colposcopy - university of kentuckyobgyn.med.uky.edu/sites/default/files/colposcopy.pdf ·...

Colposcopy

Colposcopy

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Chris DeSimone, M.D.

Chris DeSimone, M.D.

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Gynecologic Oncology

Gynecologic Oncology

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Images from

Images from

Colposcopy Cervical Pathology

Colposcopy Cervical Pathology

, 3

, 3

rd

rd

Ed., 1998

Ed., 1998

Colposcopy Cervical Pathology 3rd Ed. 1998

History

History

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Colposcopy was pioneered in Germany by Dr.

Colposcopy was pioneered in Germany by Dr.

Hinselmann

Hinselmann

during the 1920’s

during the 1920’s

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He sought to prove that microscopic examination

He sought to prove that microscopic examination

of the cervix would detect cervical cancer earlier

of the cervix would detect cervical cancer earlier

than 4 cm

than 4 cm

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His work identified several atypical appearances

His work identified several atypical appearances

which are still used today:

which are still used today:

Luekoplakia

Luekoplakia

Punctation

Punctation

Felderung

Felderung

(mosaicism)

(mosaicism)

History

History

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Through the 30’s and 40’s breakthroughs were

Through the 30’s and 40’s breakthroughs were

made regarding which appearances were more

made regarding which appearances were more

likely to progress to invasive carcinoma;

likely to progress to invasive carcinoma;

HOWEVER,

HOWEVER,

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These findings were difficult to interpret since they

These findings were difficult to interpret since they

were not correlated with histology

were not correlated with histology

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One researcher would claim his patients with X

One researcher would claim his patients with X

findings never had carcinoma while another

findings never had carcinoma while another

emphatically believed it did

emphatically believed it did

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World wide colposcopy was underutilized as a

World wide colposcopy was underutilized as a

diagnostic tool secondary to these discrepancies

diagnostic tool secondary to these discrepancies

Papanicolaou, Traut: Diagnosis of uterine

cancer by the vaginal smear, 1943

History

History

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Papanicolaou and

Papanicolaou and

Traut

Traut

revolutionized

revolutionized

screening of cervical cancer with cytology

screening of cervical cancer with cytology

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It was easy to collect and provided a more

It was easy to collect and provided a more

objective findings than colposcopy

objective findings than colposcopy

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Pap testing was rapidly accepted in North

Pap testing was rapidly accepted in North

America and Western Europe as the

America and Western Europe as the

screening test of choice

screening test of choice

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Its acceptance in Germany was poor

Its acceptance in Germany was poor

Navratil: Dysplasia, CIS and microinvasive

carcinoma of the cervix uteri: Colposcopy, 1964.

History

History

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During the 60’s colposcopy made a resurgence

During the 60’s colposcopy made a resurgence

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New studies showed that detection of carcinoma

New studies showed that detection of carcinoma

-

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in

in

-

-

situ (CIS) or invasive carcinoma were better

situ (CIS) or invasive carcinoma were better

detected by combining cytology with colposcopic

detected by combining cytology with colposcopic

directed biopsies

directed biopsies

Total 838 cases

Total 838 cases

Colposcopy 663 (79%)

Colposcopy 663 (79%)

Cytology 729 (87%)

Cytology 729 (87%)

Combination 828 (99%)

Combination 828 (99%)

History

History

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Today colposcopy has been accepted as a

Today colposcopy has been accepted as a

diagnostic tool in evaluating abnormal pap

diagnostic tool in evaluating abnormal pap

tests

tests

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Colposcopy elegantly identifies the location

Colposcopy elegantly identifies the location

of abnormal lesions allowing the practitioner

of abnormal lesions allowing the practitioner

to obtain histologic samples

to obtain histologic samples

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Its utility as a screening test is likely

Its utility as a screening test is likely

finished in westernized nations

finished in westernized nations

Overview

Overview

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Cytologic indications for colposcopy


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Cytologic correlation with histology


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Tools, Techniques and stains of colposcopy


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Normal colposcopic anatomy


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Abnormal colposcopic anatomy


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Unusual colposcopic anatomy


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Treatment of abnormal histology


Indications for Colposcopy

Indications for Colposcopy

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Abnormal pap tests suggestive of cervical

