NHSCSP cervical screening program and treatment of CIN and CGIN
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The document outlines the NHS cervical screening program and treatment guidelines for cervical intraepithelial neoplasia (CIN), emphasizing screening policies based on age and HPV status. It describes management protocols for colposcopy referrals, treatment options for different grades of CIN, and special considerations for pregnant women and those with compromised immune systems. Additionally, it discusses the advantages of HPV primary screening and its potential to extend screening intervals due to higher sensitivity compared to traditional cytology.
NHSCSP cervical screening program and treatment of CIN and CGIN
- 1. NHS cervical screening ( NHSCSP) and treatment of CIN ( CBL ) Dr Wai Phyo MBBS, MMedSc, MRCOG (UK) Consultant Gynaecologist
- 2. Outline Screening program policy Management and referral guideline for colposcopy Case base learning Treatment of CIN Treatment of CGIN Management in special circumstances HPV primary screening
- 6. Facts Age 55 to 69, a negative screening result in the previous five years offers considerable protection (83%) women aged 40 to 54 need to have a negative screening result in the previous three years to achieve a similar level of protection (84%). For women under 25, the prevalence of HPV infection after coitarche is high, with the result that sexually active women in this age group are quite likely to have HPV-associated cellular changes. Because HPV infection is less likely to persist in younger women, the majority of low-grade abnormalities detected in cytology samples taken from women will regress spontaneously with time. The incidence of cervical cancer in this age group is very low. result in a large number of referrals to colposcopy for further investigation. Unscheduled cervical screening does not form part of the NHSCSP with the exception of HIV positive women.
- 7. Liquid-based cytology Cost-effective Offering improved sensitivity without any reduction in specificity A reduction in the number of inadequate tests reported.
- 8. Management and referral guidelines for colposcopy
- 9. HPV triage and test of cure borderline/low grade dyskaryosis HPV test Negative Positive Colposcopy Routine Call
- 10. HPV triage and test of cure Negative/Boderline/LGD HPV test Negative Positive Colposcopy Recall in 3 years ( irrespective of age) Return to Routine Call if subsequence LBC is normal Six Months after treatment
- 11. HPV triage and test of cure HGL Colposcopy Without HPV test
- 12. Inadequate smear Inadequate smear Repeat at 3 months Three consecutive inadequate smear----Colposcopic referral
- 13. Boderline HPV test Negative Routine call Inadequate Repeat Cytology at 6 months BG/LG/inadequate HPV test Positive Colposcopy Negative Routine Call Positive Colposcopy
- 16. Colposcopy Biopsy Proven CIN 1 No treatment Cytology at 12 months Cytology Negative Repeat cytology at 12 months Cytology negative Routine Recall LG/borderline HPV test HPV Negative Routine Recall HPV Positive Colposcopy HPV inadequate Repeat at 3 months HG Colposcopy Treatment TOC guideline If the lesion persists for longer than 24 months the treatment should be discussed with the patient.
- 17. TOC CIN Cytology at 6 months Negative/BL/LG HPV positive Colposcopy HPV negative 3 years recall (irrespective of age) HG or Worse Colposcopy All women after treatment for CIN should be discharged from colposcopy. Either complete excision or not. Except in women over 50 years who will need repeat excision when CIN 3 at lateral margin.
- 18. CGIN TOC Completely excised First or Re-excision TOC 6 months after Rx TOC Cytology Negative, HPV inadequate Repeat at 3 months Cytology,HPV-Negative Second TOC 12 months later(18 months after Rx) Cytology,HPV- Negative Recall in 3 years Cytology abnormal HPV Positive Colposcopy Colposcopy—Normal
- 19. CGIN Incompletely excised / Declined re-excision Cytology at 6 months If Negative 2nd Cytology at 6 months later Annually for 9 years
- 21. Follow-up of untreated women Women referred with high-grade dyskaryosis (moderate or severe) with Normal colposcopy? How to manage? Women referred with high-grade dyskaryosis on their test result who have a colposcopically low grade lesion, whose colposcopy is satisfactory. How to manage?
- 22. Cytology- HG Colposcopy- LG Multiple punch biopsy No treatment Follow up
- 23. Cytology – HG Colposcopy - Normal Multiple punch biopsy No treatment Cytology+Colposcopy Every six months Cytology – HG persist Excisional treatment
- 24. Cytology – BL/LG HPV positive Colposcopy- LG and satifactory NO need biopsy to confirm LG 12 months FU
- 25. Women referred with a result of low-grade dyskaryosis or less and HPV positive that have a colposcopically low grade lesion may be followed up at 12 months in the colposcopy clinic or the community. Colposcopic biopsy at initial assessment is not essential to confirm or exclude low grade CIN. If the lesion has not resolved within two years of referral to colposcopy, at least a biopsy is warranted (more than 90%).
