Managament of Abnormal Cervical Cytology and Histology

Transcription

1 Managament of Abnormal Cervical Cytology and Histology Ali Ayhan, M.D Başkent University Faculty of Medicine Department of Gynecology and Obstetrics Division of Gynecologic Oncology

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

3 Causes of Abnormal Cervical Smears -HPV related lesions; Preinvasive lesions Invasive cancer -Lower/Higher genital cancers -Previous RT -DES-related

4 Abnormal Cytology(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

5 HPV taramalarında güncel durum

6 HPV taramalarında güncel durum

7 HPV taramalarında güncel durum

8 ABNORMAL CYTOLOGY vs HISTOLOGY Pap/HPV Finding Risk of CIN 2/3 (%) Risk of CA (%) Pap (-),HR HPV(+) 4 ASCUS ,1-0,2 ASCUS, HR HPV(-) <2 ASCUS, HR HPV(+) ASC-H LSIL <1,0 HSIL >70 1,0-2,0

9 Clinical Importance of AGC 0.3% AIS 0.8% Invasive cancer 1-9% CINs 9-54%

10 Smear Results Risk of CIN2/3 AIS or Ca AGC-NOS 9-41 AGC-favor Neoplasia AIS 48-69

11 Management of Abnormal Cervical Cytology Patients age Type of abnormality Available tests (HPV, Citology) Colposcopic equipment Special situations (Menopause, pregnancy, y, immunosupression)

12 CYTO - HPV + (30y or older) 1 year later Cytology (ASC-US or worse) or HPV + COLPOSCOPY

13 ASC-US + Reflex or Co- Test HPV + Colposcopy No CIN 12 mts later Cytology HPV - 3 years later ASC-US ( no HPV ) 12 mts later Cytology ASC-US or Worse COLPOSCOPY

14 Management of LSIL LSIL with HPV - LSIL without HPV testing LSIL with HPV+ Repeat co-testing (1 yr) Cytology neg and HPV neg ASC or worse or HPV + COLPOSCOPY Routine screening

15 Management of Women Aged with ASC-US or L-SIL ASC-US or L-SIL Repeat months Negative, ASC-US or L-SIL ASC-H, AGC, H-SIL Repeat months Negative * 2 ASC or Worse Routine Screening COLPOSCOPY

16 Management of ASC-H, HSIL, AGC ASC-H, H-SIL, AGC Colposcopy * Evaluation of results Final decision making follow-up or treatment -Regardless of HPV *35 yrs older with atypical endometrial cells

17 Management of Women Aged with ASC-H or H-SIL COLPOSCOPY No CIN 2,3 Observation with colposcopy and cytology ( 6mts interval for 2 yrs) CIN 2,3 (Go to Guideline) 2 consecutive cytology negative H-SIL ( persists 24 mts ) High grade colposcopic lesion or H-SIL(persists 1 year) Routine Screening Diagnostic Excision

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19 Biopsi Sonuçları Pre-invasive LGS (CIN1, HPV lezyonu) İnvasive Mikro-invasive HGL (CIN2, CIN3)

20 Incidence of Preinvasive Lesions 27 / (1980)* 54 / (1990)* 1.5 6% of all cytologic spesimens * SEER

21 The Aim of Therapy in Preinvasive Lesion Local control Prevention of ICC Decreased mortality related to cervical cancer

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

23 Which Lesions to Treat? all lesions (in the past) selected lesion CIN 1...1%(ICC) CIN 2...5%(ICC) CIN %(ICC)

24 Natural History of Cervical Dysplasia: Rates of Regression, Persistance, and Progression Regress to No CIN (%) Persistance (%) Progress To To CIN3 CA CIN <1 CIN CIN NA 22

25 Therapeutic Tools and Types Ablation (destruction) Excision Photo dynamic therapy Non surgical* Expectant management * Vidarabine, Podophylline (CINs + HPV)

26 Ablative or Local Destructive Methods*: Cryo surgery ECD Cold coagulator CO laser 2 * No further histologic exam.

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28 Cryotherapy

29 Excisional Tools* CONE CKC Laser LEEP Hysterectomy * in selected patients

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32 Cold-Knife Conization

33 LASER

34 LEEP

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36 Indications for Excisional Therapy (+) ECC (except CIN1) Cyto histology discrepancy Microinvasion AIS Selected high grade lesion Unsatisfactory colposcopy 2 year persiste CIN1

37 Management of CIN 1 Oncogenic and non oncogenic HPV type 16 less than CIN 3 natural history HPV + ascus and low grade SIL Regression rate is high Progression to CIN 2+ uncommon

38 Risk of Occult CIN 3 in patients with CIN 1 Previous cyt CIN 3 ASCUS, LSIL 3.8% ASC-H, HSIL, AGC 15% Follow-up: 5 years; KPNC Data

39 CIN 1 preceded by ASCUS-LSIL HPV 16, 18 and Persistant HPV Follow up without treatment Co-test at 12 months HPV- /cyt - 3 years Both negative ASC or HPV + colposcopy CIN 2-3 CIN 1 Routine screening Treatment Persist 24 months

