrast being only one cell thick, columnar cells does not demonstrate similar analogous neoplastic disease spectrum, histologic abnormalities limited to AIS or Adenocarcinoma.
  • 13. Why screen for cervical cancer? 1) It’s a highly prevalent condition in Indian population, 2) It has a long latent phase, 3) Its natural history of disease is well understood, 4) There are suitable test for screening, 5) These tests are easily available, cost-effective & well acceptable, 6) Treatment of screen positive patients will stop the disese progression
  • 16. Whom to screen? ACOG or ACS recommendations WHO recommendations
  • 17. ACOG or ACS- AGE Recommendations Before 21 yr No screening (Irrespective of sexual activity). 21 to 29 yrs Screen every 2 years with conventional PAP smear or LBC 30 to 65 yr If 3 consecutive tests in last 10 yr are negative then Screen every 3 yrly with PAP/ LBC Or Every 5 yrly with CO-TESTING (HPV-DNA + Cytology) *ACOG has no upper age limit
  • 18. ACOG & ACS After 65 yr* If 3 consecutive tests in last 10 yr are negative AND There is no h/o CIN2+ in last 20 yr Then DISCONTINUE screening (even if the women report having a new partner) Post- hysterectomised If Cervix is removed AND Hysterectomy was done for benign indication AND There is no h/o CIN2+ in last 20 yr Then DISCONTINUE screening *ACOG has no upper age limit
  • 19. ACOG & ACS- HPV vaccinated women:  Women who have been vaccinated should continue to be screened.  Screening practices should not change on the basis of HPV vaccination status. *ACOG has no upper age limit
  • 20. More frequent screening 1. History of CIN 2 or greater (screen annually for 20 yr) 2. HIV (Twice in 1st yr then annually after) or immune- suppressed 3. Diethylstilbesterol(DES) daughters.
  • 21. WHO- AGE Recommendations Before 30 yr New programmes should start screening women aged 30 years or more Before 25 yr Existing programmes should not include women < 25 years of age 25−49 years Screen every 3 yrly with Cytology >50 years Screen every 5 yrly with Cytology >65 years Screening NOT necessary provided the last two smears were negative.
  • 22. Methods of screening- Down staging screening Recommended methods Under The National Cancer Control Program, Govt. of India  VIA based screening & with Lugol’s Iodine (VILI)  Use of Magnascope  Single visit approach  Cryosurgery for VIA +ve women  Self collected samples for cytology and (HPV)-DNA testing 1. Cytology Conventional PAP smear Liquid Based Cytology 2. HPV DNA 3. Visual approach VILI, VIA.
  • 24. Sample collection CONVENTIONAL LBC  Ayre’s spatula- predominantly samples the ectocervix,  The endocervical brush- samples the endocervical canal and is used in combination with a spatula  Samples are collected in Koplik jar.  The broom- samples both endo and ectocervical epithelia simultaneously.  Samples are then collected in a jar containing special preservative solution.
  • 26. HPV DNA testing The Hybrid Capture 2, HC2, test is the most widely used HPV-DNA test  Has a very high negative predictive value (approx 99%)  Currently tests for 13 high risk HPV types, It screens for the presence of HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68.
  • 27. HPV DNA testing Almost 80% women <30 yr show +ve HPV HC-2. Most women clears of the infection within 10 yr. Due to high prevalence of this temporary infection this test has no diagnostic value <30 yr. so it should not be done <30 yr.
