Management of abnormal colposcopic findings
Heru Priyanto Oncology Division, Obstetry and Gynecology Department Dr Moewardi Hospital – Faculty of Medicine- Sebelas Maret University Solo - Indonesia
Faculty of Medicine Gajah Mada University, Dr Sardjito Hospital, The Dutch School, 2011 30/04/2014
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Introduction HPV Infection Cervical Carcinogenesis Pre-Cancer Stage gives us the opportunity to do screening and therapy, so it does not develop into invasive cancer.
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Modified Reid colposcopic index (RCI ) Scoring : A score of 0 to 2 points=Likely to be CIN 1; 3-4 points= Overlapping lesions; likely to be CIN 1-2; 5 to 8 points= Likely to be CIN 2-3 lesions
Feature
0 points
Colour of acetowhite (AW) area
Low-intensity acetowhitening; snow-white,shiny AW; indistinc AW; transparant AW; AW beyond the transformation zone AW lesion Feathered margins; angular, margin and surface jagged lesion; flat lesions configuration with indistinct margins; microconylomatous or mcropapillary surface Vessels
Iodine staining
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Fine/uniform vessels; poorly formed pattern of fine and/or fine mosaic; vessels beyond the margin of transformation zone; fine vessels within microcondylomatous or micropapillary lesions Positive iodine uptake giving mahogany brown colour; negative uptake of lesions scoring 3 points or less on the first criteria Areas beyod the margin of the transformationzone,conspicuous on colposcopy,evident as iodine-negative areas (such areas are frequently due to parakeratosis)
1 point
2 point
Grey–white AW with shiny surface
Dull, oyster-white; grey
Regular lesion with Rolled,peeling edges ; smooth, straight outlines internal demarcations (a central area of high-grade change and peripheral area of low-grade change ) Absent vessels Well defined coarse punctation or coarse mosaic
Partial iodine up-take by a lesion scoring 4 or more points on above three categories-variegated, specled appearance
Negative iodine uptake of significant lesions,i.e., yellow staining by a lesion scoring 4 or more points on the first three criteria
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Indeks KOLPOSKOPI MODERN
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1.MEDIKAMENTOSEE & TREAT:
NORMAL
SA/CHEMICAL 2.DESTRUKSI 3.EKSISI
MEMUASKAN
KOLPOSKOPI BIOPSI TERARAH
PA
ABNORMAL
TIDAK MEMUASKAN
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KONISASI
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Manajemen Lesi derajat rendah Prinsip: “(BOLEH) KONSERVATIF”
Karena: • 50 % regresi spontan (lesi hilang) • 35 % persisten • 15 % progesi menjadi Lesi derajat tinggi 30/04/2014
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Manajemen Lesi derajat rendah
1. 2. 3. 4.
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Konservatif : Observasi ulangi tes Pap 6 bulan Terapi Chemical : Imiquimod Terapi eksisi : LEEP Terapi destruksi : Cryo therapy, Electro-diathermy, Laser ablation
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Manajemen lesi derajat tinggi Prinsip: Tidak boleh konservatif Karena:
20 – 70 % progresif menjadi kanker invasif
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Terapi Lesi derajat tinggi
1.
2.
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Terapi destruksi: a. Cryo therapy b. Electro-diathermy c. Laser ablation Terapi eksisi : a. LEEP (Loop Electrosurgical Exision Procedure): bila lesi kecil b. LLETZ (Large Loop Exision of Transformation Zone): bila lesi luas atau sbg. pengganti konisasi c. Konisasi konvensional (cold knife conization) d. Histerektomi 9
Treatment may be offered at the first colposcopy visit, based on colposcopic findings : • The clinical management of women with CIN 1 lesions may take one of the following courses: (i) immediate treatment or (ii) follow the woman and then treat if the lesion is persistent or progressive after 18 to 24 months. • All women with CIN 2 and CIN 3 lesions should be treated with cryotherapy or LEEP. • Women diagnosed with invasive cancer should be promptly referred for treatment. 30/04/2014
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Treatment may be offered at the first colposcopy visit, based on colposcopic findings : • Women diagnosed with high-grade CIN during pregnancy can be reviewed at about 28 weeks gestation.If the disease is stable, the woman may be reviewed at 2-3 months post-partum for definitive diagnosis by biopsy and appropriate management of lesions. • Women treated for CIN may be reviewed at 9-12 months after treatment.
