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4 prof walter managmet of cin
This document discusses guidelines for the management and treatment of cervical intraepithelial neoplasia (CIN). It states that treatment should be based on an assessment of all case characteristics, not just test results, and aim to reduce cancer risk while minimizing side effects. For CIN3, treatment usually involves counseling, colposcopy, and excision of the entire transformation zone. Destructive methods may be used in some cases but excision allows histological examination. Larger excisions of type 2 or 3 transformation zones carry a higher risk of incomplete margins. While success rates are high, excision can increase risks of preterm birth, especially for larger specimens. Treatment should be tailored based on individual risk factors and fertility desires
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4 prof walter managmet of cin
- 1. FOGSI / FIGO 2013 Hydrabad THEMANAGEMENT OF CIN wprendiville
- 2. The management ofCIN • Should read The management of women with CIN • Should never be dictated by an individual test result, even histology • Should incorporate all the case characteristics • Is a balance of benefit vs harm
- 3. How to safelytreat CIN3 • Safely means – Reducing the risk of cervical cancer to almost zero – Reducing the side effects of treatment to as low as possible
- 4. The management ofCIN3 • Will always include – Pre-treatment counselling • Need for Rx, risks of Rx, need for follow up monitoring by cytology/HPV/Colposcopy – Assessment of all the case characteristics • Age, parity, future fertility, likelihood of default, cytology, histology, HPV status and other biomarkers where known.
- 5. Safe treatment ofCIN3 • Will always mean – A preliminary colposcopic examination • By a trained colposcopist • Documenting specific findings – If excisional, Rx will be colposcopically guided – Eradication of the entire TZ – Sufficient tissue for histology to rule out invasive or associated GIN
- 6. Safe treatment ofCIN3 • Will sometimes mean – That excision is necessary – Removal of a relatively large amount of cervical tissue – An associated increased risk of pre-term labour
- 7. Safe treatment ofCIN3 • May sometimes – Be performed at the first / assessment visit – Be performed using a destructive method – Be performed under general anaesthesia – Be deferred
- 8. Choice of treatmentfor CIN EXCISIONAL DESTRUCTIVE Hysterectomy Radical diathermy Conebiopsy(Varietyoftechniques) Cryocautery LLETZ type1 LLETZ type2 LLETZ type3 Cold (orthermal)coagulation Laser excision Laser ablation
- 9. Destructive methods of treatment Advantages Simple,cheap, Equipment widely available Very effective in expert hands, No expense of histology of TZ Disadvantages No histological examination of TZ. Concern about the margins, the true diagnosis and the depth of excision
- 10. Preconditions for ablative therapyfor CIN The TZ must be fully visible There must be no cytological or colposcopic suspicion of invasive disease There must be no cytological or colposcopic suspicion of glandular disease There should be no disparity between cytological and histological diagnosis The patient must not have had previous therapy for CIN
- 11. Indications for treatment Asever, a balance of risks 1. Risk of not treating the condition Progression to cancer ie ; 50% for CIN 3, perhaps 1% for CIN 1 2. Risk of treating the condition Short term morbidity, uncommon Long term complications in particular pregnancy related, if large type 2 or 3 TZ
- 12. Threshold for treatment •High grade disease – Virtually all CIN 3 – Most CIN 2 • High risk patient with persistent low grade disease – Smoker – Older – High default risk – Anxious – HPV and other biomarker test results
- 13. EXCISION OF THETZ • Hysterectomy is rarely appropriate – Genuine risk of inadequately treating invasive disease – Unnecessary risk of general anaesthesia and major surgery and no benefit to patient – May miss VAIN
