Managament of Abnormal Cervical Cytology And Histology

1. Managament of Abnormal Cervical Cytology And Histology Ali Ayhan, MD Baskent University School of Medicine Department of Obstetrics and Gynecology Head of Divisionof Gynecologic Oncology

2. Globocan 2008 Incidence 4,2 / 100.000 Mortality 1,6 / 100.000

4. Screening Treatment HPV - Cervical Cancer decads years months Normal epithelium HPV infection coilocytosis CIN1 CIN2 CIN3 Carsinoma HSIL ASC-US/LSIL SIL = Squamous Intraepithelial Lesion / CIN = Cervical Intraepithelial Neoplasia

6. Abnormal Cytologic Findings: (The TBS, 2001) • AS cells: • ASC – US • ASC – H • LSIL • HSIL • AG cells • AGC – NOS • AGC – favor neoplasia • AIS • Invasive Cancer

7. Abnormal Cervical Cytology in Turkey :A Turkish Gynecologic Oncology Group (TGOG) Study Ayhan et al, Int J Gyn Obst, 2009

8. AbnormalCytology(2481/140334) %1.76 • ASC (n=2341)1.66 • ASC-US rate (n=1510) %1.07 • ASC-H rate (n=100) %0.07 • LSIL rate (n=429) %0.3 • HSIL rate (n=243) %0.17 • AGC (n=111) 0.07 • Cytologic Ca (SCC+Adeno, n=88)0.062 %

9. Abnormal Cytology USA* (%) TR (%) • ASC-US 4.3 1.07 • LSIL 1.6 0.33 • HSIL 0.2 0.17 • AGC 0.3 0.07 * 2012 ASCCP Modern Colposcopy 2012

10. Abnormal Cytology-ASC *Immunosupresyon, HPV 

11. Risk for detection of CIN 2 + at Colposcopy

12. Abnormal Cytology-AGC

13. Risks of CIN 2-3 and ICC

14. Management of Abnormal Cervical Cytology Patients age Type of abnormality (Sq. vs. Glanduler) Grade Available tests (HPV,Colposcopy) Special situations (Menopause,pregnancy,adeloscent, immunosupression)

25. Management of Pregnant women LSIL Colposcopy (preferred approach for non-adolescent) Defer Colposcopy (until at least 6 weeks postpartum OR Manage per ASCCP guideline CIN 2,3 No CIN2,3 Postpartum Follow-up

26. HSIL in Pregnancy • Colposcopy is recommended • Biopsy of suspicious lesions for CIN2/3 or cancer is preferred • ECC is unacceptable • Diagnostic exicion is unacceptable unless invasive cancer • Reevaluation with cytology and colposcopy is recommended no sooner than 6-wk postpartum(with HSIL in whom CIN 2/3 is not diagnosed)

27. New Terminology LGL (CIN1 ±HPV) HGL (CIN2, CIN3)

28. Incidence of Preinvasive Lesions 27 / 100000 (1980)* 54 / 100000 (1990)* 1.5 – 6% of all cytologic spesimens * SEER

29. 5-year Survival in Cervical Cancer (%) Pre-invasive 100 Early localized 92 Regional spread 49 Distant met. 14.9 Am J Obstet Gynecol, 13-20, 188, 2003 (SEER)

30. Fundamental Objectives of Managing Preinvasive Lesions • Find the lesion • R / O invasion • Preserve fertility • Employ cost-eff. and low morbid techniques

31. The Aim of Therapy in Preinvasive Lesion • Local control • Prevention of ICC • Decreased mortality

32. CIN 1 60 % Regression 30 % Persistence 9 % CIS 1 % Invasive Cancer

33. CIN 2 40 % Regression 40 % Persistence 15 % Progression to CIS 5 % Invasive Cancer

34. CIN 3 56 % Persistence 33 % Regression 12 % Invasive Cancer

35. Which Lesions to Treat? • all lesions selected lesions • CIN 1...............1%(ICC) • CIN 2...............5%(ICC) • CIN 3.............12%(ICC)

36. Therapeutic Tools • Ablation (destruction) • Excision • Photo – dynamic therapy • Non – surgical* • Expectant management * Vidarabine, Podophylline (CINs + HPV)

37. Ablative or Local Destructive Methods: • Cryo – surgery • ECD • Cold coagulator • CO2 laser * No further histologic exam.

38. Excisional Tools* • CONE • CKC • Laser • LEEP • Hysterectomy * in selected patients

39. Indications for Excisional Therapy • (+) ECC • cyto – histology discrepancy • Microinvasion • AIS • unsatisfactory colposcopy

41. Distribution of CIN Cases • n=281 CIN 1-3 • CIN1: 68 • CIN2: 48 • CIN3: 162 Ayhan A et al., 2007

42. Treatment Modalities used in Our Center Ayhan A et al., 2007

43. Results of Re-conization after Positive Surgical Margins in CIN 2-3n=56 Ayhan A et al., 2007 (under review)

45. Cryotherapy

46. Laser

47. LEEP

49. Cold-KnifeConization

50. success rates of various methods for the treatment of CIN are similar (up to 97%)