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Screening for Female Genital Tract Malignancy

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Presentation on theme: "Screening for Female Genital Tract Malignancy"— Presentation transcript:

1 Screening for Female Genital Tract Malignancy

2 Screening Generally Is to seek about certain problem in certain high risk group.

3 Validity of Screening Test
Validity of test determined by ability to correctly categories subjects to test-positive or test-negative

4 Validity of Screening Test cont...
Sensitivity = ability of test to give a positive result when disease is present = a / a+c Specificity= ability of test to give a negative result when disease is absent = d / b+d

5 Validity of Screening Test
Predictive value is determined by sensitivity & specificity and also by the prevalence of preclinical diseas Positive predictive value = probability that a person with a positive test actually has the disease = a / a+b Negative predictive value = probability that a person with a negative test is truly disease-free = d / c+d

6 When to Suspect Gynecologic Cancer
Woman with: Ovarian mass/cyst Growth or ulcer of cervix, vagina or vulva Abdominal mass, increased abdominal girth Postcoital bleeding New onset of hematuria or renal failure New onset of bowel obstruction

7 When to Suspect Gynecologic Cancer cont….
Premenopausal woman with: Irregular menses Women older than 35 or with long history of irregular menses Postmenopausal woman with: Vaginal bleeding Abnormal vaginal discharge

8 Concept Prevention is better than cure.
Cancer cervix Screening programs are in adulthood But ovarian cancer programs are still in relative infancy, why?

9 Phases of Tumorgenesis
Normal cells Dysplasia Invasive asymptomatic As cancer ovary Cancer cx. End. C. Invasive symptomatic

10 Most Cancers Develop In The Unscreened And The Underscreened.

Disease: Must be serious enough Must be widespread enough Must be fairly reliably diagnosable Must be treatable Must be affordable Hopefully legally defensible

12 Criteria for Screening Test
1. Simple & quick 2. Capable of being performed by paramedics 3. Inexpensive 4. Acceptable to population 5. Accurate 6. Repeatable 7. Sensitive 8. Specific

13 Incidence of Gynecologic Cancers in Taiwanese Women
70 60 50 40 Incidence per 100,000 30 20 10 Breast Cancer Cervical Cancer Ovarian Cancer Uterine Cancer Source: Department of Health 2007.

14 Epidemiology of Cervical Cancer
Magnitude of the Problem: - 500,000 new cases identified each year (1725 new cases in Taiwan,2008) 80% of the new cases occur in developing countries At least 200,000 women die of cervical cancer each year (657 women in Taiwan, 2008) Cervical cancer is the second/third most common cancer worldwide

15 Epidemiology of Cervical Cancer cont….
Most common female cancer in developing countries: leading cause of cancer death in women. 10-15% cases seen at late incurable stages.

16 Epidemiology of Cervical Cancer cont….
High risk patients: High parity?!! Multiple partner Genital infections HPV & HSV II Smoking Sexual behavior of women’s partner Cervix:

17 Pathogenesis of CIN Normal Cervix HPV Infection
HPV-related Changes Normal Cervix Low-Grade SIL (Atypia, CIN I) High-Grade SIL (CIN II, III/CIS) Invasive Cancer HPV Infection Cofactors High-Risk HPV (Types 16, 18, etc.) About 60% regress within 2-3 yrs About 15% progress within 3-4 yrs 30% - 70% progress within 10 yrs

18 Morphological Changes of Cervical Cancer

19 Prevention of Cervical Cancer
Cervical cancer is a preventable disease Primary prevention: Education to reduce high risk sexual behaviour Measures to reduce/avoid exposure to HPV and other STIs Secondary prevention: Treatment of precancerous lesions before they progress to cervical cancer (implies practical screening test) Now : HPV vaccines.

20 Secondary Prevention of Ca.Cx.
Key Point is to detect precancerous lesions –BY A good screening method PAP smear test is considered to be the gold standard – Has limitations ? Alternatives to Pap Smear – What are they?

21 Why screening for cervical cancer?
1. Is relatively common in unscreened women. 2. Has a relatively good prognosis if found early stage in its natural course of disease. 3.Has a characteristic natural course that is a slow progression through a premalignant stage.

22 Why screening for cervical cancer?
4. A premalignant stage can be detected by noninvasive means (the Pap smear, colposcope). 5. There are effective treatment modalities to eradicate premalignant lesions and early invasive cervical cancer.

23 Screening by Pap. Cx. Smear
a. Importance: unscreened female have ten fold risk > screened female - Every sexually active female (3y after sex) - Specially, high risk group. - Annually up to the age of 70y - No need to extend screening > 70y if smear is N. - At each pregnancy - If new risk factors appear after 70y. b. To whom : c. When: d. Abnormal smear colposcopy

24 Limitations of Pap Smear
Complex laboratory test Requires trained cytotechnician for reading and pathologist for review Continuous monitoring needed to maintain high-quality results Reports often take minimum 1-2 weeks to obtain Follow-up of women is difficult Usually available only in large cities in many countries

25 Alternatives to Pap smear
Visual inspection with acetic acid (VIA). Liquid-based cytology (ThinPrep test). Automated pap smear (Computer reading). HPV DNA test in conjunction with pap smear. Colposcopy.

26 VIA: Normal

27 Positive VIA

28 Liquid-based Pap Smear

29 Liquid-based Pap Smear

30 Liquid-based Pap Smear

31 Liquid-based Pap Smear

32 Liquid-based Pap Smear

33 Computer assisted Pap smear interpretation

34 Computer assisted Pap smear interpretation

35 Computer assisted Pap smear interpretation

36 HPV Testing and Cervical Cytology
For Screening in Women Aged ≥ 30 Source: Obstet Gynecol 2004; 103: 304-9

Source-Program for Appropriate Technology in Health [PATH] 1997.

