clinically suspicious cervix
DESCRIPTION
Clinically Suspicious cervixTRANSCRIPT
Aboubakr Elnashar
Benha university Hospital,
Egypt
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Contents 1. Terminology & Definition
2. Causes
3. Evaluation
4. Treatment
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Abnormal-looking cervix
Unhealthy looking cervix
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DEFINE
It is the cervix which has one or more of the following:
1. White or red patches
2. Polyps
3. Nodular cervix with retention cyst
4. Hypertophied cervix
5. Ulcer
6. Purulent, or persistent discharge
7. Bleeding on touch or PCB (Sammour et al, 1985; Aboloyoun et al, 1990; Abdelshafy,1997; Chong, 2003;
Milingos et al, 2010; Darwish et al, 2013) Aboubakr Elnashar
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Women presented with suspicious cervix during
routine pelvic examination should be referred for
appropriate diagnosis mainly to exclude underling
preinvasive or invasive cervical lesions.
Proper diagnoses and management of cervical
lesions are the cornerstone for cervical cancer
prevention in settings where there is no or
disorganized cervical cancer screening program, like
Egypt
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CAUSES
1. Inflammatory:
Mechanical
Traumatic
Infections.
2. Dystrophic:
Hormonal or
Nutritional
3. Neoplastic:
Benign
Premalignant
Malignant Aboubakr Elnashar
Clinically suspicious cervix does not mean CIN, but
mostly, it is caused by benign and inflammatory
conditions:
Cervicitis
Ectopy, Ectropion
infected Nabothian cysts
polyp, or
true ulcers (Chong, 2003)
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Ectopy
Ectropion, erythroplakia, macula rubra , erosion.
single-layered secreting columnar epithelium (which
usually covers the cervical canal, i.e. the
endocervix), beyond the external cervical orifi ce.
multilayered squamous epithelium typically found in
the vagina and exocervix are replaced.
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1. sex hormones (particularly oestrogen) that
encourage the growth of columnar epithelium
over the ectocervix
2. common in pregnant
3. taking the COC
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PCB Causes (Sahu etal,2007)
Ectopy: 34%
Cervical polyp: 5-13%
Chlamydia infection: 2%
CIN: 7-17%
Invasive cervical cancer: 0.6-4%.
No specific cause: 50% .
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Cervical
Polyps
Carcinoma
Ectropion
Trauma Cervicitis
Genital warts
Vaginal
Carcinoma
Vaginitis
* Atrophic
* Infective
Endometrial
Polyps
Carcinoma
Usually, the bleeding originates from the vagina, or
cervix, rather than the endometrium.
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Cervical polyps
can also bleed and can also normally be visualised
on examination.
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Cervicitis
: vaginal discharge, bleeding.
STI:
Chlamydia
gonorrhoea
occasionally herpes.
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Invasive
cancer
CIN Total Year
19 (0.9%)
244 (11.9%) 2049 2000 Elnashar
4 (4%) 15 (16%) 95 2010 Milingos et al
Pre invasive and Invasive cancers
PCB
asymptomatic
speculum examination and refer urgently if
suspicious
Patients with a clinically suspicious cervix are
more likely to develop CIN and should have
priority in any extended screening programs.
CIN & invasive cancer in suspicious cervices
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Diagnosis
History
Speculum examination
Laboratory Tests: Infection screen
Nucleic acid amplification testing (NAAT) for N.G,
C.T, and T. V
Wet mount: most cost-effective means
of diagnosing TV, the overall sensitivity is low
and is dependent on the inoculum size; thus, NAAT
testing has become popular due to its relatively high
sensitivity and specificity.
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Cytology.
HPV.
VIA
Colposcopy
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Pap smear used for ≥50 y all across the globe. widely used for in most developed countries
Meets all the requirements for mass screening:.
• Fairly tolerated by patients, Easy to administer
• Reasonable sensitivity & specificity.
• Detection of endocervical lesions.
• It has resulted in a substantial reduction in both the morbidity & mortality of cervical cancer.
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In developed countries: Continue to be the mainstay of cervical cancer
organized program settings
adequate coverage optimal frequency. refresher training continued supplies
Infrastructure
laboratory quality assurance
In developing countries:
impractical approach
Not appropriate or adequate
Visual inspection with acetic acid (VIA)
Effects of acetic acid:
.It coagulates the proteins of the nucleus &
cytoplasm & makes the protein opaque & white.
.It dehydrates the cells, the cytoplasmic volume is
reduced & the reflection is increased.
Duration:
appears after 20 seconds
disappears after 2 minutes.
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Procedure
1.Wash the cervix with a 3%–5% acetic acid
solution.
2.Carefully inspect the cervix, especially the TZ,
with the naked eye.
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Category Clinical Findings
Negative
No acetowhite lesions or
faint acetowhite lesions;
polyp,
cervicitis, inflammation,
Nabothian cysts.
Positive Sharp, distinct, well-defined,
dense (opaque/dull or oyster white) acetowhite with
or without raised margins touching SCJ;
leukoplakia and
warts.
Suspicious
for cancer
ulcerative, cauliflower-like growth or
ulcer; oozing and/or bleeding on touch. Aboubakr Elnashar
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Negative
Positive
Suspicious for cancer
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VIA Performance:
Source: Adapted from Gaffikin, 2003
Sensitivity Specificity
Pap 47-62 60-95
VIA 76-84 79-83
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Management:
VIA: Negative:
follow-up after 3-5 ys acc to the decided policy.