Abnormal pap tests suggestive of cervical

dysplasia

dysplasia

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Types are classified according to Bethesda

Types are classified according to Bethesda

2001 nomenclature

2001 nomenclature

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Best to delineate which pap tests correlate

Best to delineate which pap tests correlate

with mild dysplasia and those which are

with mild dysplasia and those which are

more severe

more severe

2001 Bethesda Nomenclature


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Mild dysplasia

Mild dysplasia

HPV

HPV

effect (Human

effect (Human

Papilloma Virus)

Papilloma Virus)

ASC

ASC

-

-

US

US

(Atypical

(Atypical

Squamous Cells of

Squamous Cells of

Unknown Significance)

Unknown Significance)

LSIL

LSIL

(Low Grade

(Low Grade

Squamous

Squamous

Intraepithelial Lesion)


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Severe dysplasia

Severe dysplasia

ASC

ASC

-

-

H

H

(Cannot rule

(Cannot rule

out HGSIL)

out HGSIL)

HSIL

HSIL

(High Grade

(High Grade

Squamous

Squamous



CIS

CIS

(Squamous

(Squamous

Carcinoma In

Carcinoma In

-

-

Situ)

Situ)



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Glandular abnormalities

Glandular abnormalities

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Should be handled with utmost caution

Should be handled with utmost caution

AGC

AGC

(Atypical Glandular Cells of Unknown

(Atypical Glandular Cells of Unknown

Significance)

Significance)

AIS

AIS

(Adenocarcinoma In

(Adenocarcinoma In

-

-

Situ)

Situ)

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Biopsy medial to the transformation zone

Biopsy medial to the transformation zone

Frequency of Abnormal Pap Tests

Frequency of Abnormal Pap Tests

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Estimated 50

Estimated 50

million pap

million pap

tests are

tests are

performed

performed

each year

each year

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5% are

5% are

abnormal

abnormal

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2

2

-

-

3 Million

3 Million

ASCUS

ASCUS

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1 Million LSIL

1 Million LSIL

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600,000 HSIL

600,000 HSIL

ASCUS

LGSIL

HGSIL

Cancer

Histologic Nomenclature

Histologic Nomenclature

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CIN (Cervical Intraepithelial Neoplasia)

CIN (Cervical Intraepithelial Neoplasia)

CIN 1 corresponds to mild dysplasia

CIN 1 corresponds to mild dysplasia

CIN 2 corresponds to moderate dysplasia

CIN 2 corresponds to moderate dysplasia

CIN 3 corresponds to severe dysplasia

CIN 3 corresponds to severe dysplasia

CIS and CIN 3 are the same entity

CIS and CIN 3 are the same entity

Histopathology

Histopathology

Overview

Overview

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Histologic correlation


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As a colposcopist, histology is more

As a colposcopist, histology is more

important than cytology

important than cytology

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The cytology is important for two reasons:

The cytology is important for two reasons:

1) indication to perform colposcopy

1) indication to perform colposcopy

2) gives the colposcopist a “hint” of the

2) gives the colposcopist a “hint” of the

histology

histology

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Histology is important for determining

Histology is important for determining

patient treatment

patient treatment

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Cytology does not equal histology

Cytology does not equal histology

Morin et al. J Reprod Med, 2001



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ASC

ASC

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-

US

US

Most common type of abnormal pap

Most common type of abnormal pap

Is it a premalignant change?

Is it a premalignant change?

No! Roughly 70% of ASC

No! Roughly 70% of ASC

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US paps are related to

US paps are related to

vaginitis, atrophy, granulation tissue, chronic

vaginitis, atrophy, granulation tissue, chronic

cervicitis, etc

cervicitis, etc

Only 30% are dysplastic in nature

Only 30% are dysplastic in nature

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90% are CIN 1

90% are CIN 1

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5

5

-

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10% are CIN 2

10% are CIN 2

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3

3



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LSIL

LSIL

Common, 1 million paps diagnosed each year

Common, 1 million paps diagnosed each year

Most erroneously managed pap test. Why?

Most erroneously managed pap test. Why?