38 Colposcopy

39 Introduction Originally developed by Hans Hinselmann in the 1920s.
By the 1930s, colposcopy was widely used in Europe. 1970s, the colposcopy was accepted procedure for the verification of abnormal cytologic findings in the United States.

40 Introduction

41 Supplies for colposcopy
Acetic acid (3% to 5%)(vagina and cervix: 30 to 60 seconds; should be reapplied, as needed, after three to five minutes. ) (vulva: 3 to 5 minutes for the solution to permeate the cells and for the lesion to appear white. ) Lugol’s solution

42 Figure 1. A representative parous adolescent cervix showing the outer boundaries of several important areas of exocervical epithelium that correspond to the histological representations in Figure 2. External os (os), new squamocolumnar junction (nscj), area of cervical ectopy (ect) between nscj and external os, cervical transformation zone (ctz) between the original squamocolumnar junction (oscj) and nscj that includes an area of immature metaplasia (im), which is lightened by the application of 5% acetic acid. Adapted from.[15]

43 Abnormal Transformation Zone
Features suggestive of an ATZ: Leukoplakia Acetowhite epithelium Erosion/Ulceration Internal margins Abnormal/atypical vessels

44 Leukoplakia

45 Acetowhite Epithelium


47 Mosaic

48 Punctation


50 Atypical Vessels

51 MEANING OF Acetowhite Not all acetowhite patches are cancer:
Any of these epithelial changes can also become acetowhite: Healing or regenerating epithelium Congenital transformation zone Inflammation Immature squamous metaplasia

52 MEANING OF Acetowhite HPV infection CIN / CGIN Adenocarcinoma
Invasive squamous cell carcinoma

53 EFFICACY For HSIL or cancer: sensitivity: 85%, specificity: 69%
For any CIN: sensitivity: 96%, specificity: 48% It is important to note that the experience and training of the colposcopist are important factors in assuring reliable diagnostic results.

54 Take a rest !

55 Endometrial Cancer Risk Identification
Several risk factors: 1. Nulliparous women 2-3 times the risk of parous women 2. Infertility history, irregular mense, anovulatory cycles 3. Late menopause (> 52 y/o): 2.4 times for those < 49% 4. Obesity: overweight pounds: 3 times overweight > 50 pounds: 10 times (peripheral conversion of adrenally derived androstenedione by aromatization in fat to estrone) 5. PCOD -- Functioning ovarian tumors 6. HRT (E without P): 4-8 times 7. Tamoxifen for breast cancer: 2-3 times 8. DM: times

Malig. Potential Pathology Little or none Replacement of usual gland cell by cells having cilia, sq. cells Metaplasia 1-3% over 15y Irregular glands, minor budding or out pouching Simle hyperplasia 3-4% over 13y Back to back glands, budding, papillary process, minor stratification Complex hyperplasia 23% over 10y Atypism + back to back + budding Atypical hyperplasia

57 Endometrial Cancer Screening
Screening of unproven benefit Pap smear: inadequate Transvaginal sonography (TVS) examinations Helpful in evaluating vaginal bleeding Endometrial sampling Risks include discomfort, bleeding, infection, uterine perforation (rare)

58 Endometrial Cancer Screening - TVS
Endometrial Stripe Thickness Diagnosis <5mm 6-10mm 11-15mm >15mm Atrophy 93% 7% Hyperplasia 58% 42% Polyp 53% 47% Cancer 18% 41% Grigoriou: Maturitus 23:9-14,1996

59 Endometrial Cancer Screening - TVS
Normal endometrial stripe

60 Endometrial Cancer Screening - TVS
Thickened Endometrial Stripe: A case of endometrial cancer

61 Endometrial Cancer Screening - TVS
Thickened Endometrial Stripe: A case of endometrial cancer

62 Endometrial Cancer Screening – EM sampling
Endometrial Suction Curette

63 Endometrial Cancer Screening – EM sampling

64 Flow Chart for Endometerial Sampling


66 Ovarian Cancer Screening
Risk identification: Increase Decrease Age OCPs Family history Pregnancy Infertility/low parity Tubal ligation Personal cancer history Breast-feeding

67 Ovarian Cancer Screening
Benefit to screening is unproven Annual bimanual gynecologic examination Transvaginal ultrasound CA 125 serum levels Screening may result in more unnecessary surgeries than new ovarian cancers

68 Screening For Early Diagnosis Ovarian Malignancy
Multiple modalities: 1-  Clinical. 2-  Cul-de-sac evaluation (PV). 3-  Imaging techniques (TVS). 4-  Tumour markers (CA125). 5-  Multimodels.

69 Ovarian Cancer: Ultrasound Screening Studies
Screening of 5,000 women 65 exploratory surgeries for every case of ovarian cancer Screening of 1,600 women with a family history 12 exploratory surgeries for every case of ovarian cancer Survival benefit unproven

70 Ovarian Cancer: CA125 Testing
Is elevated in greater than 80% of advanced EOCs Is elevated in 25-50% of Stage I cancers Has poor specificity, especially in premenopausal women NOT a screening test for the general population

71 Screening For Early Diagnosis Ovarian Malignancy
Recommendations: 1-  Comprehensive family history on all patients. 2-  None or 1 family member Annual rectovaginal pelvic exam. 3-  2 or more family members Genetic counseling (BRCA I, II mutation) Annual rectovaginal pelvic exam, CA125, transvaginal ultrasound. 4-  Consider clinical trial participation.

72 Ovarian Cancer: Screening and prevention

73 Thanks for your attention !

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