- 14. EXCISION OF THETZ • Laser excision is entirely reasonable – Expensive – Useful for vaginal disease – Similar success and complications profile to LLETZ, with perhaps an increased risk of subsequent perinatal mortality
- 15. EXCISION OF THETZ • LLETZ – Usually an outpatient procedure – Relatively inexpensive – Simple to perform – Accommodates all cases of CIN and Microinvasive disease and glandular disease – Needs modification according to presentation If performed inexpertly may be associated with excess morbidity
- 16. Optimising the treatment experience •Informed, comfortable, relaxed • TZ has adequately analgesia • Privacy, support, confidence • Appropriately sized suction- speculum
- 17. Excision of theTZ LLETZ • Under binocular colposcopic vision • Thoroughly anaesthetised TZ • After full colposcopic exam • Low magnification
- 18. Full colposcopic exam •Size and Type of TZ • SWEDE score • Diagnostic impression of worst lesion • Documented using ifcpc nomenclature
- 19. LLETZ LLETZ using aTan Loop 2 x 2.5cms Applicable to wider type 1 TZs Dental syringe systemused for all LLETZ procedures Octapressin and citanest with a 2.2m. Vial and a 27 gauge needle
- 20. Excision: Principles of treatment •Treat the entire TZ • Excise only the TZ • Miminise the artefactual damage – Fulguration not dessication – Paint the wound with electrosurgery – Always have monsel’s paste available
- 21. Excision: Principles of treatment •Always, always treat under binocular colposcopic vision • Always ensure full vision of : – the entire TZ – the entire loop – and the adjacent vaginal wall • Pass the loop slowly from left to right
- 22. Principles of treatment •Choose the appropriate loop for the specific TZ • Modify the technique according to the TZ type • Ensure excision of the scj • Beware the type 3 TZ
- 23. Type I • Completely ectocervical •Fully visible • small or large Transformation Zone Classification
- 24. Type II • hasendocervical component • Fully visible • may have ectocervial component which may be small or large Transformation Zone Classification
- 25. Transformation Zone Classification Type III •has endocervical component • is not fully visible • may have ectocervical component which may be small or large
- 26. Excision Types new IFCPCproposal • Type 1 Excision – Resection of a type 1 TZ • Type 2 Excision – Resection of a type 2 TZ • Type 3 Excision – Resection of a type 3 TZ – Glandular disease – Suspected microinvasion – Repeat treatment
- 28. Cases which requirea type 3 excision • CIN with a type 3 transformation zone • Suspected microinvasive disease • Suspected glandular disease • Residual disease, ie previous treatment
- 29. Long loop orstraight wire for electro-surgicaltype 3 transformation zone
- 30. Type 3 TZ Type3 excision = approximately to a Cone biopsy LLETZ using a single large (blue) loop
- 31. Excision of atype 3 TZ • Using a long loop • Loop dimensions dictated by – TZ size – cervical size – patient future – pregnancy expections – anticipated grade of disease
- 32. Type 3 TZ Type3 Excision approximates to a Type 3 TZ Using a straight wire
- 33. Type 3 TZ Type3 Excision approximates to a Cone biopsy Using a straight wire ie SWETZ
- 34. Type 3 Excision •Parous woman, family complete, • V large type 3 TZ, suspicion of CIN3
- 35. Success of treatment Martin-HirschPL, Paraskevaidis E, Kitchener H., Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2000;(2):CD001318. • Published cure rates are very high no matter which technique is examined • Success is measured in surrogate ways • Cure ultimately means the woman will not develop cancer
- 36. Laser Ablation Compared With Loop Excision Residual Disease: All Grades of CIN Graph of Relative Risks Alvarez (375) Dey (285) Gunasekera (199) Mitchel (251) Meta-analysis . 0 0.1 1 10 100 favours favours Loop Excision Laser Ablation NO SIGNIFICANT DIFFERENCE FOR ALL METHODS FOR ALL GRADES OF DISEASE CRYOTHERAPY SHOULD NOT BE USED FOR HIGH GRADE DISEASE Meta-analysis
- 37. Success of treatment •Surprisingly few large RCTs – No difference between techniques in terms of success – except cryocautery
