Managament of Abnormal Cervical
Cytology And Histology
Ali Ayhan, MD
Baskent University School of Medicine
Department of Obstetrics and Gynecology
Head of Division of Gynecologic Oncology
Globocan 2008
Cervical Cancer
Case (n)
Death (n)
Worldwide
529.000
274.000
Developed
countries
76.000
33.000
Developing
countries
452.000
241.000
Turkey
1.443
Incidence 4,2 / 100.000
Mortality 1,6 / 100.000
556
HPV - Cervical Cancer
Normal
epithelium
Screening
HPV infection
coilocytosis
decads
years
months
CIN1
ASC-US/LSIL
CIN2
CIN3
HSIL
Treatment
SIL = Squamous Intraepithelial Lesion / CIN = Cervical Intraepithelial Neoplasia
Carsinoma
Abnormal Cytologic Findings:
(The TBS, 2001)
• AS cells:
 ASC – US
 ASC – H
• LSIL
• HSIL
• AG cells
 AGC – NOS
 AGC – favor neoplasia
• AIS
• Invasive Cancer
Abnormal Cervical Cytology in Turkey :
A Turkish Gynecologic Oncology Group (TGOG) Study
Ayhan et al, Int J Gyn Obst, 2009
Abnormal Cytology(2481/140334)
• ASC
– ASC-US rate
– ASC-H rate
– LSIL rate
– HSIL rate
%1.76
(n=2341)
%
1.66
(n=1510)
(n=100)
(n=429)
(n=243)
%1.07
%0.07
%0.3
%0.17
• AGC (n=111)
0.07
• Cytologic Ca (SCC+Adeno, n=88)
0.062
Abnormal Cytology
USA* (%)
ASC-US
LSIL
HSIL
AGC
4.3
1.6
0.2
0.3
TR (%)
1.07
0.33
0.17
0.07
* 2012
ASCCP Modern Colposcopy 2012
Abnormal Cytology-ASC
Abnormality
ASCS*
Biopsy
ASC-US
5-12% CIN 2-3
0.1-0.2 InvC
24-94% CIN 2-3
ASC-H
LSIL
HSIL
*Immunosupresyon, HPV
15-30% CIN 2-3

26-68% CIN 2-3
1-2% InvC
10
Risk for detection of CIN 2 + at
Colposcopy
ASCUS HPV +
%17-20
HPV -
% 0,74-1,2
Total
Risk
%6,4-11,9
Abnormal Cytology-AGC
Abnormality
Biopsy
AGC
9-54% CINs
0-8% AIS
<1-9% InvC
AGC-NOS
9-41%
(CIN2-3, AIS, InvC)
AGC-Favor neoplasia 27-96%
(CIN2-3, AIS, InvC)
AIS
48-69% AIS
38% InvC
12
Risks of CIN 2-3 and ICC
Pap/HPV
Risk of
CIN2-3
Pap(-)
HPV(+)
ASC-US
ASCUS
HPV(+)
ASCUS HPV(-)
ASC-H
LSIL
HSIL
4
6-12
17-20
<2
27-51
15-30
>70
Risk of ICC
0.1-0.2
<0.1
1-2
Management of Abnormal
Cervical Cytology
• Patients age
• Type of abnormality (Sq. vs.
Glanduler)
• Grade
• Available tests (HPV,Colposcopy)
• Special situations
(Menopause,pregnancy,adeloscent,
immunosupression)
Management of Pregnant
women LSIL
Colposcopy
(preferred approach for
non-adolescent)
No CIN2,3
OR
CIN 2,3
Postpartum Follow-up
Defer Colposcopy
(until at least 6 weeks
postpartum
Manage per
ASCCP
guideline
HSIL in Pregnancy
• Colposcopy is recommended
• Biopsy of suspicious lesions for CIN2/3 or
cancer is preferred
• ECC is unacceptable
• Diagnostic exicion is unacceptable unless
invasive cancer
• Reevaluation with cytology and
colposcopy is recommended no sooner
than 6-wk postpartum(with HSIL in whom
CIN 2/3 is not diagnosed)
New Terminology
•LGL (CIN1 ±HPV)
•HGL (CIN2, CIN3)
Incidence of Preinvasive
Lesions
27 / 100000 (1980)*
54 / 100000 (1990)*
1.5 – 6% of all
cytologic spesimens
* SEER
5-year Survival in Cervical
Cancer
Pre-invasive
Early localized
Regional spread
Distant met.