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Pap repeated frequently

Pap repeated frequently

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HPV testing

HPV testing

30% of LSIL paps harbor CIN 2 and CIN 3 on

30% of LSIL paps harbor CIN 2 and CIN 3 on

colposcopic directed biopsies

colposcopic directed biopsies

Colposcopy needs to be done first and foremost

Colposcopy needs to be done first and foremost

to ascertain histologic diagnosis

to ascertain histologic diagnosis

Sherman. Am J Clin Pathol 2001



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ASC

ASC

-

-

H

H

28

28

-

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40% of these pap tests are CIN 2

40% of these pap tests are CIN 2

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3 on

3 on

histologic biopsy

histologic biopsy

Accordingly, HPV testing is positive 70

Accordingly, HPV testing is positive 70

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86%

86%

Colposcopic examination will reveal a wide

Colposcopic examination will reveal a wide

range of findings

range of findings

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HSIL & CIS

HSIL & CIS

Expect worrisome colposcopic abnormalities

Expect worrisome colposcopic abnormalities

with these pap tests

with these pap tests

Colposcopic Correlation

Colposcopic Correlation

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Mild dysplasia

Mild dysplasia

Acetowhite changes

Acetowhite changes

Bright white

Bright white

Clear demarcation

Clear demarcation

between normal and

between normal and

abnormal epithelium

abnormal epithelium

Fine punctations

Fine punctations

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Severe dysplasia

Severe dysplasia

Dull, pearly grey

Dull, pearly grey

epithelium

epithelium

Faint to difficult to

Faint to difficult to

interpret demarcation

interpret demarcation

between abnormal and

between abnormal and

normal epithelium

normal epithelium

Coarse punctations

Coarse punctations

Mosaicism

Mosaicism

Abnormal vessels

Abnormal vessels

Overview

Overview

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Tools, Techniques and stains of

Tools, Techniques and stains of

colposcopy

colposcopy

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Tools, Techniques & Stains


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Colposcope

Colposcope

Stereoscopic binocular microscope

Stereoscopic binocular microscope

Magnification from 8

Magnification from 8

×

×

to 40

to 40

×

×

Generally panoramic view at 10

Generally panoramic view at 10

×

×

most useful

most useful

A green filter

A green filter

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Used to highlight vascular patterns

Used to highlight vascular patterns

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Demarcate color differences between normal and

Demarcate color differences between normal and

abnormal tissue

abnormal tissue

Colposcope

Colposcope



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Instruments

Instruments

Kevorkian

Kevorkian

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Younge biopsy forceps

Younge biopsy forceps

Endocervical curette

Endocervical curette

Endocervical brush

Endocervical brush

Cytology brush

Cytology brush

Silver Nitrate stick

Silver Nitrate stick

Monsel’s solution

Monsel’s solution

Instruments

Instruments

Curette

Kevorkian

Instruments

Instruments

Cytology

Broom

Endocervical Brush

Lugol’s

Monsel’s

Silver Nitrate Stick



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Stains

Stains

3% Acetic Acid

3% Acetic Acid

Works as a desiccant

Works as a desiccant

The cellular cytoplasm is reduced enhancing a

The cellular cytoplasm is reduced enhancing a

prominent nucleus

prominent nucleus

The nucleus is enlarged secondary to HPV

The nucleus is enlarged secondary to HPV

replication

replication

This nuclear enlargement is seen as acetowhite

This nuclear enlargement is seen as acetowhite

changes

changes

Acetic Acid

Acetic Acid



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Stains

Stains

Lugol’s iodine solution (Schiller test)

Lugol’s iodine solution (Schiller test)

Works by staining glycogen

Works by staining glycogen

Dysplastic tissue has an increased metabolic

Dysplastic tissue has an increased metabolic

rate thereby lowering cellular glycogen

rate thereby lowering cellular glycogen

Normal tissue stains black/brown while

Normal tissue stains black/brown while

dysplastic tissue appears highlighted or yellow

dysplastic tissue appears highlighted or yellow

Useful stain for hard to see lesions

Useful stain for hard to see lesions

Lugols Solution

Lugols Solution



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Technique

Technique

Orient colposcope so that a panoramic view is

Orient colposcope so that a panoramic view is

obtained

obtained

Start with normal light and 10× magnification

Start with normal light and 10× magnification

Entire cervix should be visualized

Entire cervix should be visualized

Apply generous amount of acetic acid while

Apply generous amount of acetic acid while

cleaning off obscuring mucous or discharge

cleaning off obscuring mucous or discharge

You can never apply too much acetic acid

You can never apply too much acetic acid



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Evaluate the squamocolumnar junction

