TREATMENT of DYSPLASIAS & CIN

HARI SHANKAR

Rx OF DYSPLASIAS BASED ON CYTOLOGY OR COLPOSCOPY ALONE IS NOT APPROPRIATE, BECAUSE OF THEIR FALSE FINDINGS

FALSE +veUNNECESSARY OR OVER Rx

FALSE –veUNDERMINES Rx & ALLOWS INVASIVE GROWTH TO OCCUR 50% PERSISTENT LSIL (CIN1) SHOW HSIL(CIN2,3)

& MANDATES COLPOSCOPIC BIOPSY PRIOR TO Rx & ALSO TO RULE OUT INVASIVE CANCER

Mild dysplasia/cin1• CIN1 CAN REGRESS SPONTANEOUSLY IN 60-

80% • IT IS MOSTLY DUE TO INFECTION

(HPV,TRICHOMONAS..),SHOULD BE TREATED & CYTOLOGY FOLLOW UP DONE EVERY 3-6 MONTHS

• INDICATIONS FOR COLPOSCOPY & Rx OF LSILi. PERSISTENT LSIL(CIN1) OVER 1 YEARii. POOR PATIENT COMPLIANCEiii. LSIL SHOWING HSIL ON COLPOSCOPY

Moderately s/v to s/v dysplasias (cin2,3)1. LOCAL DESTRUCTIVE METHODS• CRYOSURGERY• FULGURATION/ELECTROCOAGULATION• LASER ABLATION

2. EXCISION OF ABN/L TISSUE• COLD KNIFE CONIZATION• LASER CONIZATION• LLETZ• LEEP• NETZ

3. SURGERY• THERAPUTIC CONIZATION• HYSTERECTOMY• HYSTERECTOMY WITH REMOVAL OF VAGINAL CUFF IF CIS EXTENDS TO

VAGINAL VAULT

CRITERIA FOR CONSERVATIVE METHODS

ENTIRE LESION SHOULD BE VISIBLE WITHIN SCJNO MICRO OR MACRO INVASION AS PROVED BY

HISTOLOGICAL STUDY BY BIOPSYNO EVIDENCE OF ENDOCERVICAL INVOLVEMENTCYTOLOGY & HISTOLOGY MUST CORRESPONDYOUNG WOMEN DESIROUS OF CHILD BEARINGADEQUATE FOLLOW UP SHOULD BE POSSIBLE

CRYOSURGERY• SUITED FOR SMALL LESIONS• CAUSES DESTRUCTION OF CELLS BY CRYSTALLISATION OF ICF• FREEZE-THAW-FREEZE TECHNIQUE OVER 9 MINS DESTROYS

TISSUES UPTO 4-5 mm DEPTH• OPD PROCEDURE,NO ANESTHESIA• CO2 (-60),NITROUS OXIDE(-80),FREON(-60)FREEZING AGENTS• SMALL LESIONDEALT WITH ONE STROKE APPLIED FOR 3 MINS,

BUT LARGE LESIONS REQUIRE SEGMENTS TO BE DEALT WITH IN MULTIPLE STROKES

• APPLICATION OF ACETIC ACID,LUGOLS IODINE OR PREFERABLY COLPOSCOPYIC VIEW HELPS TO IRRADICATE THE ENTIRE LESION IN ONE SITTING

• ABSTAIN FROM INTERCOURSE FOR 4WKS• REPEAT CRYOSURGERY CAN BE DONE 3 MONTHS LATER IF

ENTIRE REGION IS NOT PREVIOUSLY TREATED• CRYOSURGERY IS THE BEST TOLERATED TECHNIQUE,LEAST

PAINFUL & CHEAP,BUT MAIN DIS ADV IS PROFUSE DISCHARGE• CURE RATES DEPEND UPON THE LESION• RESULTS ARE EXTREMELY GOOD FOR CIN1 & EVEN CIN2 BUT