  • 28. TRIAGE Screening It is done to reduce the load on the colposcopy centers.  If PAP smear shows atypical cells  HPV DNA testing by HC-2 method Positive Go for colposcopy Negative Repeat smear after 1 year
  • 29. Management of CIN I preceeded by ASC-US or LSIL- Follow-up without treatment Colposcopy Routine Screening •Lesser abnormalities include ASC-US or LSIL cytology. HPV16 or 18 +ve persistent HPV •Management options would vary if pregnant or age less than 21-24yrs •Cytology if less than 30yrs and cotestinf if age≥30yrs Either ablative or excisional Excisional if colposcopy inadequate or CIN II Manage According to ASCCP
  • 30. Management of CIN I preceded by HSIL or ASC-H - Cotesting at 12 & 24 months Diagnostic Excisional Procedure Review of Cytological or Histological or Colposcopic findings Colposcopy •Provided colposcopy is Adequate and EndoCx sampling is –ve •Except in special population/pregnant women/age 21-24yrs •Cytology if less than 30yrs, Cotesting if age ≥30yrs
  • 31. Management of CIN I in Special Population * Cytology at 12 months Repeat Cytology at 12months
  • 32. Management of Women with Biopsy confirmed CIN II or III Adequate Colposcopy Inadequate Colposcopy or Recurrent CIN 2/3 EndoCx sampling CIN 2/3 Excision or Ablation of the TZ Diagnostic Excisional Procedure Cotesting at 12-24months Any test Abnormal Colposcopy Two consequtive –ve results Repeat Cotesting at 3yrs Routine Screening
  • 33. Management of a Women with Biopsy-confirmed CIN 2or3 in special circumstances - A young women with CIN 2 or 3 Observation-Cytology & Colposcopy 6month interval for 12months Treatment using Excision or Ablation 2x Cytology _ve & Normal Colposcopy Cotest in 1yr Both tests -ve Cotest in 3yrs Colposcopy worsens or High- grade Cytology or colposcopy persists for 1yr Repeat Biopsy or colposcopy If CIN 2 or 3 persists for ≥ 24months Treatment Required
  • 34. Management of Women With AGC or Cytologic AIS Initial Workup :
  • 36. Treatment Modalities: a. * * Excision Ablation • LEEP • Laser Vapourization CO2 • Electrosurgical Needle Conisation • Cryotherapy • Laser Conization CO2 • Cryopen •Cold-Knife Conization • Cold Coagulation • Hysterectomy • Electrocoagulation • Electro-cautery
  • 37. Cryotherapy-  Criteria  CIN I persisted for 2yrs or CIN II  Lesion in EctoCx  Negative EndoCx sampling  Small lesion  No EndoCx gland involvement  Effective Temperature -20˚to -30˚C  Iceball of 5mm from edge of probe=Effective  Failure Rate  Size  EndoCx sample +ve  EndoCx Gland +ve *1
  • 38. CO₂ Laser Vapourization :  Outline of lesion are demarcated  Vapourization to the depth 6-7mm.  Advantages-  Precise  Spare unnecessary damage  Ability to destroy coexisting lesions  Disadvantage-  Increase preocedure time  Very expensive  Complications  Minor discomfort  Uterine cramps
  • 39. Long Loop Excision of Transformation Zone(LLETZ)-  Tissue effects depends on  Size of wire 0.5mm  Power (watts) 35-55W  Water content of tissue  Steam envelope at tissue-wire interface =cutting  Zone of 4-5mm beyond the affected area  Advantage  Specimen for Histopathological diagnosis  Less expensive  Complications  Operative/post-operative haemorrhage  Cervical stenosis
  • 40. Conization  Conization diagnostic/therapeutic  Provides tissue for further evaluation  Indications-  Microinvasive Carcinoma present in EndoCx currettings  Cytolopgy not consistent with tissue diagnosis  Entire TZ not visualized  Microinvasive Ca diagnosis by biopsy  Cytology/Biopsy evidence of Premalignant or Malignant glandular epithelium.  Lesions with +ve margins more likely to recur
  • 41. Hysterectomy- Indications:  Microinvasion  CIN III at the EndoCx limits of conization specimens in selected patients  Poor compliance with follow-up  Other gynaecologic problems requiring Hysterectomy  Histologically confirmed recurrent high-grade CIN
  • 43. Referrence 1. Jennifer E. Frank, MD (2008) The colposcopic examination,Available at: http://www.medscape.com/viewarticle/579947_4(Accessed: 21st july 2014). 2. berek jonathan s., abaid s. lisa, anderson r. jean, aubuchon mira, baker l. valerie, baram a. david, et el. Berek and Novak's Gynecology, 15th ed. united states of america: wolters kluwers / lippincott william wilkins; 2011. 3. Connor P. Joseph, Hartenbach M. Ellen. Treatment of Cervical Intraepithelial Neoplasia. http://www.glowm.com/section_view/heading/Treatment%20of%20Cervical%2 0Intraepithelial%20Neoplasia/item/228#9151 (accessed 24th july 2014). 4. Massad Stewart L.,Einstein H. Mark, Huh k. Warner, Katki A. Hormuzd, Kinney K. Walter, Schiffman Mark, et el. 2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors. http://www.omniaeducation.com/images/hpv_resource2.pdf (accessed 20th July 2014).