Screening in Gynaecological Cancers - PowerPoint PPT Presentation

Screening in Gynaecological Cancers

Prof. HYS Ngan

Department of Obstetrics & Gynaecology University of Hong Kong

Queen Mary Hospital

Fallopion tube

Uterus

Endometrium

Ovary

Cervix

Vagina

• Cervical cancer
• Ovarian cancer
• Endometrial cancer

To detect disease among

healthy

population

Without symptoms of disease

Purpose: decrease mortality due to the disease screened

• High prevalence of disease
• Known natural history, precursor lesion and course of progression
• Detection of early stage disease, amenable to cure
• Method used is simple, cheap, specific and sensitive, acceptable, risk-free and accessible

• commonest lower genital tract cancer
• about 500 new cases per year in HK
• about 140 deaths per year in HK
• median age: 50 years

• Cervical HPV is very common, related to sexual behaviour
• High spontaneous remission rate
• lower remission rate in CIN
• LSIL progress to HSIL in 70% in 10 yrs

regress persist CIN3 Ca

CIN I 57% 32% 11% <1%

CIN2 43% 35% 22% 5%

(100 prospective studies)

• Overall sensitivity: 61-64%, cervical cancer: 82-95%
• Overall specificity : 99 - 99.4%

Quantin.C 1992, Soost.HJ 1991

• Low-moderate dysplasia: 73-76%
• severe dysplasia : 85-90%
• Invasive cancer: 95%

Quantin.C 1992, Soost.HJ 1991

• Depends on the quality of the smear taking and the laboratory
• estimated to be 3-30%

• automation for cervical cancer screening
• liquid-based cytology - thin layer preparation

Eliminate

• air-dried artifact
• inflammatory cells
• blood
• mucus

Increase

• detection of abnormal cytology

• cervicography
• polar probe
• HPV typing

• HPV based instead of cytology based screening
• triage of patients with equivocal or ASCUS
• external quality control of cytology
• high risk HPV predicts high grade SIL in the absence of cytology abnormality
• molecular variant predicts carcinoma

• Finland and Sweden

decrease in indicence and mortality of cervical cancer

concentrate resources

wide coverage

• Policy decision

Age:

• Europe: 35-60 yrs for invasive ca

25-65 yrs for preinvasive lesions

• USA: 18 yrs old

Interval:

• Europe: 3-5 years
• USA: annual

low risk, 3 consecutive negative, space out

• Age: sexually active to 65
• Interval: 2 consecutive annual normal smears, 3 yearly

• Speculum
• adequate exposure
• light source
• sampling device - Ayres’ spatula, brush or broom
• transformation zone

• Blood in vagina, on the cervix - usually because of menstruation
• Obvious or gross growth on the cervix - a biopsy is more appropriate
• Cervix cannot be seen

• Some physiological or medical conditions may lead to difficulty in the interpretation of a smear.

• contraceptive history
• menopausal status
• date of last menstrual period
• prior radiotherapy or current chemotherapy
• hysterectomy
• drugs or hormones
• parity

• Negative
• Squamous cell - ASCUS, ASC-H (cannot exclude HSIL)

- LSIL

- HSIL, HSIL with features suspicious of invasion

- SCC

• Glandular cell

- Atypical : endocervical cells, endometrial cells, glandular cells

- Atypical, favor neoplastic: endocervical cells, glandular cells

- Endocervical adenocarcinoma in-situ

- Adenocarcinoma: endocervical, endometrial, extrauterine, NOS

Cytology screening

No. Unsat. ASCUS AGUS LG HG Inv

Conven 95874 0.44 4.36 0.1 1.24 0.29 0.02

1999

Thin Prep 100420 0.32 4.78 0.1 1.6 0.3 0.001

2000 (4800) (1600)

A Cheung

• Koilocytes : human papillomaviral changes
• Cervical intraepithelial neoplasia (CIN)
• 1 : dysplastic cells in lower one third of epithelium
• 2 : lower two third
• 3 : almost the whole thickness

• could be due to vaginitis or infection such as monilia, trichomonas, herpes or condyloma.
• Treat the cause and repeat the smear 4 to 6 months later to ensure that dysplastic cells were not masked by the previous inflammatory cells.

