2 prof james bently differentiating high and low grade

COLPOSCOPY OF CIN; DIFFERENTIATING HIGH GRADE FROM LOW GRADE LESIONS

James Bentley , Professor Department of Obstetrics and Gynecology, Dalhousie University, Halifax NS, Canada

Normal

CIN 1

CIN 2

CIN 3

Cancer

Progression/Regression of CIN

Regress Persist Progress

to CIS

Progress

to

invasion

Months to

CIS from

baseline

CIN 1 57% 32% 11% 1% 58

CIN 2 43% 35% 22% 5% 38

CIN 3 32% <56% - >12% 12

Oster AG. Int J Gynecol Pathol 1993;12:86Richart RM, Barron BA. A follow-up study of patients with cervical dysplasia. Am J Obstet Gynecol.1969;105:386–393

Resolution of CIN 1 in adolescent is 90%

CIN 3/ CIS progression to cancer in 31% of cases treated by Bx;

McCredie et al Lancet Oncology 2008 9(5) 425-34

ASCUS

LSIL

Images downloaded from http://nih.techriver.net/bethesdaTable.php

Results: hc2 +ve

Pap smear history Number of cases Hybrid Capture 2 +ve 1

95% Confidenceintervals

ASCUS/ASCUS 87 58 (67%) 56% to 76%

ASCUS/LSIL 33 23 (74%) 52% to 82%

LSIL/ASCUS 19 18 (95%) 73% to 100%

LSIL/LSIL 21 15 (71%) 49% to 86%

All cases 160 114 (72%) 64% to 78%

1 note 10 specimens had insufficient sample

•No significant difference between groups for hc2

Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC

2008

Results: CIN2 + on Bx

Pap smear history Number of cases CIN 2 or greater 95% CI

ASCUS/ASCUS 87 23 (26%) 18% to 37%

ASCUS/LSIL 33 7 (21%) 10% to 38%

LSIL/ASCUS 19 2 (10.5%) 1.7% to 32%

LSIL/LSIL 21 3 (14%) 4% to 35%

All cases 160 35 (22%) 16% to 29%

•No significant difference between groups for histology

Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC

2008

CIN2 and 3 after low grade cytology ALTS trial:

Progression to CIN2 or 3 in 13% of women referred for the evaluation of LSIL or ASCUS HPV +ve smear

NS Data:

2 ASCUS, 2 LSIL, or combination

HR HPV +ve 72 %

CIN2 or > 22%

ASC-H

Images downloaded from http://nih.techriver.net/bethesdaTable.php

CIN2 or > after ASC-H

Significant pathology seen in the majority of cases

Barreth et al.:

CIN2 or > in 70% of cases

2.9% invasive disease

1.7% AIS

CIN2 or > after HSIL

Wright ASCCP:

CIN2 or > 53%-66% with Biopsy

90% if policy of immediate colposcopy

AGC cytology

Pathology finding1

CIN 1 7%

CIN 2 or 3 36%

Adenocarcinoma in situ 20%

Cervical Cancer 9%

Endometrial Pathology 29%

1Daniel A Int.J.Gynaecol.Obstet 2005; 91(3)238-2422 Wright T Emerging Issues on HPV infections 2006 p140-146

Cytology2 Any high-grade lesion

High grade glandular

AGC-NOS 9-14% 0-15%

AGC-N 27-96% 10-93%

ASC-H

Colposcopy

No CIN

Manage as per SCC guidelines

CIN1 or >

Colposcopy, cytology, at 6 months x 2 (HPV

testing at 6 or 12 months ideally)

Return to screening protocol

CIN 1 or >

No CIN

HPV +ve follow in colposcopy clinic

HSIL

Colposcopy(Bx, +/- ECC)

No CIN 2, 3

Manage as per SCC guidelines

CIN 2 or greater

SatisfactoryColposcopy

UnsatisfactoryColposcopy

Observe with

Colposcopy and cytology

Q 6/12 x2*


Diagnostic Excision procedure

* Consider HPV testing

Cytology/histology review

disagreeagree

Colposcopic Approach

Examine whole lower genital tract

Use acetic acid liberally

Beware the small lesion

Take >1 biopsy

Liberal use of ECC

Always do ECC with unsatisfactory colposcopy

High grade features: Snow white epithelium

Low grade colposcopic features: colour

The acetowhite reaction is slower in onset and more transient than high grade lesions

Semi-transparent

Snow-white colour

Gray-white colour higher grade

Low grade: colour

Low grade Colposcopic features: size / position

Peripheral lesions

Often smaller

Low grade Colposcopic features: size / position

Low grade Colposcopic features: margins

Feathered

Geographic

Flat with indistinct margins

Satellite lesions

Colposcopic features: margins

Low grade Colposcopic features: margins

Colposcopic features: iodine staining

High grade features: Coarse Mosaicism

Low grade Colposcopic features: vessels

Ill defined areas of fine punctation or mosaicism

Colposcopic features: vessels

High grade features: Irregular vessels vascularity

Hair pin vessels from cancer

Punctation from CIN2

High grade features: Thick keratosis

High grade features: inner border sign

High grade features: ridge sign

High grade features: papillary lesion; sharp border

CIN 3 in pregnancy

Colposcopic mimics of CIN 1

CIN 2Photo courtesy of Dr L Geldenhuys

Histology of CIN 2

CIN 3 Photo courtesy of Dr L Geldenhuys

Histology of CIN 3

CIN 1 on Biopsy or ECC

Satisfactory Colposcopy

Observe with

Colposcopy and cytology

Q 6/12 x2


Unsatisfactory Colposcopy

Observe with Colposcopy

and cytologyat 24 months2

Treatment1

1 consider ablative therapy for persistent CIN12 if cytology persists continue FU in colposcopy

Colposcopy and cytology -ve

CIN persists or progresses


and cytology12 months

persistent

CIN 2,3 on Biopsy



CIN 2,3

Treatment1

Satisfactory Colposcopy Unsatisfactory Colposcopy

Follow-up at 6 and 12 months with colposcopy

and cytology

Follow-up at 6 months with colposcopy and cytology and HPV2

OR

Treat per guidelines

CIN Negative

1 LEEP or excision preferred for CIN 32 HPV testing for high risk HPV

CIN 2,3 on Biopsy in women < 25 yrs old

CIN 2



CIN 3


and cytologyQ 6/12 x2 yrs

Treatment

Satisfactory ColposcopyUnsatisfactory

Colposcopy

CIN persists or progresses

CIN Resolves

CIN 3 with AIS (on final LEEP)

HSIL pap: colposcopic view after acetic acid

21 yr old G0 P0 with LSIL pap, CIN 1 on Bx

20 yr old with ASC-H on pap and CIN 2 on Biopsy

Adolescent

Conclusion

CIN 1 does not warrant therapy as most will resolve spontaneously

CIN 3 and CIN 2 are recognised cervical cancer precursors

They can be identified following both high grade and low grade cytology

The colposcopic features should allow differentiation between CIN 1 and CIN 2/3

2 prof james bently differentiating high and low grade

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