Presentation on theme: "Cervical Disease and Neoplasms"— Presentation transcript:
1 Cervical Disease and Neoplasms Maria Horvat, MD, FACOG
2 Cervical Disease – Risk factors HPVSmoking – 2 fold increaseYoung age at 1st coitusMultiple sexual partnersA partner with multiple sexual partnersHigh parityLower socioeconomic statusYoung age at 1st pregnancy
10 Potential Co-Factors in Cervical Carcinogenesis Other infectious agentsHerpesChlamydiaHIV and other immunosuppressionDietSmokingHormonal contraceptivesWeak immunomodulatory effectEversion of columnar epitheliumDecrease in blood folate levelsProgesterone effect on HPV
11 Management of Adolescent Women (<18 yrs) with histological diagnosis of CIN – Grade 1 < 18 yrs old with CIN 1Repeat Cytology at 12 mos< HSIL > HSILNegative > ASC ColposcopyRoutine Screening
12 Management of Adolescent women (<18 yrs) with histological diagnosis of CIN – grade 2,3 <18 yrs old with CIN 2,3Either treatment or observation is acceptable, provided colposcopy is satisfactory.When CIN 2 is specified, observation is preferred. When CIN 3 is specified, or colposcopy is unsatisfactory, treatment is recommended.Observation OR TreatmentWith colposcopy and cytology with excision orat 6 mos intervals for 24 mos ablation of T-zone2x negative cytology colposcopy worsens orAnd normal colpo High-grade cytology orcolpo. Persists for 1 yr.Routine Screening Repeat Biopsy CIN 3, or CIN 2 that persistsRecommended for 24 mos since initial dx
13 Coloposcopic Examination Management of Women with Atypical Squamous Cells: Cannot exclude high grade SIL (ASC – H)>20 yrs old with ASC-HColoposcopic Examination
14 >20 yrs old with ASC-US Management of Women with Atypical Squamous cells of undetermined significance - ASC-US>20 yrs old with ASC-USRepeat Cytology HPV DNA testing@ 4-6 mosNegative >ASC Positive Negative(for high risk type)Repeat@ 4-6 mos Colposcopy Repeat cytol.@ 12 mos
16 Cervical Intraepithelial Neoplasia Biopsy ResultRegressPersistProgress to CISProgress to invasionCIN 157%32%11%1%CIN 243%35%22%5%CIN 3<56%----->12%
17 Acetowhite Epithelium Colposcopic GradingLow GradeHigh GradeAcetowhite EpitheliumShiny or snow white, semitransparentDull, oyster whiteSurfaceFlatFlat or irregular contourDemarcationDiffuse, irregular, flocculated, featheredInternal demarcation line absentSharp, straight lineInternal demarcation line may be presentVesselsFine, with regular shapes, uniform caliber, normal aborization patternPunctation or mosaicism associated with coarse, dilated vessels with increased intercapillary distance; bizarre vessels without aborization, commas, hockey sticks, corkscrews, sharp bendsIodineYellow, or variegated brownMustard yellow, yellow or iodine negative
18 Summary for the non-gynecologist ASCUSNegative HPV type PositiveRepeat Pap Refer forin 6 mos coloposcopy
19 CIN 1 – mild dysplasia < 18 yrs old >18 yrs old Repeat Pap Colposcopy
21 Confirmed CIN 2,3 Excision (adolescents may perform colposcopy q 6 mos up to 24 mos)
22 Interventional Techniques - Excisional ConizationCone of tissue is excised for further examination and/or to remove a lesionTissue is usually stained with iodine to demarcate the area of resectionCold knifeLaserLEEPLoop electrosurgical excision procedureMay be complicated by burn artifactsAblativeCryotherapyUse of a probe containing carbon dioxide or nitrous oxide to freeze the entire transformation zone and area or the lesionLaser vaporization therapy
23 Atypical Glandular Cells AGUSColposcopyECCEndometrial Sample, women >35 yrs
25 Cervical Cancer – staging review Stage 0: CIS, CIN grade IIIStage 1: carcinoma strictly confined to the cervixStage 2: cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vaginaStage 3: carcinoma has extended to the pelvic wall. On rectal exam there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower 1/3 of the vagina. All cases with hydronephrosis or non-functioning kidney unless known to be due to other causes.Stage 4: Carcinoma has extended beyond the true pelvis, or has involved the mucosa of the bladder or rectum.
26 Cervical Cancer Staging Stage 0: The cancer cells are very superficial (only affecting the surface) are found only in the layer of cells lining the cervix, and they have not grown into (invaded) deeper tissues of the cervix. This stage is also called carcinoma in situ (CIS) or cervical intraepithelial neoplasis (CIN) grade III.
27 Cervical Cancer Staging Stage I: In this stage the cancer has invaded the cervix, but it has not spread anywhere else.Stage IA: This is the earliest form of stage I. There is a very small amount of cancer, and it can be seen only under a microscope.Stage IA1: The area of invasion is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide.Stage IA2: The area of invasion is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide.Stage IB: This stage includes Stage I cancers that can be seen without a microscope. This stage also includes cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm.Stage IB1: The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches).Stage IB2: The cancer can be seen and is larger than 4 cm
28 Cervical Cancer Staging Stage II: In this stage, the cancer has grown beyond the cervix and uterus, but hasn't spread to the walls of the pelvis or the lower part of the vagina.Stage IIA: The cancer has not spread into the tissues next to the cervix (called the parametria). The cancer may have grown into the upper part of the vagina.Stage IIB: The cancer has spread into the tissues next to the cervix
29 Cervical Cancer Staging Stage III: The cancer has spread to the lower part of the vagina or the pelvic wall. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder).Stage IIIA: The cancer has spread to the lower third of the vagina but not to the pelvic wall.Stage IIIB: The cancer has grown into the pelvic wall. If the tumor has blocked the ureters (a condition called hydronephrosis) it is also a stage IIIB.
30 Cervical Cancer Staging Stage IV: This is the most advanced stage of cervical cancer. The cancer has spread to nearby organs or other parts of the body.Stage IVA: The cancer has spread to the bladder or rectum, which are organs close to the cervix.Stage IVB: The cancer has spread to distant organs beyond the pelvic area, such as the lungs.
31 Question #1.What if HGSIL pap and normal colposcopy?
37 Phase 2 Trial of Quadrivalent HPV Vaccine: Conclusions The vaccine was highly effective in reducing incidence of persistent HPV infectionEfficacy with regard to clinical disease associated with HPV types 6,11,16,18, was 100%The vaccine was highly immunogenic, inducing high antibody titers to each HPV typeThe vaccine was generally well tolerated
38 Do condoms help prevent? YES!60% decrease in transmissionDoes not eliminate risk.
39 Pap smear schedules:Many different recommendationsACOGAPGOACS
40 Pap smear recommendations 1st pap by age 21 or within 3 years of 1st coitusAnnually until the age of 30Pap with HPV at age 30, then can perform every few years.
41 Pap smear recommendations: Post MenopausalSome guidelines: No PapACOG: q 3-5 yearsHysterectomized female:If hysterectomy for benign reasons, then pap q 3-5 yearsYearly if:Cervix presentHistory of abnormal papsHistory of gyne cancerHistory of DES exposureHistory of cervical cancerSmoking (increases chance of vaginal cancer)
42 ReferencesAPGO Educational Series on Women’s Health Issues: Advances in the Screening, Diagnosis, and Treatment of Cervical DiseaseReview in Obstetrics and Gynecology, Vol. 1 NoAmerican Society for Colposcopy and Cervical PathologyCrosstalk; Preventing Cervical Cancer and Other Human Papillomavirus-related diseases