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Cervical Disease and Neoplasms Maria Horvat, MD, FACOG.

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Presentation on theme: "Cervical Disease and Neoplasms Maria Horvat, MD, FACOG."— Presentation transcript:

1 Cervical Disease and Neoplasms Maria Horvat, MD, FACOG

2 Cervical Disease – Risk factors HPV Smoking – 2 fold increase Young age at 1 st coitus Multiple sexual partners A partner with multiple sexual partners High parity Lower socioeconomic status Young age at 1 st pregnancy

3 HPV in the United States

4 Cervical Disease HPV associated with 99.7% of all cervical cancer HPV types associated with higher oncogenic risk: 16, 18 31, 33, , 56

5 HPV – high risk types

6 HPV Obligatory intra-nuclear virus Most remit spontaneously 5% of infected women have persistent infection

7 PAP test Only a screening test Goal: To prevent cervical cancer

8 Histology of (SIL) squamous intraepithelial lesions. Grade 1 = CIN 1; Grade 2 = CIN 2; Grade 3 = CIN 3

9 Cervical Neoplasia

10 Potential Co-Factors in Cervical Carcinogenesis Other infectious agents Herpes Chlamydia HIV and other immunosuppression Diet Smoking Hormonal contraceptives Weak immunomodulatory effect Eversion of columnar epithelium Decrease in blood folate levels Progesterone effect on HPV

11 Management of Adolescent Women (<18 yrs) with histological diagnosis of CIN – Grade 1 < 18 yrs old with CIN 1 Repeat Cytology at 12 mos HSIL Repeat Cytology at 12 mos Negative > ASC Colposcopy Routine Screening

12 Management of Adolescent women (<18 yrs) with histological diagnosis of CIN – grade 2,3 <18 yrs old with CIN 2,3 Either 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 Treatment With colposcopy and cytology with excision or at 6 mos intervals for 24 mos ablation of T-zone 2x negative cytology colposcopy worsens or And normal colpo. High-grade cytology or colpo. Persists for 1 yr. Routine Screening Repeat Biopsy CIN 3, or CIN 2 that persists Recommended for 24 mos since initial dx

13 Management of Women with Atypical Squamous Cells: Cannot exclude high grade SIL (ASC – H) >20 yrs old with ASC-H Coloposcopic Examination

14 Management of Women with Atypical Squamous cells of undetermined significance - ASC-US >20 yrs old with ASC-US Repeat Cytology HPV DNA 4-6 mos Negative >ASC Positive Negative (for high risk type) 4-6 mos Colposcopy Repeat 12 mos

15 Naming

16 Cervical Intraepithelial Neoplasia Biopsy Result RegressPersistProgress to CIS Progress to invasion CIN 157%32%11%1% CIN 243%35%22%5% CIN 332%<56%----->12%

17 Colposcopic Grading Low GradeHigh Grade Acetowhite Epithelium Shiny or snow white, semitransparentDull, oyster white Surface FlatFlat or irregular contour Demarcation Diffuse, irregular, flocculated, feathered Internal demarcation line absent Sharp, straight line Internal demarcation line may be present Vessels Fine, with regular shapes, uniform caliber, normal aborization pattern Punctation or mosaicism associated with coarse, dilated vessels with increased intercapillary distance; bizarre vessels without aborization, commas, hockey sticks, corkscrews, sharp bends Iodine Yellow, or variegated brownMustard yellow, yellow or iodine negative

18 Summary for the non-gynecologist ASCUS Negative HPV type Positive Repeat Pap Refer for in 6 mos coloposcopy

19 CIN 1 – mild dysplasia 18 yrs old Repeat Pap Colposcopy

20 CIN 2,3 Colposcopy

21 Confirmed CIN 2,3 Excision (adolescents may perform colposcopy q 6 mos up to 24 mos)

22 Interventional Techniques - Excisional Conization Cone of tissue is excised for further examination and/or to remove a lesion Tissue is usually stained with iodine to demarcate the area of resection Cold knife Laser LEEP Loop electrosurgical excision procedure May be complicated by burn artifacts Ablative Cryotherapy Use of a probe containing carbon dioxide or nitrous oxide to freeze the entire transformation zone and area or the lesion Laser vaporization therapy

23 Atypical Glandular Cells AGUS Colposcopy ECC Endometrial Sample, women >35 yrs

24 What is colposcopy?

25 Cervical Cancer – staging review Stage 0: CIS, CIN grade III Stage 1: carcinoma strictly confined to the cervix Stage 2: cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina Stage 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?

32 Answer #1. LEEP or cone biopsy.

33 Question #2. Biopsy on face cervix is normal and ECC is positive, what is the next step?

34 Answer #2. LEEP or cone biopsy.

35 There is hope! Gardisil immunization guards against types 6, 11, 16, and 18. Administer at 0, 2, and 6 months for females 9 years or older.

36 HPV Vaccine Trials

37 Phase 2 Trial of Quadrivalent HPV Vaccine: Conclusions The vaccine was highly effective in reducing incidence of persistent HPV infection Efficacy 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 type The vaccine was generally well tolerated

38 Do condoms help prevent? YES! 60% decrease in transmission Does not eliminate risk.

39 Pap smear schedules: Many different recommendations ACOG APGO ACS

40 Pap smear recommendations 1 st pap by age 21 or within 3 years of 1 st coitus Annually until the age of 30 Pap with HPV at age 30, then can perform every few years.

41 Pap smear recommendations: Post Menopausal Some guidelines: No Pap ACOG: q 3-5 years Hysterectomized female: If hysterectomy for benign reasons, then pap q 3-5 years Yearly if: –Cervix present –History of abnormal paps –History of gyne cancer –History of DES exposure –History of cervical cancer –Smoking (increases chance of vaginal cancer)

42 References APGO Educational Series on Womens Health Issues: Advances in the Screening, Diagnosis, and Treatment of Cervical Disease Review in Obstetrics and Gynecology, Vol. 1 No American Society for Colposcopy and Cervical Pathology Crosstalk; Preventing Cervical Cancer and Other Human Papillomavirus-related diseases

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