Prof. Aboubakr ElnasharBenha University Hospital, EGYPT

Aboubakr Elnashar

Aboubakr Elnashar

CIN: WHO Recommendation 2014. CIN 1:(i)immediate tt(ii)follow the woman and then tt if the lesion is persistent or progressive after 18 to 24 months.CIN 2 and CIN 3: Cryotherapy or LEEP.AIS (adenocarcinoma in situ)CKC

Aboubakr Elnashar

StrategyThree visits strategyone for screeningone for colposcopy,one for treatment: poor compliance, especially among rural women.

Single visit: see-and-treat strategysatisfactory resultsno significant extra morbidity [Emam et al, 2009].

Aboubakr Elnashar

See & treat (Single visit diagnosis & tt)•It means

(Cryo therapy, cold coagulator or LEEP) at first visit to women with (VIA or colposcopic) findings suggestive of SIL.

•Advantages:

False negative histology is low (4.7% )

Reduce waiting lists & anxiety

•Disadvantages:

Over tt of insignificant lesions•It should be limited to HGSIL (Pastner,1994)

Aboubakr Elnashar

Aboubakr Elnashar

Swede score

Aboubakr Elnashar

Swede score of 4 and above: Punch biopsies of the cervixSwede score 6 and above: immediate treatment with cold coagulation under visualisation with the Gynocular and local anaesthesia. patients not suitable for cold coagulation or with biopsies revealing microinvasive cervical disease or worse: appropriate diagnostic workup and management protocol.

Aboubakr Elnashar

Aboubakr Elnashar

MethodsIndications of ablative therapy

1. Satisfactory colposcopy

2. No suggestion of invasive disease

3. No suspicion of glandular disease

4. Cytology & histology correspond

suspicion of invasion or unsatisfactory colposcopic assessment excludes any ablative method of treatment.

Aboubakr Elnashar

Indication of Excisional therapy

1. Unsatisfactory colposcopy.

2. Suspicion of invasion

3. Suspicion of glandular disease

4. Discrepancy between cytology & histopathology

Aboubakr Elnashar

I. Ablative1. Cryotherapy

Relies on :steady supply of compressed refrigerant gases (N2O or CO2) in transportable cylinders. Mechanism:Excellent contact between the cryoprobe tip and the ectocervix: N2O-based cryotherapy: –89°CCO2-based system: –68°C at the core of the ice ball and –20°C at the edges. Cells reduced to –20°C for one or more minutes will undergo cryonecrosis.

Aboubakr Elnashar

Eligibility criteria •The entire lesion is located in the ectocervix without extension to the vagina and/or endocervix• The lesion is visible in its entire extent and does not extend more than 2 to 3 mm into the canal• The lesion can be adequately covered by the largest available cryotherapy probe (2.5 cm); the lesion extends ≤2 mm beyond the cryotherapy probe

Aboubakr Elnashar

• There is no evidence of invasive cancer• The endocervical canal is normal and there is no suggestion of glandular dysplasia• The woman is not pregnant• If the woman has recently delivered, she is at least three months post-partum• There is no evidence of PID• The woman has given informed written consent to have the treatment

• CIN is confirmed by cervical biopsy/colposcopy

Aboubakr Elnashar

• Healing: six weeksSide effects:watery vaginal discharge for 3-4 w after tt• Advisenot to use a vaginal douche, tampons or have sexual intercourse for one month after tt..• Treatment failure: 5-10%

Aboubakr Elnashar

Aboubakr Elnashar

Technique:Two sequential freeze-thaw cycles,Each cycle consisting of :3 min of freezing followed by 5 min of thawing (3min freeze-5 min thaw-3 min freezethaw).

Adequate freezing: when the margin of the ice ball extends 4-5 mm past the outer edge of the cryotip: cryonecrosis down to at least 5 mm depth.

Aboubakr Elnashar

Advantages1. Favorable safety profile2. Outpatient procedure3. No anesthetic requirements4. Ease of procedure5. Low-cost equipment with minimal maintenance6. Bleeding complications rare7. No proven adverse reproductive effects8. Acceptable primary cure rate

Aboubakr Elnashar

Disadvantages1. No tissue specimen for histopathology2. Cannot treat lesions with unfavorable sizes or shapes3. Uterine cramping4. Potential for vasovagal reaction5. Profuse vaginal discharge postprocedure6. Cephalad migration of SCJ

Video

Aboubakr Elnashar

2. Cold coagulationMethod:lesion is treated with tefloncoated probe to 100°C-120°CThe probe is applied to each part of the cervix for 30-40 sec. ensuring that the whole TZ is destroyed beyond the limit of acetowhite epithelium. Sultrin cream vaginally, nightly for one weekavoid intercourse and use of tampons for 3w.

Aboubakr Elnashar

Advantages:1.All grades of CIN can be treated2.outpatient clinic. 3.Relatively painless procedure requiring minimal or no analgesia. 4.Safe, efficient, with a very low morbidity rate. 5.Short tt time6.Well accepted by both patients and colposcopists

Aboubakr Elnashar

Success RateCINIII: 95% CIN I and III: 96.5% -99% following one or more tt Persistent disease:very low rate (7. 1%) (Semple. Et al; 2008)

Recurrence ratevery low, 5.6%,

Aboubakr Elnashar

Aboubakr Elnashar

II. Excesional

1. LEEPLoops:

0.2 mm hard stainless steel or titanium

Diameters : 1-3 cm.