Evaluate the squamocolumnar junction

(SCJ) or transformation zone (TZ)

(SCJ) or transformation zone (TZ)

Dysplasia originates from this boundary and

Dysplasia originates from this boundary and

spreads lateral to this junction

spreads lateral to this junction

Medial to this border are columnar

Medial to this border are columnar

cells/glandular cells

cells/glandular cells

A large volume of glandular cells are called

A large volume of glandular cells are called

ectropion

ectropion

Young women and pregnant women generally

Young women and pregnant women generally

have ectropion

have ectropion

Colposcopy

Colposcopy

Ectropion or

Ectropion or

glandular cells

glandular cells

Endocervical Os

Endocervical Os

Squamous

Squamous

Epithelium

Epithelium

3% Acetic acid applied to cervix

3% Acetic acid applied to cervix

Cervix viewed under magnification and green light

Cervix viewed under magnification and green light

Entire transformation zone must be visualized

Entire transformation zone must be visualized

Dysplastic epithelium will be

Dysplastic epithelium will be

“acetowhite” due to higher

“acetowhite” due to higher

Nuclear/cytoplasmic ratio

Nuclear/cytoplasmic ratio

Squamocolumnar

Junction

Squamocolumnar Junction

Squamocolumnar Junction

SCJ



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Evaluate areas of acetowhite changes

Evaluate areas of acetowhite changes

Are they small or larges patches?

Are they small or larges patches?

Does it have a sharp or indistinct border?

Does it have a sharp or indistinct border?

Is it a bright white or a dull, pearly grey?

Is it a bright white or a dull, pearly grey?

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Evaluate areas of punctation

Evaluate areas of punctation

Are the punctations small or large caliber?

Are the punctations small or large caliber?

Are the punctations sparse or numerous?

Are the punctations sparse or numerous?

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Evaluate areas of mosaicism

Evaluate areas of mosaicism

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Evaluate areas of abnormal blood vessels

Evaluate areas of abnormal blood vessels

Are the blood vessels uniform or sporadic?

Are the blood vessels uniform or sporadic?

Are the vessels large caliber or small caliber?

Are the vessels large caliber or small caliber?

Adequacy of Colposcopy

Adequacy of Colposcopy

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Must evaluate the entirety of the lesion

Must evaluate the entirety of the lesion

Can you follow the entire lesion?

Can you follow the entire lesion?

Does it go past the SCJ and into the endocervix?

Does it go past the SCJ and into the endocervix?

Does it move into the vagina?

Does it move into the vagina?

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Must evaluate the entirety of the SCJ

Must evaluate the entirety of the SCJ

Is it obscured by prior treatments?

Is it obscured by prior treatments?

Does it recede into the endocervix?

Does it recede into the endocervix?

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Proper evaluation of both the lesion and the SCJ is an

Proper evaluation of both the lesion and the SCJ is an

adequate colposcopy

adequate colposcopy

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Failure of either criteria is an inadequate colposcopy and

Failure of either criteria is an inadequate colposcopy and

leads to changes in treatment NOT diagnosis of

leads to changes in treatment NOT diagnosis of

histopathology

histopathology

Biopsies

Biopsies

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Best to obtain biopsy of worst area

Best to obtain biopsy of worst area

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Try to incorporate SCJ if at all possible

Try to incorporate SCJ if at all possible

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Multiple biopsies are recommended but

Multiple biopsies are recommended but

should be kept within reason (2

should be kept within reason (2

-

-

3)

3)

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Endocervical curettage (ECC) should

Endocervical curettage (ECC) should

generally be included as part of each

generally be included as part of each

colposcopy

colposcopy

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Having the patient cough during biopsy is

Having the patient cough during biopsy is

good distraction

good distraction

Williams. Obstet Gynecol, 2000

To ECC or not to ECC

To ECC or not to ECC

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Never wrong to perform

Never wrong to perform

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However, ECC can be avoided if entire lesion is