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TREATMENT MODALITY Ablative Cryosurgery E Cautery E. Coagulation Laser vap
Excision Conization Cold knife LEEP/LLETZ. Hysterectomy CHEMICAL
OBSERVATION
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Interferon Retinoid 5-FU topical
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TREATMENT MODALITY
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CIN 1
: Follow Up CIN I and HPV + ( ? )
CIN 2
: Cryosurgery/ LEEP/LLETZ
CIN 3
: LLETZ
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Whether it's LEEP / LLETZ? LEEP
: Loop Electrosurgical Excision Procedure
LLETZ : Large Loop Excision of the Transformation Zone An excision method, using a thin electric wire to remove a part or the entire TZ and therefore removes the affected tissue which can be examined further
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Basic Principle The disease site is SQJ – TZ HGSIL rarely propagated more than 1.5cm to endocervical canal Endocervical neoplasia mean dept was 3mm Just a small volume of the cervix must be destroyed or removed for CIN treatment
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Anatomy of the cervix
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Anatomy of the cervix
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Why LEEP / LLETZ for CIN ? Hysterectomy It is too radical Only for positive cone margin Micro invasive Associated gyn problem (Prolapse, fibroid)
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LEEP / LLETZ The cost of equipment & maintenance is low The technique is simple It can be done by local anesthesia Produce specimen for histopathology The patient can be treated at the first visit Replace Laser
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Equipment ESU Hand piece
electrode
Ground pad Speculum; bivalve & lateral vaginal Smoke evacuator
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Equipment Loops, ball electrode
NaCl 0,9%,
Tissue forceps, Gauze
Aceto-acetate 3-5%, Lugol sol Colposcope
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LEEP Technique
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Technique Lithotomic position Insert vaginal speculum Colposcopic procedure -satisfactory Local anesthesia Place ground plate Setting ESU, choose hand piece Movement electrode should be laterolatero-lateral or posterior to anterior Collect specimen Haemostatic control
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Movement of the electrode Just after switch pad has been turned on Lateral - lateral or posterior - anterior direction ( anterior - posterior: bleeding will infer electric current and disturb cutting or coagulating ) Slightly deeper at the middle to get doom shape specimen
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LEEP picture
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Procedure - picture
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PIT POGI XIX Jakarta 26 2011
Video
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LEEP
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LEEP (
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E Cautery )
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COLPOSCOPY / Lugol Sol
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Video : LLETZ
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Bleeding Occurred at lateral or posterior of cervix Can be managed by : electro coagulation monsel’s solution nitras argenti suture vaginal tampon
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Krioterapi Crisp 1967 Jaringan akan rusak pd suhu dibawah –20ºC Freezing Thawing
Intracelular crystalization
CO2 (-600C) N2O (-900C) Modalitas terapi untuk NIS 1 / 2
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2 mm 5 mm
cervix
Recovery zone
- 20 0C 0 0C
Lethal zone - 85 0C
probe
Ketebalan bola es 7 mm < 20ºC
lethal
0 ~ - 20 0C : recovery zone - 20 ~ - 85 0C : lethal zone
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Recovery zone
Tidak dpt merusak kedalaman Lesi > 5mm
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Efektifitas dari Krioterapi Temperatur Waktu pembekuan Tipe probe ukuran & gradasi lesi
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Indikasi IVA + Lesi derajat rendah (NIS 1 - 2 ) Lesi Derajat tinggi (NIS 3 ?)
Lesi Derajat rendah : kedalaman kripta rata-rata : 1,24 mm, kadang mencapai ~ 7 mm Lesi Derajat tinggi : ada keterlibatan kelenjar Krioterapi dapat merusak jaringan dgn kedalaman 5 mm Beberapa peneliti merekomendasikan lesi derajat tinggi dgn metode eksisi daripada krioterapi
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Alat dan Bahan Krioterapi
Cryo gun
Probes • gas cair : CO2 or NO2 • jely larut air • Disinfectant • spekulum vagina • Asam asetat 3 – 5 % • kolposkopi
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KRIOTERAPI keuntungan Efektif pd CIN 1/2
Tidak efektif pd CIN 3
Teknik mudah
Spesimen PA (-)
Tidak perlu listrik
Perubahan SQJ
Anesthesia (-)
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kerugian
Keputihan banyak
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KONISASI ADALAH SUATU TINDAKAN EKSISI PADA SERVIKS YANG BERBENTUK KERUCUT ATAU TEPI SILINDRIS YANG MELIPUTI DAERAH ZONA TRANSFORMASI DAN SEMUA / SEBAGIAN DARI KANALIS SERVIKALIS
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Post procedure advice Abstinence for about 6 week Avoid heavy work fo 3 days Be alert for bleeding, foul smell discharge
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Comparison of therapeutic Modalities for CIN Procedure Rates
Technical Ease
Equipment Cost
Complication Rates
Primary Cure
Cryosurgery
+++
+++
++
80%
Loop electrosurgical excision procedures
+++
++
+++
95%
Laser ablation
+
+
+++
95%
Laser excision
+
+
++
95%
Cold-knife conization
++
+++
+
98%
+, low; ++, medium; +++, high 30/04/2014
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Take Home Message LEEP and LLETZ technique is simple, effective and capable governance and a light treatment costs because it can be done in polyclinics. Understanding the natural history of the development of cervical cancer, early detection capabilities as well as good training in the management of para-cancerous lesions is expected to reduce morbidity and mortality of cervical cancer patients.
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Take Home Message Only by treating patient as an individual will the result be obtained but it must be stressed that expert colposcopic assessment is the key to good treatment
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Thank You
Sebelas Maret University – The Ducth School – Dr Mewardi Hospital
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