cervical disease and neoplasms maria horvat, md, facog

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Cervical Disease and Neoplasms Maria Horvat, MD, FACOG Slide 2 Cervical Disease Risk factors HPV Smoking 2 fold increase Young age at 1 st coitus Multiple sexual partners A partner with multiple sexual partners High parity Lower socioeconomic status Young age at 1 st pregnancy Slide 3 HPV in the United States Slide 4 Cervical Disease HPV associated with 99.7% of all cervical cancer HPV types associated with higher oncogenic risk: 16, 18 31, 33, 35 45 51, 56 Slide 5 HPV high risk types Slide 6 HPV Obligatory intra-nuclear virus Most remit spontaneously 5% of infected women have persistent infection Slide 7 PAP test Only a screening test Goal: To prevent cervical cancer Slide 8 Histology of (SIL) squamous intraepithelial lesions. Grade 1 = CIN 1; Grade 2 = CIN 2; Grade 3 = CIN 3 Slide 9 Cervical Neoplasia Slide 10 Potential Co-Factors in Cervical Carcinogenesis Other infectious agents Herpes Chlamydia HIV and other immunosuppression Diet Smoking Hormonal contraceptives Weak immunomodulatory effect Eversion of columnar epithelium Decrease in blood folate levels Progesterone effect on HPV Slide 11 Management of Adolescent Women ( ASC Colposcopy Routine Screening Slide 12 Management of Adolescent women ( Management of Women with Atypical Squamous Cells: Cannot exclude high grade SIL (ASC H) >20 yrs old with ASC-H Coloposcopic Examination Slide 14 Management of Women with Atypical Squamous cells of undetermined significance - ASC-US >20 yrs old with ASC-US Repeat Cytology HPV DNA testing @ 4-6 mos Negative >ASC Positive Negative (for high risk type) Repeat @ 4-6 mos Colposcopy Repeat cytol. @ 12 mos Slide 15 Naming Slide 16 Cervical Intraepithelial Neoplasia Biopsy Result RegressPersistProgress to CIS Progress to invasion CIN 157%32%11%1% CIN 243%35%22%5% CIN 332%12% Slide 17 Colposcopic Grading Low GradeHigh Grade Acetowhite Epithelium Shiny or snow white, semitransparentDull, oyster white Surface FlatFlat or irregular contour Demarcation Diffuse, irregular, flocculated, feathered Internal demarcation line absent Sharp, straight line Internal demarcation line may be present Vessels Fine, with regular shapes, uniform caliber, normal aborization pattern Punctation or mosaicism associated with coarse, dilated vessels with increased intercapillary distance; bizarre vessels without aborization, commas, hockey sticks, corkscrews, sharp bends Iodine Yellow, or variegated brownMustard yellow, yellow or iodine negative Slide 18 Summary for the non-gynecologist ASCUS Negative HPV type Positive Repeat Pap Refer for in 6 mos coloposcopy Slide 19 CIN 1 mild dysplasia 18 yrs old Repeat Pap Colposcopy Slide 20 CIN 2,3 Colposcopy Slide 21 Confirmed CIN 2,3 Excision (adolescents may perform colposcopy q 6 mos up to 24 mos) Slide 22 Interventional Techniques - Excisional Conization Cone of tissue is excised for further examination and/or to remove a lesion Tissue is usually stained with iodine to demarcate the area of resection Cold knife Laser LEEP Loop electrosurgical excision procedure May be complicated by burn artifacts Ablative Cryotherapy Use of a probe containing carbon dioxide or nitrous oxide to freeze the entire transformation zone and area or the lesion Laser vaporization therapy Slide 23 Atypical Glandular Cells AGUS Colposcopy ECC Endometrial Sample, women >35 yrs Slide 24 What is colposcopy? Slide 25 Cervical Cancer staging review Stage 0: CIS, CIN grade III Stage 1: carcinoma strictly confined to the cervix Stage 2: cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina Stage 3: carcinoma has extended to the pelvic wall. On rectal exam there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower 1/3 of the vagina. All cases with hydronephrosis or non-functioning kidney unless known to be due to other causes. Stage 4: Carcinoma has extended beyond the true pelvis, or has involved the mucosa of the bladder or rectum. Slide 26 Cervical Cancer Staging Stage 0: The cancer cells are very superficial (only affecting the surface) are found only