However, ECC can be avoided if entire lesion is

visible on ectocervix

visible on ectocervix

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This position is strengthened since squamous

This position is strengthened since squamous

dysplasia is continuous; it does not skip

dysplasia is continuous; it does not skip

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Others proclaim it evaluates occult endocervical

Others proclaim it evaluates occult endocervical

dysplasia

dysplasia

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Ultimate decision lies with wisdom and expertise

Ultimate decision lies with wisdom and expertise

of practitioner

of practitioner

Tate. Obstet Gynecol, 1997

ECC

ECC

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Most uncomfortable portion of colposcopic

Most uncomfortable portion of colposcopic

directed biopsies

directed biopsies

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Good to have patient take NSAID 30 min before

Good to have patient take NSAID 30 min before

colposcopy

colposcopy

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Apply curette at four cardinal directions

Apply curette at four cardinal directions

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Swirl curette in fixative then take endocervical

Swirl curette in fixative then take endocervical

brush to collect rest of sample

brush to collect rest of sample

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Prospective randomized trial showing better

Prospective randomized trial showing better

results with curette and brush than either alone

results with curette and brush than either alone

Overview

Overview

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Normal Colposcopy

Normal Colposcopy

Normal Histology

Normal Histology

Normal Colposcopy/Ectropion

Normal Colposcopy/Ectropion

Normal Colposcopy

Normal Colposcopy

Close

Close

-

-

up of SCJ

up of SCJ

Overview

Overview

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Abnormal Colposcopic Anatomy


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Acetowhite epithelium or changes

Acetowhite epithelium or changes

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Punctations

Punctations

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Mosaicism

Mosaicism

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Abnormal Vessels

Abnormal Vessels

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Invasive carcinoma

Invasive carcinoma



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Acetowhite changes

Acetowhite changes

Mildest changes of cervical dysplasia

Mildest changes of cervical dysplasia

Caused by desiccation of cytoplasm from acetic

Caused by desiccation of cytoplasm from acetic

acid leading to increased nuclear /cytoplasmic

acid leading to increased nuclear /cytoplasmic

ratio

ratio

Other areas of abnormal change can be found

Other areas of abnormal change can be found

within acetowhite lesions

within acetowhite lesions

Often times very clear area of demarcation from

Often times very clear area of demarcation from

normal to abnormal

normal to abnormal

Normal versus Abnormal


SCJ

Post Acetic Acid

Post Acetic Acid

Acetowhite changes

Acetowhite changes

Acetowhite changes

Acetowhite changes

Mosaicism

Line of

demarcation

Line of demarcation

Line of demarcation

Acetowhite changes

Acetowhite changes

Punctations

Faint Acetowhite

Faint Acetowhite

Lesion Found

Lesion Found

Punctations

Punctations

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Punctations are vessels that run

Punctations are vessels that run

perpendicular to the portio of the cervix

perpendicular to the portio of the cervix

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They are end on end to the colposcopist

They are end on end to the colposcopist

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The green filter removes red light thus

The green filter removes red light thus

vessels are darkened

vessels are darkened

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Punctation can be small vessels (fine

Punctation can be small vessels (fine

punctation) or large vessels (coarse

punctation) or large vessels (coarse

punctation)

punctation)

Punctations

Punctations

Coarse Punctations

Coarse Punctations

Punctations

Punctations

Fine

Punctations

Punctations

Punctations

Bright

Acetowhite

lesion with

coarse

punctations

Mosaicism

Mosaicism

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A mosaic is a large image pieced together

A mosaic is a large image pieced together

by smaller usually colorful tiles

by smaller usually colorful tiles

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In colposcopy it is essentially the same

In colposcopy it is essentially the same

-

-

a

a

larger lesion made of small heaped

larger lesion made of small heaped

epithelial islands and tiny vessels

epithelial islands and tiny vessels

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These islands look like a cobblestone road

These islands look like a cobblestone road

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Islands are separated by vessels running