40 CIN 1 preceded by ASC-H or HSIL Co-test at 12 and 24 months HPV(-) cyto (-) at both visits Age-specific re-test at 3 years HPV + or any cytologic abnormality except HSIL colposcopy HSIL Diagnostic Excisional procedures Re-evaluation of cytologic, histologic and colposcopıc findings

41 Management of CIN 1: Young Women (21-24 y) After ASC-US or LSIL Repeat cytology at 12 months < ASC H or HSIL ASC-H or HSIL Rep cyto at 12 months negative ASC Colposcopy Routine screening

42 Management of CIN 1 after ASC-H or HSIL in Young Women (21-24y) Inadequate colp Diag exc Procedure Adequate colposcopy Review materials if change in diagnosis manage up to results Observation with colposcopy and cyto at 6 months for 1 year Negative cytology both visits routine SCC HSIL Excisional procedures

43 CIN 2 and CIN 3 or CIN 2, 3 Initial Management: Satisfactory or adequate Colposcopy 1. Ablation 2. Excision* *Except for pregnant and young woman

44 Excisional Procedures 1. Inadequate colposcopy with: CIN 2, CIN 3 or CIN 2,3 2. Endocervical sampling positive CIN 2, CIN 3, CIN 2, 3 or CIN ungraded 3. Recurrent CIN 2 and 3 or CIN 2, 3 4. Hysterectomy is not accaptable for initial treatment

45 CIN 2, 3: Follow-up after Treatment Co-testing at 12 months and 24 months Co-testing Abnormal (-) 3 years interwal Colp+ ECC All tests negative Routine screening at least 20 years up to 65 years of age To repeat treatment or hysterectomy based on positive HPV is unacceptable

46 CIN 2, CIN 3 and CIN 2, 3 in Pregnant Woman Cytology + colposcopy (at 12 weeks int.) Repeat biopsy; apperance of lesion worsens or if cytology suggests invasive cancer Diagnostic excisional procedure is recommended if invasive cancer is suspected (ring shape) Re-evaluation with cytology and colposcopy at post-partum 6 weeks

47 Young women with CIN 2, 3 Adequate colposcopy treatment or observation CIN 2: just observation CIN 3: inadequate colposcopy treatment: excision Observation: colposcopy/cytology at 6 months interval up to 12 mths

48 Management of CIN 2, 3 in Young Women (21-24yrs) Cytology negative 2 times and normal colposcopy Colposcopy worsens or HSİL perists for one year Co- test in one year Both tests negative Abnormal test Repeat colposcopy/biopsy Co-test in three years CIN 2,CIN2/3 persists for 24 months Treatment

49 Management of CIN1 in ECC CIN 1 after lesser abnormalities no CIN 2 + on biopsy manage as CIN1 add ECC 1 year later CIN 1 in ECC and cytology ASC-H, HSIL or AGC Colposcopic findings CIN 2 + Manage for the spesific abnormalities

50 Management of Positive Margine / ECC in CIN2, CIN 3 or 2, 3 Reassesment using cytology with ECC at 4-6 months Repeat diagnostic exc procedures If repeating is not feasible, hysterectomy is acceptable (also in recurrent and persistent CIN 2+)

51 Adeno Carcinoma In Situ (AIS) Low but rising Multifocal Skip lesion Difficult to diagnose Colposcopic appereance Determination of limits R/O of invasion needs excisional procedures

52 Management of AIS Excisional procedures Hysterectomy Conservative Margine or Apex positive Apex /margine negative Re-excision Re-eveluation with co-test and colposcopy At 6 months intervals Follow up

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

54 N=28 randomized study The evidence suggests that there is no obvious superior surgical technique for treating CIN

55 Treatment Failures Poor techniques Glandular involvement Grade of CIN Size of lesion Margin status

56 5-year Survival in Cervical Cancer (%) Pre-invasive 100 Early localized 92 Regional spread 49 Distant met Am J Obstet Gynecol, 13-20, 188, 2003 (SEER)

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62 2012 US PSTF 2012 ACS/ASCCP/ASCP Ne Zaman? 21 yaş 21 yaş 21 yaş 2015 ACOG/ASSCCP Interim Ne Sıklıkta? PAP 3 yılda bir veya 30 yaş ve üstünde 5 yılda bir co-testing yaş 3 yılda bir PAP, yaş arası cotesting veya 3 yılda bir PAP 3 yılda bir PAP, yaş yaş arası co-testing veya 3 yılda bir PAP 25 yaş ve üstü 3 yılda bir high risk HPV Ne Zaman Bırakılacak? 65 yaş, yeterince tarama yapılmışsa Üst üste 3 HPV veya negatif PAP Histerektomi sonrası benign patolojilerde Üst üste 3 HPV veya negatif PAP Histerektomi sonrası benign patolojilerde

63 Türkiye da HPV Taraması

64 Thank you