Cervical Dysplasia

Question 1

Pathophysiology

Answer 1

> 99% of cervical cancers contain HPV DNA
- 70% are due to Type 16/18
- Smoking increases risk of cervical cancer

Question 2

Prevention of Cervical cancer/dysplasia

Answer 2

• HPV vaccine given to all year 7 students since 2013
• Gardasil 4 protects against 16,18 (70% of cervix ca) and 6,11 (Warts)
• 16, 18, 31,33,45,52,58,6,11
• 3 doses at 0,2 and 6 months

Question 3

Cervical Screening test

Answer 3

• HPV DNA every 5 years Age 25-69 years with exit test up to 74 years
• Nil HPV: Rescreen in 5 years
• Pos HPV 16/18: Reflex liquid based cytology and Refer for colposcopy
• Pos HPV non 16/18: Reflex LBC and manage according to cytology

Question 4

LBC

Answer 4

1. Smear not satisfactory: repeat in 6-12 weeks
   Correct factors that may contribute
   - atrophy: Vaginal oestrogen
   - Inflammation: Antibiotics
   - Menstruation: Better timing
2. Normal LBC: Repeat test 12 months

3.LSIL
- reassure not cancer
- o Education
- Present on 5% of smears
- 80% of women will clear infection and LSIL within 1 year
- 20% will persist
* 4% progress to HSIL
* <0.1% progress to cancer
- If first LSIL smear: Repeat CST in 12 months
- If recurrent LSIL/Persistent HPV( non 16/18) after 12 months
- Repeat CST 12 months: No HPV 5 yearly screen, Persisent HPV or LSIL: Colposcopy
Exception at first 12 month repeat: Refer for Colposcopy
- Women >50 years
- Aboriginal or TSI women
- Overdue for screening by at least 2 years on initial screen
o General advice
- HPV vaccination if not completed
- Quit smoking
- Review women’s health issues: contraception, STI testing
- Annual cytology until 2 normal, then return to normal screening

4. Possible HSIL
   - Refer for Colposcopy
   o Education
   - Possible reasons for result
   * Invasive SCC 3%
   * True HSIL 40%
   * LSIL
   * Squamous metaplasia
   * HPV effect* Infection (HSV, BV, thrush, chlamydia) or irritation (intercourse)
   * Lab error
5. HSIL
   - Immediate referral Colposcopy
   o Education
   - Abnormal squamous cells on cervix
   - A pre-cancerous lesion that if left for many years may progress to cancer
   * Roughly:
   o 33% progress
   o 33% regress
   * Risk of persistence or progression greater for CIN3 than CIN2

o Management
- Colposcopy
* Targeted biopsy
- Treatment
* If CIN 2/3 confirmed
o Treatment with laser or LLETZ to depth of 7mm
* If inadequate colposcopy (ie type 3 TZ)
o Cone biopsy
* If normal colposcopy
o Repeat cytology and colposcopy in 3-6/12
o If still abnormal a cone is indicated

• Follow-up
• 6/12 colposcopy
• 12/12 HPV and cytology
• 24/12 HPV and cytology
• Repeat annually until 2 negative then return to normaln screening

Question 5

Adenocarcinoma in situ

Answer 5

• ACIS is a premalignant glandular condition and the only known precursor to cervical adenocarcinoma
• Interval between ACIS and adenocarcinoma is >5years
• Aetiology
  o HPV infection (particularly serotypes 16 and 18)
  o OCP use may also increase risk
• All women with ACIS on smear should have colposcopy
  o Repeat cytology
  o Targeted biopsy to exclude invasion

Management
* All women with ACIS should have cone biopsy regardless of colposcopy findings
* Endocervical curettage may increase detection rate
* Cone biopsy with negative margins
o 20% risk of recurrent ACIS, 1% risk of progression to adenocarcinoma
o Extrafascial hysterectomy is standard of management
o If childbearing desired, can have close surveillance with 6/12 cytology and HPV testing and completion hysterectomy once childbearing completed

• Cone biopsy with positive margins
  o >50% risk of recurrent ACIS, 6% risk of progression to adenocarcinoma
  o Need to repeat cone to gain negative margins
  o Do not perform TAH without a cone with negative margins
• Risk of co-existing invasive adenocarcinoma, then the incorrect procedure has been performed
• Invasive disease requires a radical hysterectomy

