CIN pesentation new

NORMAL STRUCTURE OF CERVIX : 

NORMAL STRUCTURE OF CERVIX The cervix is the entrance or neck of the uterus at the top of the vagina. A narrow passage called the cervical canal (or endocervical canal) goes from the cervix to the inside of the uterus. The surface of the cervix is covered with skin-like cells (epithelium). There are also some tiny glands in the lining of the cervical canal which make and secrete mucous.

ANATOMY OF FEMALE REPRODUCTIVE TRACT : 

ANATOMY OF FEMALE REPRODUCTIVE TRACT

SQUAMOUS COLUMNAR JUNCTION : 

SQUAMOUS COLUMNAR JUNCTION Junction where there two epithelium meet is called SQUAMOUS COLUMNAR JUNCTION. The squamous columnar junction are Called TRANFORMATION ZONE because tall columnar cell are constantly being transformed into squamous cell. The transformation zone is the site for growth and dysplasia.

TRANSFORMATION ZONE : 

TRANSFORMATION ZONE

CERVICAL INTRAEPITHELIAL NEOPLASIA(CIN) : 

CERVICAL INTRAEPITHELIAL NEOPLASIA(CIN) EPITHELIUM: Surface layer of cell . PLASIA : Means growth. DEFINATION: CIN means disordered arrangement of basal cell of stratified squamous epithelium.but basement membrane is not invading.

Epidemiology and Risk Factor : 

Epidemiology and Risk Factor 5,00,000 cases of cervical cancer diagnosed 2nd leading cause of cancer death Risk factors Sexually transmitted disease Human papilloma virus(16,18,31,45 Multiple sexual partners Intercourse at early age Poor personal hygiene Immunocompromise Cigarette smoking

HISTOLOGICAL GRADING OF CIN : 

HISTOLOGICAL GRADING OF CIN

SYMPTOM : 

SYMPTOM CIN has no symptom .so it is essential to women to have regular cervical screeing to detect any early change.

Screeing Interval for National Cervical Screeing Programme : 

Screeing Interval for National Cervical Screeing Programme AGE GROUP FREQUENCY OF SCREEING 25 YRS FIRST VISIT 25_49YRS EVERY THREE YEAR 50_64YRS FIVE YERLY 65 PLUS ONLY SCREEN THOSE WHO NOT SCREENED SINCE 50 YRS WHO HAVE HAD RECENT ABNORMAL TEST.

CERVICAL SCREEING : 

CERVICAL SCREEING NATIONAL HEALTH SERVICE cervical screening program established in 1988. The aim is to reduce the incidence and mortality by invasive cancer by detection at early stage.

PROCEDURE FOR CERVICAL SCREEING IN CIN : 

PROCEDURE FOR CERVICAL SCREEING IN CIN PAP SMEAR LIQUID BASED CYTOLOGY

PAP SMEAR : 

PAP SMEAR

PREQURITES FOR PAP SMEAR : 

PREQURITES FOR PAP SMEAR The best time to take test any middle of your menstrual timing Don't use any vagina douching Don’t do intercourse before 24hrs of this procedure. THIS PROCEDURE TAKE LESS THAN FIVE MINUTES.

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METHOD OF PAP SMEAR

PAP SMEAR : 

PAP SMEAR PAP SMEAR is taken by scarping of transformation zone with Ayer's spatula at 360 degree and spread over slide which is fixed with 95%ethyl alcohol and sent it to laboratory for histopathlogy.

PROCEDURE FOR PAP SMEAR : 

PROCEDURE FOR PAP SMEAR

Pit fall of pap smear : 

Pit fall of pap smear TECHINCAL ERROR DEEP SEATED LESION UNDERESTIMATION

LIQUILD BASED CYTOLOGY : 

LIQUILD BASED CYTOLOGY Prequrites is same as pap smear technique. Liquid based cytology is now commonly uses method of collecting cell from cervix in U.K

STEPS : 

STEPS Patient lying comfortably on couch Clean the area Put the speculum gentally into vagina to keep it open. A special brush will used to gentle to take cell from cervix The head of the brush is rinsed into small container pf preservative and sent to lab for histopathlogy.

Advantage : 

Advantage Liquid bases cytology to preserve more cell Need for repeat test less likely then with pap smear.

POINTS REGRADING TO PROGRESS : 

POINTS REGRADING TO PROGRESS 10% cases to progress to invasive cancer. 18% take 10 to 15 yrs to progress 36% to take 20 yrs to progress .