- 38. Excision • Margin Status •Volume excised • TZ type • These three aspects of excision will inform both doctor and patient in terms of prediction of success and morbidity
- 39. Margin Status • Markerfor risk of residual disease – Cytological suspicion 5 - 51% – Histologically proven 3 - 7% • Negative margins don’t preclude risk of residual disease
- 40. Margin status atexcision • Ghaem-Maghami et al • Meta-analysis 35,109 subjects • Recurrence rate, high grade – Complete excision 3% – Incomplete excision 18%
- 41. The relation oftype of excision and clear histopathological margins after LLETZ Dimitriou E., Martin M., Farrar K & Prendiville W. • 1071 women who underwent LLETZ between January 2004 and October 2008
- 42. The relation oftype of excision and clear histopathological margins after LLETZ Dimitriou E., Martin M., Farrar K & Prendiville W. Small type 1 vs large type 2 RR=1.92 95%CI 1.19-3.08 Small type 1 vs large type 3 RR=3.41 95%CI 1.83-6.37 0% 20% 40% 60% 80% 100% Small TZ1 Large TZ2 Large TZ3 complet e pos ecto pos endo
- 43. The relation oftype of excision and clear histopathological margins after LLETZ Dimitriou E., Martin M., Farrar K & Prendiville W 2009. • Large type 2 or 3 TZ excisions are associated with an increased risk of incomplete excision margin status • Perform larger TZ excisions in these circumstances and counsel appropriately
- 44. Complications after LLETZ •Short term morbidity low • Recent reviews have examined long term complications, specifically pregnancy related morbidity – Kyrgiou et al,Lancet 2006 – Arbyn et al BMJ, 2008
- 45. Risk of perinataldeath by technique of excision • Estimate of one perinatal death for every 70 pregnancies in women treated by CKC, laser cone or RD compared to one in 500 for women treated by LLETZ
- 46. Severe pregnancy related outcomesArbyn et al 2008 • The current meta-analysis demonstrates that CKC and probably also LC and radical diathermy place women at increased risk of PM and other serious pregnancy outcomes. LLETZ and Laser ablation do not.
- 47. Morphological damage afterexcision • Biologically plausible • Perhaps related to extent or amount of excision • Applies largely to cases where ablation would be inappropriate – Large type 2 or 3 TZ, – Previously treated patients, – Glandular or suspected Microinvasion
- 48. 48 Preterm delivery (<37W):Excision vs no treatment ~heigth Height < 10mm Risk ratio .1 .2 .5 1 2 5 10 Risk ratio (95% CI) Raio, 1997 0.52 ( 0.06, 4.83) Sadler, 2004 0.99 ( 0.57, 1.72) Samson, 2005 3.02 ( 1.65, 5.53) Nohr, 2007 0.83 ( 0.21, 3.25) Overall 1.32 ( 0.59, 2.95) Risk ratio .1 .2 .5 1 2 5 10 Raio, 1997 4.64 ( 1.20, 17.88) Sadler, 2004 1.64 ( 1.13, 2.37) Samson, 2004 3.84 ( 1.66, 8.88) Nohr, 2007 2.46 ( 1.45, 4.16) Overall 2.39 ( 1.55, 3.69) Height >= 10mm Risk ratio (95% CI)
- 49. Risk of pretermlabour after LLETZ Does size matter? A retrospective study Khalid S, Dimitriou E & Prendiville W BSCCP (poster) 2009
- 50. Excision dimensions andpreterm labour Khalid S, Dimitriou E & Prendiville W 2009 • 1999 - 2002 • Obstetric & Colpo databases • 353 pregnancies in women after LLETZ
- 51. Excision dimensions andpreterm labour Khalid S, Dimitriou E & Prendiville W 2009 Increased risk of preterm labour if specimens larger than 6 cubic cms RR 3.17, 95%CI 1.56 - 6.38
- 52. Excision dimensions andpreterm labour Khalid S, Dimitriou E & Prendiville W 2009 Increased risk of preterm labour if specimens thicker than 12 mms RR 3.05, 95%CI 1.37 - 7.08
- 53. Choices in treatment •Depends on the case characteristics – Age, parity, contraception • Nulliparous 27yr old, minimum risk of default with a moderate cytological and colposcopic abnormality • Sterilised parous 24 yr old with a moderate cytological and colposcopic abnormality
- 54. In summary • Defineyour treatment threshold • Always treat under colposcopic vision • Excise the entire TZ preferably as one piece • Minimise the excision of normal tissue • Minimise morbidity of wound managment
- 55. The BSCCP invites youto the 15th World Congress On behalf of IFCPC In London 26-30th May 2014 www.IFCPC2014.c