(%)
100
92
49
14.9
Am J Obstet Gynecol, 13-20, 188, 2003 (SEER)
Fundamental Objectives of
Managing Preinvasive Lesions
• Find the lesion
• R / O invasion
• Preserve fertility
• Employ cost-eff. and
low morbid techniques
The Aim of Therapy in
Preinvasive Lesion
•Local control
•Prevention of ICC
•Decreased
mortality
CIN 1
• 60 % Regression
• 30 % Persistence
• 9 % CIS
• 1 % Invasive Cancer
CIN 2
• 40 % Regression
• 40 % Persistence
• 15 % Progression to CIS
• 5 % Invasive Cancer
CIN 3
•56 % Persistence
•33 % Regression
•12 % Invasive Cancer
Which Lesions to Treat?
• all lesions
selected lesions
• CIN 1...............1%(ICC)
• CIN 2...............5%(ICC)
• CIN 3.............12%(ICC)
Therapeutic Tools
• Ablation (destruction)
• Excision
• Photo – dynamic therapy
• Non – surgical*
• Expectant management
* Vidarabine, Podophylline (CINs + HPV)
Ablative or Local Destructive
Methods:
• Cryo – surgery
• ECD
• Cold coagulator
• CO2 laser
* No further histologic exam.
Excisional Tools*
• CONE
• CKC
• Laser
• LEEP
• Hysterectomy
* in selected patients
Indications for Excisional
Therapy
• (+) ECC
• cyto – histology discrepancy
• Microinvasion
• AIS
• unsatisfactory colposcopy
Distribution of CIN Cases
57,7
60
50
40
30
24,2
Patoloji
sonuçları
17,4
20
10
0
0,7
CIN 1
CIN 2
CIN 3
CIN 1-3
n=281 CIN 1-3
CIN1: 68
CIN2: 48
CIN3: 162
Ayhan A et al., 2007
Treatment Modalities used in Our
Center
60
50,5
50
40
30,6
30
17,1
20
10
0,7
0
observation
1,1
Laser
Con.
TAH/BSO
LEEP
Ayhan A et al., 2007
Results of Re-conization after Positive Surgical Margins in
CIN 2-3
n=56
50
45
40
35
30
25
20
15
10
5
0
49,1
37,7
11,3
1,9
Cr. servisit
CIN 3
Invazive
Ca
CIN 2
Ayhan A et al., 2007 (under review)
Cryotherapy
Laser
LEEP
ColdKnife
Conization
success rates of various methods
for the treatment of CIN
are similar
(up to 97%)
• N=28 randomized study
• The evidence suggests
that there is no
obviously superior
surgical technique for
treating CIN
Reason of Treatment
Failures
• poor techniques
• Glandular involvement
• grade of CIN
• size of lesion
• margin status
AIS
AIS
Incidence :1,25/100.000
CIN 2-3 :41.4/100.000
Charareteristics of AIS;
-Multifocality
-Colposcopic evaluation limited
-Complete excision difficult
-Skip lesions (Margin(-) Residu (+) )
Management of CIN-2/3 in
pregnant women
• Minimal invasive management
• High regression
• Repeat cytology/colposcopy (for every
12week)
• Repeat biopsy (colposcopic – epithelial inv
ca?)
• Reevaluation postpartum after 6weeks
• No treatment during pregnancy
Posttreatment follow-up
• Why?
–İnvasive Cx Ca increase 10 fold
–Non invasive 1-21%
• Which tools?
–HPV (6-12 ms)
–Cytology only (6-12 ms)
–Cytology + colposcopy (6-12 ms)
Grade, size, margin status , histology……..
New Cervical Cancer Screening
ACS 2012
• Cervical cancer screening should begin at
age 21 years, regardless of the age of sexual
initiation or other risk factors
• For women 21to 29 years of age cytology
alone and every 3 years
• 21 to 29, 2 or more consecutive negatif
cytology, screening interval longer than 3
years
• İn this age group, HPV testing should not be
used
New Cervical Cancer Screening
ACS 2012
• Age 30-65,
– HPV + cytology every 5 years
– Cytology alone, every 3 years
– In this age group should not be screened with
HPV testing alone
– >65 years, negative prior screening and no history
of CIN2+ within the prior 20 years should not be
screened
– Recommended screenin practice should not
change on the basis of HPV vaccination status
Cervical Cancer Screening in
Turkey
• Cervical cancer screening begin at
age 30 years
• Cervical cancer screening finish at
age 65 years if negative 2 or more
consecutive cytology
• Repeating every 5 years
• Screening in KETEM
Conclusion
• Cervical cancer increasing in Turkey.
• Abnormal cytology is lower than western
countries
• Cytology reduce invasive cancer and
mortality
• Abnormal cytology is not enough for
treatment
• Abnormal cytology- colposcopy -directed
biopsy –finally treatment
Thank you for your attention...