• 5% of smears reported as ASCUS
• Majority of ASCUS turn out to be normal or of low grade CIN
• Less than 1 % associated with cancer

• 1.5-2.5 % of smears screened were of LGIL
• 15-30% associated with HG CIN
• about 1% associated with cancer
• 2 options:
• repeat smear 4-6 months interval
• refer for colposcopic assessment (HKCOG guideline)

• Gross examination showed a growth - biopsy
• Grossly normal - refer colposcopy

• Normal: 19-34%
• Significant pathology: 15-37%

CIN 16-54%

AIS 3-5%

Ca cervix 2-3%

Ca corpus 1-4%

• AGUS- favor neoplasia, co-existing with squamous neoplasia, previous hx of cervical lesion: refer colposcopy, D&C and cone
• AGUS- favor reactive, not otherwise specified: repeat cytology with adequate endocervical sampling

• Department of Obs & Gyn of major hospitals of the Hospital Authority
• Lady Helen Woo Women’s Diagnostic and Treatment Centre at Tsan Yuk Hospital
• Private gynaecologist with colposcopy training

• ablative therapy
• cryotherapy
• cold coagulation
• diathermy
• laser evaporisation
• excision therapy
• cone (knife, laser, loop excision)
• hysterectomy is rarely indicated

Hong Kong College of Obstetricians & Gynaecologists -

Guidelines on The Management of An Abnormal Cervical Smear

New Cases : 220

Death : 95

Median age : 51

(1992)

• High mortality due to late diagnosis
• 75% of ca ovary at diagnosis were at late stage with a 28% 5 yr survival
• Stage I ca ovary has 95% 5 yr survival

Symptoms of ovarian cancer :

• asymptomatic
• Lower abdominal pain/pressure
• mass
• Abdominal enlargement
• Vaginal bleeding
• Urinary/bowel symptoms

Risk factors :

1) majority has no risk factor

2) family history 10%

- familial ovarian syndrome

2) nulliparous

3) racial and social

• Anatomic location of the ovary, not easily accesible
• Lack well defined precursor lesion and has poorly defined natural history
• Low prevalence, need exquisite specificity to avoid unnecessary intervention
• Lack of a good method

• Serum CA125
• Transvaginal ultrasonogram
• Multimodal
• New method under investigation - lysophosphatidic acid

• Elevated in 82% of ovarian cancer and <1% of healthy women
• rising pattern over time preceded ovarian cancer
• limitations: lack of sensitivity in Stage I disease, poor specificity (elevated in benign and other malignant conditions)

Kentucky study 2000

• 14,468 postmenopausal women
• annual TVS
• total 57,214 scans
• 180 laparotomies: 17 ov ca (stage I=11, stage II=3, stage III=3)
• sensitivity 81% specificity 98.9% PPV 9.4% NPV 99.97%
• Survival at 2 yr 92.9% and at 5 yr 83.6%

• Jacobs et al. 1993
• 22000 women over 45 yrs
• CA125 and transvaginal ultrasound
• 125 elevated CA125, FU with CA125 and TVS
• 41 laparotomies: 11 ovarian ca vs 8 in control gp
• specificity = 99.9%
• sensitivity = 78.6%
• positive predictive value = 26.8%

• Not cost-effective
• May be considered in high risk population
• No place for population screening yet

Incidence : third commonest malignant tumour of genital tract

Age : 58

New cases : 200

Death : 50

Median age : 60

(1992)

• nulliparity, anovulation, late menopause
• exogenous estrogen
• endogenous estrogen
• DM, HT, obesity
• smoking, white
• tamoxifen
• familial history

1) carcinoma of endometrium 14%

2) other gynecological malignancy 14%

3) atrophic endometritis 20%

4) endometrial hyperplasia 12%

5) cervicitis/erosion 8%

6) endometrial polyp 8%

7) cervical polyp 8%

(f) D&C near 100%

uterine aspirate 90%

endocervical aspirate + vaginal 65% aspirate

vaginal aspirate + cervical smear 40%

cervical smear 15%

• High prevalence in the West, low (same as ovarian ca) in Hong Kong
• precursor lesion, atypical endometrial hyperplasia
• accessibility of endometrium to sampling
• high cure rate for early disease

Cons: majority detected at early stage because of abnormal bleeding esp PMB

• Tools explored
• pelvic ultrasound (>8mm endometrial thickness in postmenopausal women) Karlsson 1995
• endometrial aspirate (inadequate sampling in menopausal women)

• Sensitivity for endometrial ca 94% in patient with symptoms
• sensitivity for hyperplasia 31%

Cons: discomfort to patient

lack of known efficiency in asymtomatic patients

• Croatia study (Kurjak 1994)
• 5013 asymptomatic women
• ca endometrium 6 and hyperplasia 18, no false positive

(low prevalence of ca endometrium in asymptomatic patients, ? Advantage)

• Not justified in population screening
• excellent prognosis of majority of ca endometrium unlikely will result in decreased mortality rates

• Cervical cancer screening is the most successful programme in gynaecological cancers
• Ovarian cancer screening is not proven to be cost-effective yet, may be considered in high risk groups
• Endometrial cancer screening may be consider in high risk groups