Question 6

Atypical Glandular cells on LBC

Answer 6

• Counselling
  o 0.8% risk of having invasive malignancy
  o 9.4% risk of having a high-grade intraepithelial abnormality
• Investigation
  o Formal colposcopy is indicated
• Less reliable in identification of glandular lesions
• Aim is to exclude overt carcinoma, identify the transformation zone, determine the extent of squamous disease (present in 60% of
  women) and plan treatment
  0 Biopsy only indicated to confirm a clinical diagnosis of invasive carcinoma
• Consider endocervical curettage
  o Assess for presence of endometrial hyperplasia/carcinoma
• TV USS
• Pipelle sampling
• Cone biopsy
  o Indicated for assessment of glandular lesions
• Cone biopsy is gold standard as has fewer positive endocervical margins compared to LLETZ

o Consider concurrent endocervical curettage (however unreliable as diagnostic procedure alone)
o Consider concurrent hysteroscopy if endometrial origin of cells not excluded
* Conservative management
o Suitable only for those with a normal (and adequately assessed) transformation zone on colposcopy who will attend for follow-up
o Need to repeat cytology and colposcopy in 3/12

Question 7

LEEP (Loop electrosurgical excision procedure)

Answer 7

• advantages: Tissue for sample in addition to treatment
• alternatives:
  Laser to cervix
  Surveillance
• Risks
  o Bleeding (immediate or late)
  o Infection
  o Damage to vaginal wall
  o Preterm birth with repeated procedure
  o Incomplete excision
  Need for follow-up

Procedure:
- BHCG
- Consent
- LA/GA
- Lithotomy
- Colposcopy with Acetic acid/Lugols
- Settings coag 80/80 or 70/70
- Single pass excision aiming for depth appropriate for size of lesion and type TZ
- Cautery for haemostasis
- ensure canal patent
- monsels
- Tissue for histopath

• Follow-up
  o Nothing in vagina (ie intercourse, tampons, swimming, spas) for 3-6/52
  o Advise to represent if bleeding >1pad/hour, pain, fever, offensive discharge
  o Ensure histology reviewed
  o Repeat colposcopy in 6/12

Question 8

Cone Biopsy

Answer 8

Indications
* Inadequate colposcopy
* Discordance between colposcopy/biopsy findings and cytology
* ACIS/possible high grade glandular lesion/AGUS on smear
* 1a1 cervical cancer

Riskso Bleeding
- Transfusion
- Vaginal pack 10%
- Hysterectomy
o Infection
o DVT/PE
o Anaesthetic risk
o Damage to vaginal wall or bladder/bowel
o Cervical incompetence 1.5%
- Increased risk of pregnancy loss/preterm birth RR 2.5
o Cervical stenosis 8%
- Infertility, haematometra
o Positive margins
- Need for repeat procedure
o Difficulty visualising TZ in follow-up colposcopy
Procedure
* Preparation
o bhCG, FBE

• Procedure
  o GA, lithotomy, prep and drape, in-out catheter
  o Colposcopy
  o Local anaesthetic with adrenaline infiltration to cervix
  o Haemostatic sutures at 3 and 9 o’clock
  o Cervical suture for manipulation and to mark specimen
  o Place cervical dilator into os to identify canal
  o Scalpel to excise cone of 1.5-3cm deep
  o Dilate cervix
  o Endocervical curettage
  o Cauterize bed and place haemostatic sutures if required
  o Monsel’s +/- pack
• Follow-up
  o No intercourse, tampons, swimming, spa baths 3-6/52
  o Observe for increasing bleeding, fevers, offensive discharge
  o Delay pregnancy 12/12 until follow-up complete
  o Review with histology results to make ongoing plan

Question 9

Clinical Haemorrhage post cone/Colp etc

Answer 9

• Clinical assessment
  o History
• Bleeding severity and onset
• Symptoms of infection
  o Examination
• Vitals
• Abdominal palpation
• Speculum and HVS
  o Investigations
• HVS MCS
• Urine MCS
• Bloods: FBE, CRP, G&H/x-match, coagulation studies, blood cultures
• Management
  o IV access and fluid resuscitation
  o IDC insertion
  o Broad spectrum IV antibiotics
  o Speculum
• Apply Monsel’s/silver nitrate to isolated bleeding point
• Vaginal pack if generalised bleeding
  o EUA if ongoing bleeding or unstable
• Correct coagulopathy
• Diathermy (usually ineffective)
• Haemostatic sutures
• Interventional radiology if available
• Hysterectomy if above measures ineffective