Sensivity : 

Sensivity Sensivity of pap smear for detection of CIN is 47% compared to 66% for liquid base cytology

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COLPOSCOPY Ideally all women with abnormal cytology should have colposcopic assessment

COLPOSCOPY : 

COLPOSCOPY Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix and the tissues of the vagina and vulva It helps to visualize n distinguish Many premalignant lesions and malignant lesions helps take direct biopsies for further pathological examination

COLPOSCOPE : 

COLPOSCOPE Colposcopy is the "gold standard" tool in the United States for diagnosing cervical abnormalities after an abnormal pap smear. Colposcope

COLPOSCOPY : 

COLPOSCOPY The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them Varies parameters of colposcopic assesment are vascular pattren,degree of acetowhite epithelium,surface pattren,surface area.

Indications for colposcopy : 

Indications for colposcopy Abnormal pap smear an abnormal appearance of the cervix as noted by a physician. Prior to ablative and excisionl treatment of CX for CIN

PROCEDURE : 

PROCEDURE Pt is placed in lithotomy position A speculum is placed gently in the vagina to apart & expose cervix. visualize cervix through the colposcope. Acetic acid solution and iodine solution (Lugol's or Schiller's) are applied to the surface to improve visualization of abnormal areas.

PROCEDURE : 

PROCEDURE

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Three percent acetic acid is applied to the cervix using cotton swabs Areas of the cervix which turn white after the application of acetic acid or have an abnormal vascular pattern are often considered for biopsy

Slide 39: 

If no lesions are visible, an iodine solution may be applied to the cervix to help highlight areas of abnormality. After a complete examination areas with the highest degree of visible abnormality their biopsy may obtain

COMPLICATIONS : 

COMPLICATIONS bleeding infection failure to identify the lesion Most patients experience some degree of pain

What happens if you are pregnant : 

What happens if you are pregnant You can have a colposcopy if you are pregnant.  It is perfectly safe for you and your baby, and will not affect the delivery.  It won't affect your ability to get pregnant in future either. In most cases, any treatment for pre-cancerous cells can be planned for after you've had the baby.   Your doctor will not suggest a cone biopsy if you are pregnant unless he or she suspects there is a cervical cancer.

Clinico Colposcopic Index : 

Clinico Colposcopic Index Variable zero point one point two points ________________________________________________________________________ Index cytology low grade _____ high grade Smoking status No _____ yes AGE <30yrs >30yrs ____ Acetowhitning slight Marked _____ Surface area of lession <1cm2(small lesion) >1cm2(large lesion) _____ Intracapilary distance <350um >350um _____ (fine/no mosac) (coarse mosac/punctation) Focality of lesion Uni/multifocal Annular _____ Surface pattren smooth Irregular _____ ___________________________________________________________________________ Scoring 0-2 = Insignificant lession Scoring 3-5 = tendency to CIN I & II Scoring6-10 = high grade disease present (CIN III)

Treatment of CIN : 

Treatment of CIN All women with truly pre malignant lessions to develop cancer could be selected & treated Treatment should be simple rapid,non morbid & effective

Treating CIN : 

Treating CIN CIN 1: observe or trerat acording to clinical situation. Mostly it will return to normal without any treatment at all further screening tests should be done (with the first repeat test after six months) to make sure that more cell changes do not take place. CIN 2 and 3 should be treated.

Treatment of CIN2,3 : 

Treatment of CIN2,3 Basically all the treatments aim to do the same thing - remove or destroy the abnormal cells. Two main methods of Rx are Ablative excisional Recently there has been tendency towards using excisional methods

METHODs OF TREATMENT OF CIN : 

METHODs OF TREATMENT OF CIN ABLATIVE methods Treated by just removing the part of the cervix that contains abnormal cells.  This allows normal cells to grow back in their place. Cryo cauterytreat Electrodiathermy Cold co-agulation Corbon dioxide laser

Methods of treatmen of CIN : 

Methods of treatmen of CIN Excisional Methods remove the whole area of the transformation zone - the area containing all the cells that could become precancerous or develop into cervical cancer. Loop TZ excision Laser TZ excision Knife cone biopsy Laser cone biopsy Loop cone biopsy hystrectomy

An important aspect is the depth of destruction of any local treatment modality. : 

An important aspect is the depth of destruction of any local treatment modality. Studies to asses Depth of crypt involvement with CIN suggest tht a depth destruction to 3.8 mm would eradicate premalignant disease in 99.7% of cases. Some glands crypts with involvement by CIN to 5mm depth observed,therefore destructive depth more then this is desireable. If desruction depth is inadequate then deep seated component may CAUSE recurrent disease

Ablative techniques : 

Ablative techniques CRYOCAUTERY: Destroy tissue by freezing using probes of various shapes n size.  Best reserved for small lession. Depth of destruction is 4mm which may be inadequate for some CIN lessions.