Islands are separated by vessels running

parallel to the portio or colposcopist

parallel to the portio or colposcopist

Mosaicism

Mosaicism

Large lesion

composed of

multiple

islands and

intervening

small vessels

Islands

Microscopic Mosaicism

Microscopic Mosaicism

Mosaicism

Mosaicism

Mosaicism

Mosaicism

Punctations

Area of

mosaicism

with large

punctations

consistent

with CIN 3

Abnormal Vessels

Abnormal Vessels

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In the natural progression of dysplasia to

In the natural progression of dysplasia to

invasive cervical cancer, many genetic and

invasive cervical cancer, many genetic and

pathologic changes occur

pathologic changes occur

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One important change is angiogenesis

One important change is angiogenesis

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The evolving carcinoma needs oxygen and

The evolving carcinoma needs oxygen and

nutrients to grow at an exponential rate

nutrients to grow at an exponential rate

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In order to achieve maximal growth, new

In order to achieve maximal growth, new

blood vessels are synthesized

blood vessels are synthesized

Abnormal Vessels

Abnormal Vessels

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The newly created vessels are perfect for

The newly created vessels are perfect for

pooling blood

pooling blood

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They have low flow, little

They have low flow, little

pulsativity

pulsativity

and

and

poor resistance

poor resistance

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The above factors are caused by multiple

The above factors are caused by multiple

tributaries arising from any one vessel

tributaries arising from any one vessel

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End result is like a delta from a river, lots of

End result is like a delta from a river, lots of

nutrients are brought in but blood is slow to

nutrients are brought in but blood is slow to

return

return

Examples of Normal Vessels

Examples of Normal Vessels

Abnormal Vessels

Abnormal Vessels

Invasive Cancer

Invasive Cancer

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Conglomeration of all colposcopic finding:

Conglomeration of all colposcopic finding:

acetowhite, punctations, mosaicism, and vessels

acetowhite, punctations, mosaicism, and vessels

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Necrotic tissue results in anaerobic odors

Necrotic tissue results in anaerobic odors

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Think ahead when performing biopsies: Monsel's,

Think ahead when performing biopsies: Monsel's,

packing and even suture might be necessary to

packing and even suture might be necessary to

control hemorrhage

control hemorrhage

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Shoot for a good tissue collection, often time not

Shoot for a good tissue collection, often time not

enough tissue is obtained for pathologist to

enough tissue is obtained for pathologist to

document invasion!!!

document invasion!!!

Invasive Cancer

Invasive Cancer

Microscopic Invasion

Microscopic Invasion

Invasive Cancer

Invasive Cancer

Overview

Overview

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Polyps

Polyps

Polyp

Polyp

Polyps

Polyps

Nabothian Cysts

Nabothian Cysts

Normal

Vessels

Nabothian Cysts

Nabothian Cysts

Prominent

vessels of

normal

caliber

surrounding

multiple

Nabothian

cysts

Condylomas

Condylomas

Heaped

vaginal/

cervical

condyloma

in a gravid

female

Overview

Overview

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Treatment Modalities

Treatment Modalities

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Cryosugery

Cryosugery

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Loop Electricosurgical Excision Procedure

Loop Electricosurgical Excision Procedure

(LEEP)

(LEEP)

►

►

Laser Ablation

Laser Ablation

►

►

Cold Knife Conization

Cold Knife Conization

►

►

Hysterectomy

Hysterectomy

Cryosurgery

Cryosurgery

►

►

Inexpensive, easy to perform, tolerated well by

Inexpensive, easy to perform, tolerated well by

patients

patients

►

►

Cells are destroyed by (cold) thermal damage

Cells are destroyed by (cold) thermal damage

►

►

3 minute freeze/ 1 minute thaw/ 3 minute freeze

3 minute freeze/ 1 minute thaw/ 3 minute freeze

well documented technique

well documented technique

►

►

Does cause 2

Does cause 2

-

-

3 weeks of malodorous discharge

3 weeks of malodorous discharge

►

►

Does hinder repeat colposcopy (SCJ often

Does hinder repeat colposcopy (SCJ often

obscured)

obscured)

LEEP

LEEP

►

►

Procedure of choice for most OB/

Procedure of choice for most OB/

GYN’s

GYN’s

►

►

Easy to perform, well tolerated and provides

Easy to perform, well tolerated and provides

specimen for pathologic evaluation

specimen for pathologic evaluation

(Margins)

(Margins)

►

►

Good rule to keep specimens less than 4 cm

Good rule to keep specimens less than 4 cm

wide and 2 cm tall

wide and 2 cm tall

►

►

Concern that multiple excisions or one large

Concern that multiple excisions or one large

excision will increase rate of preterm

excision will increase rate of preterm

labor/incompetent cervix

labor/incompetent cervix

Preterm Delivery and LEEP


►

►

Kyrgiou

Kyrgiou

et al. Lancet 2006; 367: 489

et al. Lancet 2006; 367: 489

-

-

98.

