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Colposcopy & Treatment

Colposcopy & Treatment. Philippe De Sutter Gynaecology - Oncology. Colposcopy & Treatment. Colposcopy has a central place in the management of abnormal cervical cytology Colpo- cyto- histological correlation is the key to an adequate triage for treatment

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Colposcopy & Treatment

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  1. Colposcopy & Treatment Philippe De Sutter Gynaecology - Oncology

  2. Colposcopy & Treatment • Colposcopy has a central place in the management of abnormal cervical cytology • Colpo- cyto- histological correlation is the key to an adequate triage for treatment • Never perform a treatment without prior colposcopic assessment • Perform any treatment technique under colposcopic guidance and control Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  3. Colpo- cyto- histological TriageConclusion for clinical management • Treatment • Ablation / destruction • Excision / conization • Colpo-cytological follow-up • 3 - 6 months • Cytological control with earlier interval • 6 - 12 months • Return to screening with normal interval Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  4. Cervical Intraepithelial NeoplasiaPrinciples of treatment • High grade lesions; CIN 2-3 • Are true precursors of invasive cervical cancer • Should be treated to prevent progression • CIN is a squamous intraepithelial disease • Removal of the stromal tissue is not necessary • Removal of the glandular epithelium is not necessary • CIN is located at the Transformation Zone • The TZ can be assessed by colposcopy Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  5. Inappropriate colposcopic triage Under-treatment • Inadequate interpretation of cytology report • Inadequate patient recall • Diagnosis based on cervical cytology only • Unreliable colposcopic evaluation • Unreliable punch biopsy • Inappropriate treatment by ablation Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  6. Inappropriate colposcopic triage Over-treatment • Infrequent occurrence of CIN in GP • Unawareness of natural history of disease • Creating patient anxiety (…HPV !) • Treatment based on cervical cytology only • Treatment based on macroscopic acetowhite changes • Unreliable colposcopic evaluation • Excessive use of excisional treatment techniques • Young age ! Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  7. Low Grade LesionsOver-treatment ? • Not useful in the prevention of cervical cancer • Consider • Persistent lesion • HR-HPV + • Age • >35-40y, children • Topography of the lesion • Endocervical involvement • Risk of lost to follow-up • Patient fear • Cost-benefit Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  8. Young womenOver-treatment ? • < 20 - 25y • Usefulness of screening ? • In the prevention of cervical cancer • Frequent HR-HPV + • LSIL / ASCUS • Sometimes “acute” HPV infection • HSIL • Impressive colposcopic image • Biopsy CIN 2/3 • Avoid surgical treatment ! Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  9. Historical review on treatment techniques • All provide therapeutically comparable results • Any method is acceptable • More "conservative" colposcopic guided methods • Hysterectomy > Conization > Ablation • Invasive cancer after treatment by ablation • Incorrect triage by colposcopy • Specimen for pathology! • Exclusion of occult (micro)invasion • Assessment of margins • Ablation > Excision Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  10. Electrosurgery of the cervixLEEP / LLETZ • Loop Electrosurgical Excision Procedure • Large Loop Excision of the Transformation Zone • Obtain an adequate specimen for histologic evaluation • Excise CIN and whole TZ with free margins • Exclusion of (micro-)invasion • Avoid thermal artefacts • Cause minimal damage to the cervix • Preserve endocervical glands and stromal tissue • Avoid haemorrhagic complications • Avoid stenosis, fertility and pregnancy disorders Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  11. Advantages Histology Office procedure Local anaesthesia Fast and easy to perform Low material costs Few complications Disadvantages Too easy Several pieces Orientation Evaluation of margins Thermal artefacts Electrosurgery Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  12. ElectrosurgeryTissue effects • Use high power level • Maintain efficient cutting at maximum depth • High current density • Vaporisation of cells • Steam interface • Current arcs • Adequate speed • Start current before touching tissue • Continuous movement • No contact or force Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  13. LEEPLocal anaesthesia • Potocky needle 27g x 31” • Or dental needle 30g • Dental syringe • 1 - 2 x 1.8ml Lidocaine 2% + Noradrenaline • Circumferential submucosal cervical infiltration (4-6x) • Apply tampon and wait till bleeding stops Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  14. LEEP ProcedureLarge, irregular, fully ectocervical TZ • Large wide Loop • TZ one sweep • Ball • Blend • Coagulation Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  15. LEEP ProcedureLarge, irregular, fully ectocervical TZ • Medium Loop • Anterior TZ • Posterior TZ • Ball • Blend • Coagulation Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  16. LEEP ProcedurePartly or fully endocervical TZ • Medium Loop • Ectocervix • Small deep Loop • Endocervix • Ball • Blend • Coagulation Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  17. Margin involvement • Larger cone size is related to: • Less involved margins • Higher cure rate • More complications ! • Adjust cone size for optimal therapeutic efficiency • Provide good access to cervix • LEEP treatment under colposcopic control !!! • Locate TZ, SCJ and extension of lesion(s) • Use adequate Loop size and excision technique • Crater base is vaporized with blend current Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  18. Margin involvement • Adequate interpretation / review of pathology • Limited involvement • 10-20% acceptable • Follow-up sufficient • Deep involvement CIN3 or possible invasion • < 1-5% • Second LEEP • Hysterectomy • Beware occult invasion ! Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  19. "See and treat"Principle • Diagnosis and treatment in one session • By excision ! • Consider if intention to treat irrespective of result of punch biopsy • Cytology HSIL (or LSIL) • and colposcopy suggestive of HGL • Cytology HSIL (reliable or confirmed) • and colposcopy negative or only suggestive of LGL • Colposcopic suspected early invasion Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  20. Follow-up • Post-op control at 1 month • Optional • Pathology result • First follow-up visit earliest at 4-6 months • Cytology + HPV • Colposcopy optional • Every 6 months for 1-2 years • Yearly Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

  21. Recurrence • ~ 20 % remains HR-HPV positive • Is predictive risk factor for recurrence • No recurrence without HPV (?) • ~ ½ will develop cytological SIL • ~ ½ will need second treatment for CIN2+ • > 5% true recurrences • More in younger women ?! Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

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