Ablative techniques : 

Ablative techniques Electrodiathermy: Used under colposcopic control Does require analgesia(GENERAL,REGIONAL,LOCAL) Depth destruction is upto 1cm using combination of needle n ball electrodes

Ablative methods : 

Ablative methods COLD CO-AGULATION This is a misleading name, as the abnormal cells are removed by heating, not freezing. Heat is applied to tissue using teflon-coated thermosound for 20 sec at 100 C. Depth of destruction is approx: 2.5-4mm or more after treatment at 120 C for 30 secs. Usualy does not require analgesia.

ABLATIVE methods : 

ABLATIVE methods Laser therapy or laser ablation: A micromanipulator is attached to colposcope is used to manipulate the laser. treament is conducted under direct vision. It allows good control of depth destruction. Good haemostasis and healing Useful for treating premalignant disease with vaginal involvement.

EXCISIONAL METHODS : 

EXCISIONAL METHODS More common & succesful then ablative method brecause nature of lession can exectly be defined on histology,completeness of excission can be confoirmed & unexpected microinvasive or invasive carcinoma can be ruled out Over all cure rate:98% Aim of excisional method is to remove abnormal tissue

Indications: : 

Indications: Suspicion of invasive dis: Suspicion of glandular abnormality SC junction not clearly visible Pt: treated with ablative therapy previously THANKS!!!!!

TYPES OF EXCISIONAL METHODS : 

TYPES OF EXCISIONAL METHODS Excisional methods include Loop TZ excision Laser TZ excision Knife cone biopsy Laser cone biospsy Loop cone biopsy Hystrectomy

LLETZ : 

LLETZ Large loop excision of transformation zone In this method,TZ is excised with removal of only small amount of underlying tissue & performed by colposcopic guidance. PROCEDURE Loop is advanced in to the cervix just lat: to the TZ untill the required depth has been achived.it is then taken slowly across the cervix envoleping the TZ. The loop is with drawn just beyound other lat: margin of TZ. It is moved superficial co-agulative effect , while if loop is pushed across the CX too forcefully there will be deper co-agulation but less cutting effect The depth of excision varies depending upon the size of loop. But generally removal upto 2cm is recommended.

LLETZ : 

LLETZ

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ADVANTAGES: Provide histologic specimen but surgical margins are difficult to evaluate Relatively painless Inexpensive OPD procedure DISADVANTAGES: In complete excision in upto 40 or over 50% cases

Slide 60: 

COMPLICATION Vaginal bleeding & discharge (settle within 2 wks) Secondery haemorahge Cervical stenosis

Cone biopsy : 

Cone biopsy Removal of TZ along with underlying tissue In past cone biopsy was performed with knife but now adays it is replaced by colposcopic controlled laser conization

CONE BIOPSY : 

CONE BIOPSY

ADVANTAGES : 

ADVANTAGES Allow to remove abnormal tissue by avioding un-necessary removal of surrounding normal tissue Provide histologic specimen High cure rate

DISADVANTAGES : 

DISADVANTAGES Haemorrahge Infection Uterine perforation Pelvic abcess Cervical stenosis Cervical incompetance

Hystrectomy : 

Hystrectomy Indication: Pt; with repeated recurrance after conservative method CIN present with other gynaecological conditions (fibriod,prolapse,menorrhagia)

CIN in Pregnancy : 

CIN in Pregnancy There is no effect of pregnancy on course of CIN. It is better to avoid the treatment of abnormal smear during pregnancy: CIN III managed conservativetly with colposcopy performed every 3 months. LLETZ is performed over cone biopsy with 5% fetal loss If the pt: become pregnant after LLETZ or conization her C/S is perferable to avoid cervical dystocia & cervical injury.

FOLLOW UP : 

FOLLOW UP All cases of CIN irrespective of their mode of treatment must be followedup by exfoliative cytology at reguler interval In the beginning follow up should b at quarterly interval n then every year for 1st 10 yr after Rx. 5 yrs servival rate after treatment of CIN 96-99% Recuurance of CIN after excission biopsy 2-3% 1-2 %after hystrectomy