Aboubakr Elnashar

Aboubakr Elnashar

The eligibiligy criteria that must be met before LEEP is performed• If the lesion involves or extends into the endocervical canal, the distal or cranial limit of the lesion should be seen; the furthest (distal) extent is no more than 1 cm in depth• No evidence of invasive cancer or glandular dysplasia• No evidence of PID, cervicitis, vaginal trichomoniasis, bacterial vaginosis, anogenital ulcer or bleeding disorder

Aboubakr Elnashar

• If the woman has recently delivered, sheshould be at least three months postpartum• Women with hypertension should have theirblood pressure well controlled•CIN is confirmed by cervical biopsy, when possible

Failure rate: 10%.

Aboubakr Elnashar

Technique1.Lithotomy position, speculum inserted, colposcopy , cervix is painted with Lugol’s iodine.2.Patient grounded with pad return electrode 3.Circumferential cervical block using 1% lidocaine. Inject just beneath & lateral to the lesion4.Short lasting IV sedation is given to women who so demanded.5.A loop wider than the lesion(s) and the TZ to be removed should be used; otherwise, the lesion should be removed with multiple passes6.Depending on the loop size, a power setting 25-55 watts of blend (cutting plus coagulation) current

Aboubakr Elnashar

7. An attempt to remove entire involved lesion in a single pass moving from right to left.

8. If endocervical excision is needed, a smaller loop (usually 0.8 cm in width) is used for second pass, removing the region around the endocervical canal in a “top hat” fashion. The power setting is lowered when using the smaller loop.

9. Coagulate the base of the cone by the ball electrode (60 W) even if no apparent bleeding

Aboubakr Elnashar

Haemostasis 1. Roller ball coagulation 2. Monsel’s paste 3. Silver nitrate3. Packing with roller gauz soaked in povidone iodin4. In case of a spurting vessel not controlled by

cautery: 2-0 chromic catgut suture .

Aboubakr Elnashar

Advise Avoid: for one month after LEEP. vaginal doucheTamponsexual intercourseany vaginal medicationTo report immediately on having severe painfoul smelling discharge or severe bleeding.

Aboubakr Elnashar

Follow up At one week: review of Histopathology reportAt one month: to examine cervix ask about problems At 6 &12 months: VIA, VILLI and Colposcopy.

Aboubakr Elnashar

Complications

1.Bleeding: primary secondary

Moderate to severe: ≤2%

2. Infection

3. Discharge: brown or black for up to two weeks

4. Incomplete removal of lesion

5. Inadvertent burns

6. Cervical stenosis

Aboubakr Elnashar

Advantages

Over ablative methods

Tissue specimen for histopathology evaluation

Over laser

tt time is shorter

Easier to learn

No hazard to the eyesight

Equipment breakdowns occur less often

Cone sampling is better than laser

less handling of tissue

Discomfort is reduced

Low costs of equipment

Aboubakr Elnashar

Disadvantages1. Thermal damage may obscure specimen margin status2. Special training required3. Risk of post procedure bleeding4. Theoretical risk of vapor plume inhalation

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Video

Aboubakr Elnashar

2. Cold-knife conizationIndications •The lesion extends into the endocervical canal and it is not possible to confirm the exact extent.• The lesion extends into the canal and the farthest extent exceeds the excisional capability of the LEEP cone technique (maximum excisional depth of 1.5 cm).• The lesion extends into the canal and the farthest extent exceeds the excisional capability of the colposcopist.• The cytology is repeatedly abnormal, suggesting neoplasia, but there is no corresponding colposcopic abnormality of the cervix or vagina on which to perform biopsy.

Aboubakr Elnashar

• Cytology suggests a much more serious lesion than that which is seen and biopsy-confirmed.• Cytology shows atypical glandular cells that suggest the possibility of glandular dysplasia or adenocarcinoma.• Colposcopy suggests the possibility of glandular dysplasia or adenocarcinoma.• Endocervical curettage reveals abnormal histology.

Aboubakr Elnashar

Begin the cone biopsy by placing lateral sutures at the cervicovaginal junction to decrease bleeding.

Use a #11 surgical blade to make the circular incision, angling the tip of the blade toward the endocervical canal.

Aboubakr Elnashar

Grasp the specimen, including the entire transformation zoneand distal endocervical canal, with an Allis clamp.

Complete the cone excision by cutting across endocervix. Applylight cautery to the edges of the cervical bed.

Aboubakr Elnashar

Advantages Tissue specimen for histopathology without margin compromiseDisadvantages Potential for hge Lengthier procedure Postoperative discomfort General or regional anesthesia required Operating room setting High cost Larger volume of cervical stroma removed Increased risk of adverse reproductive outcomes

Aboubakr Elnashar

III. HysterectomyIndications

1. Other gynecological conditions:

.fibroid, prolapse, endometriosis, PID .

2. Refuse all other forms of therapy

3.SIL at limits of conization specimen

4. Poor compliance with follow-up

Sterilization is not an indication

Aboubakr Elnashar

Follow up after treatment of CIN

• Non of the methods for tt of CIN offers an absolute cure rate.

• Recurrences most common: in the first 2 yr, in the os & on the outside margins

Aim

Persistent or recurrent disease (after 12 mo)

Visits

6 mo intervals for 2 yr, then annually

Assessment

Combined cytology & colposcopy at first visits, then cytology (endocx & ectocx), VIA

Aboubakr Elnashar

Treatment of CIN during pregnancy

•Abnormal cytology Colposcopy

•Colposcopically directed punch biopsy or

small loop biopsy

•Knife or LLE cone: rarely indicated

•Colposcopy/ 3 m to ensure that the lesion is not progressing

•CIN 3: treatment after delivery

Aboubakr Elnashar

Prof. Aboubakr ElnasharBenha University Hospital, EGYPT

E-mail: elnashar@hotmail.com

Aboubakr Elnashar