NOT CIN3• NOT SUITABLE FOR LESIONS EXTENDING MORE THAN 25% OF

CERVIX & THOSE WITH EXTENSIONS TO THE ENDOCERVICAL CANAL & VAGINAL FORNICES

ELECTROCOAGULATION

• USES TEMP OVER 700 DEGREE CELCIUS & DESTROYA TISSUES UPTO 8-10 mm DEPTH

• DONE UNDER GA,AS IT IS PAINFUL

• COMPLICATIONS INCLUDE RECCURENCE,BLEEDING,SEPSIS & CERVICAL STENOSIS

• ALSO SCJ GETS INDRAWN WITHIN THE CERVICAL CANAL

• LASER ABLATION

• BOILS,STEAMS & EXPLODES CELLS• USEFUL WHEN CIN EXTENDS UPTO THE VAGINAL VAULT• MINIMAL BLEED,NO INFN,NO POST LASER SCAR FORMATION• OPD PROCEDURE,DONE UNDER LA & UNDER COLPOSCOPIC

GUIDANCE• UNLIKE CAUTREY OR CRYOSURGERY,LASER DOESNOT CAUSE SCJ

INDRAWING,SO REPEAT LASER IS POSSIBLE FOR RESIDUAL LESIONS

• BUT,IT IS VERY EXPENSIVE & CAN CAUSE BURN INJURIES TO THE EYES & SKIN OF TECHNICIAN

CONISATION/CONE BIOPSY• BOTH DIAGNOSTIC & THERAPUTIC• BEFORE COLPOSCOPY IT WAS THE STD METHOD FOR

EVALUATION OF ABN/L SMEAR,BUT NOW WITH COLPOSCOPY,INDICATIONS HAVE BEEN NARROWED DOWN TO

INDICATIONS1. LIMITS OF LESION NOT VISIBLE(EXTENDING >1.5cm INTO

ENDOCERVICAL CANAL)2. SCJ NOT SEEN COLPOSCOPICALLY3. ENDOCERVICAL CURETTAGE POSITIVE FOR CIN 2 OR 34. DISCREPENCY IN CYTOLOGY,BIOPSY & COLPOSCOPY FINDINGS5. SUSPICION OF MICROINVASION ON CYTOLOGY,COLPOSCOPY OR

BIOPSY6. SUSPICION OF ENDOCERVICAL GLANDULAR ATYPIA

PROCEDURE• CAN BE COLD KNIFE CONE OR USING LASER OR ELECTRO

SURGICAL WIRE• DONE IN OT UNDER GA• SIZE & SHAPE OF CONE VARIES DEPENDING ON LOCATION OF

LESION• TO REDUCE BLOOD LOSS,Cx IS INJECTED WITH A

VASOCONSTRICTIVE AGENT• Cx STAINED WITH LUGOL’S IODINE TO OUTLINE LESION• SOME PREFER LIGATING DESCENDING CERVICAL ARTERIES BY 2

LATERAL SUTURES AT 3 & 9’O CLOCK POSITIONS• THEN CONE IS TAKEN WITH SCALPEL OR ELECTROSURGICAL WIRE• CONE SHOULD BE SYMMETRICAL AROUND THE ENDOCERVICAL

CANAL WITH APEX IN THE CANAL BUT BELOW THE INTERNAL OS

• IT IS DESIRABLE TO REMOVE THE CONE INTACT IN ONE PIECE & MARK IT WITH A SUTURE AT 12’O CLOCK POSITION

• ENDOCERVICAL CURETTAGE IS PERFORMED ABOVE APEX OF CONE TO SCREEN FOR RESIDUAL D/S DISTAL TO EXCISED SPECIMEN

• ANY BLEEDING,ARRESTED WITH CAUTREY,HEMOSTATIC SUTURES• IF MARGINS OF CONE ARE FREE OF CIN,CONISATION IS

ADEQUATE Rx,BUT IF NOTHYSTERECTOMY MAY BE NECESSARYCOMPLICATIONSa. INTRA & POST OP H’GEb. CERVICAL STENOSISc. RECCURENT MISCARIAGE,PRETERM LABOUR,PPROM…PUNCH BIOPSY- UNDER COLPOSCOPIC VIEW CAN REMOVE THE ENTIRE LESION,IF SMALL & CAN BE PERFORMED UNDER SEDATION OR LA