in the layer of cells lining the cervix, and they have not grown into (invaded) deeper tissues of the cervix. This stage is also called carcinoma in situ (CIS) or cervical intraepithelial neoplasis (CIN) grade III. Slide 27 Cervical Cancer Staging Stage I: In this stage the cancer has invaded the cervix, but it has not spread anywhere else. Stage IA: This is the earliest form of stage I. There is a very small amount of cancer, and it can be seen only under a microscope. Stage IA1: The area of invasion is less than 3 mm (about 1/8-inch) deep and less than 7 mm (about 1/4-inch) wide. Stage IA2: The area of invasion is between 3 mm and 5 mm (about 1/5-inch) deep and less than 7 mm (about 1/4-inch) wide. Stage IB: This stage includes Stage I cancers that can be seen without a microscope. This stage also includes cancers that can only be seen with a microscope if they have spread deeper than 5 mm (about 1/5 inch) into connective tissue of the cervix or are wider than 7 mm. Stage IB1: The cancer can be seen but it is not larger than 4 cm (about 1 3/5 inches). Stage IB2: The cancer can be seen and is larger than 4 cm Slide 28 Cervical Cancer Staging Stage II: In this stage, the cancer has grown beyond the cervix and uterus, but hasn't spread to the walls of the pelvis or the lower part of the vagina. Stage IIA: The cancer has not spread into the tissues next to the cervix (called the parametria). The cancer may have grown into the upper part of the vagina. Stage IIB: The cancer has spread into the tissues next to the cervix Slide 29 Cervical Cancer Staging Stage III: The cancer has spread to the lower part of the vagina or the pelvic wall. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). Stage IIIA: The cancer has spread to the lower third of the vagina but not to the pelvic wall. Stage IIIB: The cancer has grown into the pelvic wall. If the tumor has blocked the ureters (a condition called hydronephrosis) it is also a stage IIIB. Slide 30 Cervical Cancer Staging Stage IV: This is the most advanced stage of cervical cancer. The cancer has spread to nearby organs or other parts of the body. Stage IVA: The cancer has spread to the bladder or rectum, which are organs close to the cervix. Stage IVB: The cancer has spread to distant organs beyond the pelvic area, such as the lungs. Slide 31 Question #1. What if HGSIL pap and normal colposcopy? Slide 32 Answer #1. LEEP or cone biopsy. Slide 33 Question #2. Biopsy on face cervix is normal and ECC is positive, what is the next step? Slide 34 Answer #2. LEEP or cone biopsy. Slide 35 There is hope! Gardisil immunization guards against types 6, 11, 16, and 18. Administer at 0, 2, and 6 months for females 9 years or older. Slide 36 HPV Vaccine Trials Slide 37 Phase 2 Trial of Quadrivalent HPV Vaccine: Conclusions The vaccine was highly effective in reducing incidence of persistent HPV infection Efficacy with regard to clinical disease associated with HPV types 6,11,16,18, was 100% The vaccine was highly immunogenic, inducing high antibody titers to each HPV type The vaccine was generally well tolerated Slide 38 Do condoms help prevent? YES! 60% decrease in transmission Does not eliminate risk. Slide 39 Pap smear schedules: Many different recommendations ACOG APGO ACS Slide 40 Pap smear recommendations 1 st pap by age 21 or within 3 years of 1 st coitus Annually until the age of 30 Pap with HPV at age 30, then can perform every few years. Slide 41 Pap smear recommendations: Post Menopausal Some guidelines: No Pap ACOG: q 3-5 years Hysterectomized female: If hysterectomy for benign reasons, then pap q 3-5 years Yearly if: Cervix present History of abnormal paps History of gyne cancer History of DES exposure History of cervical cancer Smoking (increases chance of vaginal cancer) Slide 42 References APGO Educational Series on Womens Health Issues: Advances in the Screening, Diagnosis, and Treatment of Cervical Disease Review in Obstetrics and Gynecology, Vol. 1 No. 1 2008 American Society for Colposcopy and Cervical Pathology Crosstalk; Preventing Cervical Cancer and Other Human Papillomavirus-related diseases