VIA test: positive
Offer to treat immediately. or
Refer for colposcopy and biopsy and then offer tt if a
precancerous lesion is confirmed.
VIA : suspicious for cancer:
Refer for colposcopy and biopsy and further
management
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WHO guidelines for screening and tt of CIN, 2013
In developing counteries, where screening with an HPV
test is not feasible: screen with VIA and treat.
Use a strategy of screen with VIA and treat, over a
strategy of screen with cytology followed by colposcopy
(with or without biopsy) and treat.
Screen-and-treat strategies involve tt with
cryotherapy, or LEEP when the patient is not eligible for
cryotherapy.
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Colposcopy
Indications 1. Part of any gynecologic examination 2. Primary screening for cervical cancer. 3. Clinically suspicious cervix. 4. Abnormal Pap smear 5. Evaluation & treatment of CIN. 6. Follow up after conservative therapy of CIN. 7. Postcoital bleeding. 8. Patients with external vulval warts 9. Evaluation of sexual assault victims. 10. Patients with history of DES exposure
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Swede score
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Swede score of 4 and above: Punch biopsies of the cervix
Swede score 6 and above:
immediate treatment with cold coagulation under visualisation with the Gynocular and local anaesthesia. patients not suitable for cold coagulation or with biopsies revealing microinvasive cervical disease or worse: appropriate diagnostic workup and management protocol.
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TREATMENT
Of the cause
Cervicitis
Ectopy, Ectropion
Infected Nabothian cysts
Polyp
True ulcers
CIN
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Cervicitis.
CT:
Doxycycline 100mg twice daily for 7 days or
Azithromycin 1gm orally stat dose.
Gonorrhoea
Ceftriaxone 250mg IM stat dose or
Cefixime 400mg oral stat dose.
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Cervical Ectropion.
Indications:
Routine tt is not recommended
To relieve symptoms
No tt unless PCB is persistent
Further studies to test that tt: protection against
cervical cancer
Prior tt, ruled out underlying malignancy
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Methods:
1. Cervical ablation: with either
Cryotherapy
Electrocautery
microwave tissue coagulation laser cauterisation Side effects:
copious vaginal discharge until healing is complete
cervical stenosis
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2. An alternative therapy
Acidifying agents: boric acid suppositories 600mg
vaginally at bedtime
Alpha interferon suppository Polydeoxyribonucleotide vaginal suppositories.
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Polyps.
Removal
1. Symptomatic
2. Suspicious
Often performed in the office without sedation
{Most are pedunculated and detach easily and
painlessly).
more persistant, or larger polyps, which are more
likely to bleed
electrosurgical excision
hysteroscopic polypectomy if they appear to be
coming from the endocervix or higher.
should be sent to pathology to be evaluated for
malignancy Aboubakr Elnashar
Vaginal Atrophy.
1. Vaginal moisturizers and lubricants
prior to and during intercourse (Avetrix gel)
not have any direct effect on improving atrophic
changes.
2. Vaginal estrogen therapy.
PCB despite lubricants
most effective: thickens the vaginal epithelium and
decreases dryness.
1st line tt for postmenopausal women.
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CIN: WHO Recommendation 2014. CIN 1:
(i) immediate tt
(ii) follow the woman and then tt if the lesion is
persistent or progressive after 18 to 24 months.
CIN 2 and CIN 3:
cryotherapy or LEEP.
AIS (adenocarcinoma in situ)
CKC
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Cryotherapy Cryotherapy relies on a steady supply of compressed refrigerant gases (N2O or CO2) in transportable cylinders. Cryotherapy is not adequate to treat lesions involving the endocervix. If excellent contact between the cryoprobe tip and the ectocervix is achieved, N2O-based cryotherapy will achieve –89°C and CO2-based system will achieve –68°C at the core of the ice ball and temperatures around –20°C at the edges. Cells reduced to –20°C for one or more minutes will undergo cryonecrosis.
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Cryotherapy should consist of
two sequential freeze-thaw
cycles, each cycle consisting of
3 min of freezing followed by 5
minutes of thawing (3min
freeze-5 min thaw-3 min
freezethaw).
Adequate freezing has been
achieved when the margin of
the ice ball extends 4-5 mm
past the outer edge of the
cryotip. This will ensure that
cryonecrosis occurs down to at
least 5 mm depth.
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Advantages
Favorable safety profile
Outpatient procedure
No anesthetic requirements
Ease of procedure
Low-cost equipment with minimal maintenance
Bleeding complications rare
No proven adverse reproductive effects
Acceptable primary cure rate
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Disadvantages
No tissue specimen for histopathology evaluation
Cannot treat lesions with unfavorable sizes or
shapes
Uterine cramping
Potential for vasovagal reaction
Profuse vaginal discharge postprocedure
Cephalad migration of squamocolumnar junction
Adapted from Martin-Hirsch, 2010, with permission.
Video
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LEEP
Technique
• Colposcopy & lesion outlined
• Patient grounded with pad return electrode
•Inject anaesthetic just beneath & lateral to the lesion
•Set cut/blend to 25-50 watts & excise lesion using the LEEP
•Coagulate the base of the cone by the ball electrode(60 W) even if no apparent bleeding
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Advantages Favorable safety profile
Ease of procedure
Outpatient procedure using local anesthesia
Low costs of equipment
Tissue specimen for histopathology evaluation
Disadvantages
Thermal damage may obscure specimen margin
status
Special training required
Risk of postprocedure bleeding
Theoretical risk of vapor plume inhalation
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Video
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Thanks
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