LARGE LOOP EXCISIONOF THE TRANFORMATION ZONE(LLETZ)

• USES LOW VOLTAGE DIATHERMY• LOOP IS ADVANCED INTO Cx, LATERAL TO LESION UNTIL THE

REQD DEPTH IS REACHED.LOOP IS THEN TAKEN ACROSS TO THE OPPOSITE SIDE & A CONE OF TISSUE REMOVED

• LOOP SIZE <2cm GIVES BETTER CONE THAN LARGER ONE• LOW COST,HARMLESS TO TECHNICIAN• REQUIRES LESSER TIME TO PERFORM THAN LASER• SIMILAR SUCCESS RATES TO LASER• PREFERED OVER LASER

LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP)• SIMPLER THAN LLETZ,APPLICABLE ANYWHERE IN THE

LOWER GENITAL TRACT UNLIKE LLETZ• NOW, THE MOST COMMONLY USED TECHNIQUE FOR Rx

OF CIN• >95% CURE RATE• SIMPLE & SAFE PROCEDURE,DONE IN OPD UNDER LA• THE PROCEDURE OF CHOICE IN CIN 2 & 3 WHERE

COLPOSCOPY IS SATISFACTORY• MOST IMP ADVG OF LEEP OVER CRYOTHERAPY IS THAT

WE GET TISSUE FOR HP STUDYNO CHANCE OF MISSING AN INVASIVE CANCER

NEEDLE EXCISION OF TRANSFORMATION ZONE (NETZ)• REMOVES CERVICAL TISSUE IN ONE PIECE• ALL EXCISION PROCEDURES SHOULD BE DONE IN THE

IMMEDIATE POST MENSTRUAL PHASE,UNDER COLPOSCOPIC VIEW & LA TO REDUCE THE RISK OF INCOMPLETE EXCISION

• AS EXCISIONAL Rx MAY CAUSE CERVICAL STENOSIS, ABORTION & PRETERM LABOUR, ABLATION THERAPY MAY BE SUITED TO YOUNG WOMEN DESIRING CHILD BIRTH

• RECCURENCE OR PERSISTENT LESION CAN BE REDUCED BY APPLICATION OF SCHILLER IODINE DURING THERAPY

• REPEAT THERAPY IF REQD,BE DELAYED 3 MONTHS FOR HEALING OF PRIMARY Rx

HYSTERECTOMYHYSTERECTOMY IS DESIDABLE IN

1) OLDER & PAROUS WOMEN2) WHEN A WOMEN CAN’T COMPLY WITH FOLLOW UP3) UTERUS ASSO WITH FIBROIDS,DUB OR PROLAPSE4) IF MICRO INVASION EXISTS5) IF RECCURENCE OCCURS FOLLOWING

CONSERVATIVE THERAPY OR PERSISTENT LESION

PROPHYLAXIS• MAJORITY OF Ca CERVIX ARE HPV RELATED• FORTUNATELY HPV VACCINE IS AVAILABLE THOUGH EXPENSIVE• IF GIVEN (BEFORE SEXUAL ACTIVITY IS BEGUN) TO

ADOLOSCENTS70% PROTECTIONVACCINES• BIVALENT VACCINE AGAINST HPV 16 & 18CERVARIX• QUADRIVALENT VACCINE AGAINST HPV 6,11,16,18 GARDSIL

1sT DOSE AT ELECTED TIME BEFORE EXPOSURE TO SEXUAL ACTIVITY (0.5 ml)

2nd DOSE 2 MONTHS AFTER 1st INJECTION

3rd DOSE 6 MONTHS AFTER 1st INJECTION

• VACCINES ARE CONTRAINDICATED DURING PREGNANCY• S/E FEVER,LOCAL PAIN & ERYTHEMA• OTHER VACCINES MAY BE GIVEN SIMULTANEOUSLY BUT IN

DIFFERENT SITES

THANK YOU