EM3 - Management of Abnormal Smears. The State of the Art

Screening Programmes in Europe
J. Patnick

• Organised screening programmes have succeeded in controlling cervical cancer and achieving cost effectiveness.
• 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.

The Polarprobe (TruScan®): Clinical Prospectives
A. Singer

• 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 cervical neoplasia.
• 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 in progress.

Visual Inspection with Acetic Acid (VIA)
L. Gaffikin

• 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 of providers.
• Advantage in countries where
  • Cytology unreliable
  • Follow up rates low
  • Ressources, human and financial, are limited.
• A "two step" process

Indications for Referral for Colposcopy
E. Diakomanolis

• 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 cytology
  • Suspicious appearence to cervix and/or post coital or intermenstrual loss
  • 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 mandatory.
• Training of colposcopist must be of highest standards.
• Computerization of clinic data, files and digital photography now possible.

Quality Standard in Colposcopy and Cervical Pathology. Training in Colposcopy
H. Kitchener

• Essential for ensuring high standard of practice.
• UK based.
• Colposcopy must be undertaken by:
  • Individual (Dr or nurse) skilled in its usage
  • Suitable setting
  • Adequate equipment
  • 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.

Counselling of patients referred for colposcopy
P. Walker

• Women experience high levels of anxiety and emotional responses at all stages of sreening pathways.
• 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.
• Challenge:
  • 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.

Diagnostic triage of ASCUS and AGUS Pap Smears
J. Monsonego

• 50% of HG-SIL had previous ASCUS.
• 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.

Management and therapeutic options of low-grade SIL
A. Singer

• Women with minor cytological abnormalies
  

  * if HPV/DNA is negative		routine follow-up (6-12 months)
  * if HPV/DNA is positive		colopscopy
  Without HPV/DNA testing		colposcopic examination after 6 months

  	Normal		6 months follow-up
  	Abnormal (large lesion)		treatment immediately

Optimal management 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 used.

Treatment protocols for Adenocarcinoma in situ (AIS)
I.J. Etherington - J.C. Boulanger

• Local treatment is appropriate provided the length of the cone is >= 25mm and free margins.
• AIS is a rare pre-malignant condition often diagnosed by chance on a cervical cone performed for co-existing CIN.
• No reliable colposcopic features of AIS.

Use and abuse of LLETZ
W. Prendiville

• 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
J. Monaghan

Stage 1a₁: conization or simple hysterectomy where desired.

Stage 1a₂: 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 Situations
J.L. Mergui

Focus 3 entities :
                              Pregnancy
                              Menopause
                              HIV patients

• 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.

Post-treatment Follow-up Protocols
A. Singer

• 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.