- Management of Abnormal Smears. The State of the Art
Dexeus - P. Bosze
McGoogan - C. de Oliveira
Singer - G. de Palo
Meijer, The Netherlands
Programmes in Europe
- Organised screening
programmes have succeeded in controlling cervical cancer and achieving
- Incidence rates,
screening intervals and age-grouping vary between countries.
- Countries with
organised programmes and high coverage rate i.e. UK, are proceeding
towards "irreducible numbers" of cases seen with conventional
screening. New methods i.e. liquid cytology and HPV screening may help
to achieve even lower rates.
(TruScan®): Clinical Prospectives
- A real-time electronic
device for detection of cervical neoplasia.
- Applied directly
to cervix with instant recognition of normal and abnormal tissue.
- One of a number
of real time devices including those using ultra-violet (UV) fluorescence
spectroscopy with white light elastic backscatter spectroscopy for detecting
- Major use foreseen
in primary screening with complementary employment in triage of minor
cellular abnormalities and as an adjunct to exfoliative cytology.
- Preliminary date
shows as sensitive as cytology with specificity better than cytology
when compared with local cytological assessment in high risk populations.
- Further trialling
with Acetic Acid (VIA)
- Technique used
for over 15 years. Mature studies in developing countries comparing
VIA to screening cytology.
- Sensitivity of
VIA consistently higher than cytology i.e.>70%. Specificity (false
positive rate) between 60-90% depending on training and supervision
- Advantage in countries
Follow up rates low
Ressources, human and financial, are limited.
- A "two step"
Referral for Colposcopy
- Colposcopy essential
in triage of women presenting
with abnormal smear
X 1 HG SIL
X 2 LG SIL 6 months apart except in countries with unreliable
Suspicious appearence to cervix and/or post coital or intermenstrual
In cases of multicentric disease i.e. cervix (CIN), vagina (VAIN),
vulva (VIN) and perianal (PAIN)
- Pathology essential
to efficient colposcopy communication between colposcopist/cytologist/pathologist
- Training of colposcopist
must be of highest standards.
of clinic data, files and digital photography now possible.
in Colposcopy and Cervical Pathology. Training in Colposcopy
- Essential for ensuring
high standard of practice.
- UK based.
- Colposcopy must
be undertaken by:
Individual (Dr or nurse) skilled in its usage
Communication between colposcopist/pathologist/cytologist
- Audit essential
to ensure good practice.
- For audit need
quality standards with achievable targets with which to compare individual's
and clinic's performance.
- In UK, national
colposcopy quality assurance group overseeing quality standards.
patients referred for colposcopy
- Women experience
high levels of anxiety and emotional responses at all stages of sreening
- Anxiety high
when called for colposcopy (most women believe have cancer)
when abnormal smear found after supposed curative treatment.
- Women concerned
about mortality (from cancer), fear of loss of reproductive potential
and embarrassment during investigations.
- Level of anxiety
higher than in women experiencing major surgery or news of abnormal
fetal screening test.
To sexuality (i.e. having a sexually transmitted disease)
Self esteem (i.e. negative body image common).
- Colposcopy clinic
personnel must be aware of problem and show understanding and empathy.
- Information pre-treatment
essential especially in form of simple leaflet and/or video.
of ASCUS and AGUS Pap Smears
- 50% of HG-SIL had
- Repeat cytology
gives a high false negative rate (2/3 cases). With HPV testing, it is
possible to increase the results of cytology.
- Colposcopy gives
less than 50% specificity and more than 90% sensitivity.
therapeutic options of low-grade SIL
- Women with minor
if HPV/DNA is negative
follow-up (6-12 months)
if HPV/DNA is positive
examination after 6 months
of HG Lesions
S. Dexeus et al.
- "Must be treated".
- Success rate similar
with Layer or Loop (98% versus 95.3%).
- The size of the
cone is also similar.
- Failure occurs
because of blatant deviation from protocols.
- Success depends
on the knowledge of the gynecologist more than the method of treatment
for Adenocarcinoma in situ (AIS)
I.J. Etherington - J.C. Boulanger
- Local treatment
is appropriate provided the length of the cone is >= 25mm and
- AIS is a rare pre-malignant
condition often diagnosed by chance on a cervical cone performed for
- No reliable colposcopic
features of AIS.
Use and abuse of
- 3 indices which
determine the classification of T.Z.
1. completely exocervical
2. fully visible with an endo-cervical component
3. not fully visible.
- Each of the 3 types
warrant an individualized therapeutic approach.
The Managment of
Microinvasive carcinoma of the cervix
conization or simple hysterectomy where desired.
conization with satisfactory margins. Assessment of pelvic nodes is recommended
and can be by former open lymphaderectomy or MAS (minimal access surgical
approach). At the extreme end of Stage 1a2, a larger dissection
radical trachelectopy or Coelic strauta will be appropriate. MAS nodal
dissection is mandatory.
Management of Difficult
3 entities :
- colposcopic grading
during pregnancy is very often over-estimated
- only 18% of CIN
is detected post-menopause. The use of local estrogens is suggested
to improve the sensitivity of colposcopy and to promote visualisation
of the junction
- there is good correlation
(colposcopy, cytology and histology) in HIV patients. Close control
of the LGT of these patients is suggested.
- Patients with treated
HG-SIL must be followed intensively for at least 10 years.
- Persistent positive
HPV/DNA testing with LG-SIL cytology should have excisional techniques.