98.

►

►

Meta

Meta

-

-

analysis of 27 studies

analysis of 27 studies

►

►

Studies chosen had to have a control group

Studies chosen had to have a control group

►

►

Evaluation of CKC, LEEP and laser for:

Evaluation of CKC, LEEP and laser for:

preterm delivery (<37 weeks gestation)

preterm delivery (<37 weeks gestation)

Low birth weight (<2500 g)

Low birth weight (<2500 g)

Cesarean delivery

Cesarean delivery



►

►

CKC

CKC

Preterm delivery

Preterm delivery

-

-

RR 2.59 (95% CI 1.80

RR 2.59 (95% CI 1.80

-

-

3.72)

3.72)

Low birth weight

Low birth weight

-

-

RR 2.53 (95% CI 1.19

RR 2.53 (95% CI 1.19

-

-

5.36)

5.36)

Cesarean section

Cesarean section

-

-

RR 3.17 (95% CI 1.07

RR 3.17 (95% CI 1.07

-

-

9.40)

9.40)

►

►

LEEP

LEEP

Preterm delivery

Preterm delivery

-

-

RR 1.70 (95% CI 1.24

RR 1.70 (95% CI 1.24

-

-

2.35)

2.35)

Low birth weight

Low birth weight

-

-

RR 1.82 (95% CI 1.09

RR 1.82 (95% CI 1.09

-

-

3.06)

3.06)

Cesarean section

Cesarean section

-

-

RR 2.69 (95% CI 1.62

RR 2.69 (95% CI 1.62

-

-

4.46)

4.46)

►

►

Laser

Laser

NS for Preterm delivery

NS for Preterm delivery

-

-

RR 1.71 (95% CI 0.93

RR 1.71 (95% CI 0.93

-

-

3.14)

3.14)



►

►

Summary

Summary

►

►

CKC patients are 2.5 times more likely to

CKC patients are 2.5 times more likely to

have a preterm delivery, low birth weight

have a preterm delivery, low birth weight

infant and/or cesarean section

infant and/or cesarean section

►

►

LEEP 1.5 times more likely

LEEP 1.5 times more likely

►

►

Incidence of preterm delivery is 2

Incidence of preterm delivery is 2

-

-

3%

3%

CKC ~ 7.5% (1 in 15 women)

CKC ~ 7.5% (1 in 15 women)

LEEP ~ 4.5% (1 in 20 women)

LEEP ~ 4.5% (1 in 20 women)

Dietrich, Obstet Gynecol 2002

Margins and LEEP

Margins and LEEP

►

►

Margin status helpful in predicting

Margin status helpful in predicting

recurrence of cervical dysplasia

recurrence of cervical dysplasia

►

►

Negative margins ~15%

Negative margins ~15%

►

►

Positive margins ~ 30

Positive margins ~ 30

-

-

60%

60%

►

►

Re

Re

-

-

excision not needed. Follow patient with

excision not needed. Follow patient with

serial pap tests and treat accordingly if

serial pap tests and treat accordingly if

patient recurs

patient recurs

Laser

Laser

►

►

CO2 laser works by vaporizing cervical cells

CO2 laser works by vaporizing cervical cells

►

►

Very precise method; only need 5

Very precise method; only need 5

-

-

7 mm of

7 mm of

vaporization for treatment

vaporization for treatment

►

►

Heals great, spares cervical excisions

Heals great, spares cervical excisions

►

►

COST major problem

COST major problem

►

►

No pathology specimen

No pathology specimen

Cold Knife Conization (CKC)

Cold Knife Conization (CKC)

►

►

Used to be the treatment of choice before

Used to be the treatment of choice before

LEEP

LEEP

►

►

Surgically excises dysplasia with

Surgically excises dysplasia with

scalpel/scissors

scalpel/scissors

►

►

Large cost to patient from physician,

Large cost to patient from physician,

anesthesia, and hospital charges

anesthesia, and hospital charges

►

►

Incompetent cervix an issue

Incompetent cervix an issue

►

►

Indications to perform are few

Indications to perform are few

Hysterectomy

Hysterectomy

►

►

The final treatment for cervical dysplasia

The final treatment for cervical dysplasia

►

►

Comes with significant morbidity/ mortality

Comes with significant morbidity/ mortality

and lengthy recovery (6 weeks)

and lengthy recovery (6 weeks)

►

►

Complications include: hemorrhage,

Complications include: hemorrhage,

infections, bowel & bladder injuries, MI,

infections, bowel & bladder injuries, MI,

pulmonary embolus, stroke, death

pulmonary embolus, stroke, death

►

►

10

10

-

-

20% of patients will continue to have

20% of patients will continue to have

abnormal pap tests: vaginal dysplasia

abnormal pap tests: vaginal dysplasia

Mitchell, Obstet Gynecol 1998.

Efficacy of treatment


►

►

Randomized controlled trial between

Randomized controlled trial between

cryosurgery, LEEP and laser showed no

cryosurgery, LEEP and laser showed no

statistical difference in efficacy

statistical difference in efficacy

►

►

Recurrences were measure from 6

Recurrences were measure from 6

-

-

37

37

months

months

►

►

Cryosurgery 19%

Cryosurgery 19%

►

►

LEEP 13%

LEEP 13%

►

►

Laser 13%

Laser 13%

Reich, Obstet Gynecol. 2001 and 2002



►

►

Reich et al. performed two retrospective studies

Reich et al. performed two retrospective studies

on cold knife conization

on cold knife conization

►

►

4417 women with CIN 3 were treated with CKC

4417 women with CIN 3 were treated with CKC

and followed for median 107 months (negative

and followed for median 107 months (negative

margins)

margins)

►

►

Only 15 women developed recurrence (0.35%)

Only 15 women developed recurrence (0.35%)

►

►

390 women with CIN 3 were treated with CKC and

390 women with CIN 3 were treated with CKC and

followed for a median of 19 years (positive

followed for a median of 19 years (positive

margins)

margins)

►

►

84 women developed recurrence (22%)

84 women developed recurrence (22%)

Which method to chose?


►

►

Several factors to consider: age, desire for

Several factors to consider: age, desire for

fertility, size of lesion, size of the cervix,

fertility, size of lesion, size of the cervix,

severity of dysplasia, and prior therapies

severity of dysplasia, and prior therapies

►

►

Generalizations:

Generalizations:

Cryosurgery

Cryosurgery

-

-

best for young women with few

best for young women with few

finances and CIN 1 or 2.

finances and CIN 1 or 2.

LEEP

LEEP

-

-

the majority of women with CIN 2 or 3.

the majority of women with CIN 2 or 3.

Women with endocervical lesions also suited for

Women with endocervical lesions also suited for

LEEP

LEEP



Laser

Laser

-

-

women who have had multiple

women who have had multiple

recurrences of CIN 2 or 3 and who want to

recurrences of CIN 2 or 3 and who want to

retain fertility. Example: a 19 year old G

retain fertility. Example: a 19 year old G

0

0

who

who

has CIN 3, prior LEEP, and a small cervix.

has CIN 3, prior LEEP, and a small cervix.

CKC

CKC

-

-

glandular abnormalities (AIS) or early

glandular abnormalities (AIS) or early

invasive cancer

invasive cancer

Hysterectomy

Hysterectomy

-

-

women finished with

women finished with

childbearing and who have persistent CIN.

childbearing and who have persistent CIN.

Often best utilized with other gynecologic

Often best utilized with other gynecologic

problems like pelvic pain or abnormal uterine

problems like pelvic pain or abnormal uterine

bleeding

bleeding

Unknowns

Unknowns

colposcopy - university of kentuckyobgyn.med.uky.edu/sites/default/files/colposcopy.pdf ·...

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