- 26. Swede score 0 1 2 Aceto uptake Nil or transparent Thin, milky Distinct, stearin Margins Nil or diffuse Sharp but irregular, jagged, satellites Sharp and even, difference in level Vessels Fine, regular Absent Coarse or atypical vessels Lesion size < 5 mm 5-15 mm or 2 quadrants >15 mm, 3-4 quadrants, or endocervically undefined Iodine uptake Brown Faintly or patchy yellow Distinctly yellow Final Swede score: 1 Provitional diagnosis --- Type 1 TZ, Normal Biopsy ----- Not done Management ------ Routine screen
- 27. Swede score 0 1 2 Aceto uptake Nil or transparent Thin, milky Distinct, stearin Margins Nil or diffuse Sharp but irregular, jagged, satellites Sharp and even, difference in level Vessels Fine, regular Absent Coarse or atypical vessels Lesion size < 5 mm 5-15 mm or 2 quadrants >15 mm, 3-4 quadrants, or endocervically undefined Iodine uptake Brown Faintly or patchy yellow Distinctly yellow Provisional diagnosis: Type 1 transformation zone; normal. Management: Routine screening after 5 years. Histopathology: Normal. Comment: Thin acetowhite areas with centripetal tongue-like projection that are faintly yellow after Lugol’s iodine are characteristic of immature metaplasia.
- 28. Swede score 0 1 2 Aceto uptake Nil or transparent Thin, milky Distinct, stearin Margins Nil or diffuse Sharp but irregular, jagged, satellites Sharp and even, difference in level Vessels Fine, regular Absent Coarse or atypical vessels Lesion size < 5 mm 5-15 mm or 2 quadrants >15 mm, 3-4 quadrants, or endocervically undefined Iodine uptake Brown Faintly or patchy yellow Distinctly yellow Provisional diagnosis: Type 1 transformation zone; CIN1 with SPI. Management: Punch biopsy from the lesion on the posterior lip. Histopathology: LSIL-CIN1. Comment: Colposcopy should be repeated after 1 year. The lesion should be treated if the lesion is persistent after 2 years or increases in size or severity at any time.
- 29. Swede 0 1 2 Aceto uptake Nil or transparent Thin, milky Distinct, stearin Margins Nil or diffuse Sharp but irregular, jagged, satellites Sharp and even, difference in level Vessels Fine, regular Absent Coarse or atypical vessels Lesion size < 5 mm 5-15 mm or 2 quadrants >15 mm, 3-4 quadrants, or endocervically undefined Iodine uptake Brown Faintly or patchy yellow Distinctly Provisional diagnosis: Type 1 transformation zone; high-grade squamous intraepithelial lesion (HSIL). Management: LLETZ (type 1 excision). Histopathology: HSIL-CIN2. Comment: TOC followup
- 30. Swede score 0 1 2 Aceto uptake Nil or transparent Thin, milky Distinct, stearin Margins Nil or diffuse Sharp but irregular, jagged, satellites Sharp and even, difference in level Vessels Fine, regular Absent Coarse or atypical vessels Lesion size < 5 mm 5-15 mm or 2 quadrants >15 mm, 3-4 quadrants, or endocervically undefined Iodine uptake Brown Faintly or patchy yellow Distinctly yellow Provisional diagnosis: Type 1 transformation zone; high-grade squamous intraepithelial lesion (HSIL). Management: LLETZ (type 1 excision). Histopathology: HSIL-CIN3. Comment: Although the acetowhite lesion is visible only in part of the posterior lip, all four quadrants are iodine-negative. The entire iodine-negative area should be excised during LLETZ. The acetowhite area may not be visible in of high-grade lesions, due to erosion.
- 31. Swede score 0 1 2 Aceto uptake Nil or transparent Thin, milky Distinct, stearin Margins Nil or diffuse Sharp but irregular, jagged, satellites Sharp and even, difference in level Vessels Fine, regular Absent Coarse or atypical vessels Lesion size < 5 mm 5-15 mm or 2 quadrants >15 mm, 3-4 quadrants, or endocervically undefined Iodine uptake Brown Faintly or patchy yellow Distinctly yellow Provisional diagnosis: Type 3 transformation zone; high-grade squamous intraepithelial lesion (HSIL) of the cervix extending to the vagina. Management: LLETZ (type 3 excision) with laser ablation of the residual vaginal lesion. Histopathology: HSIL-CIN3. Comment: CIN3 lesions may extend to the vagina, especially in elderly women. In such cases, LLETZ is crucial to exclude invasive focus, especially inside the endocervical canal. Hysterectomy with removal of adequate vaginal cuff may be performed after excluding invasive cancer by LLETZ.
- 32. Treatment of CIN
- 33. Colposcopic Excisional biopsy An excisional form of biopsy is recommended in the following circumstances: When most of the ectocervix is replaced with high-grade abnormality When low-grade colposcopic change is associated with high-grade dyskaryosis (severe) or worse When a lesion extends into the endocervical canal, sufficient cervical tissue should be excised to remove the entire endocervical lesion ( Atypical transformation zone )
- 34. Colposcopically directed punch biopsy Unless an excisional treatment is planned, biopsy should be carried out when the cytology indicates high-grade dyskaryosis (moderate) or worse, and always when a recognizably atypical transformation zone is present. Cases occurring in pregnancy are an exception. Low-grade cytological abnormality (low-grade dyskaryosis or less) and a low-grade or negative colposcopic examination do not require colposcopic biopsy if there is no atypical transformation zone present. In deciding on treatment (and especially if destructive methods are being considered) associated cytological and colposcopic findings are as important as the result of directed biopsy.
- 35. Surgical techniques There is no obviously superior conservative surgical technique for treating and eradicating CIN, however, ablative techniques are only suitable when: The entire transformation zone is visualised (100%) There is no evidence of glandular abnormality (100%) There is no evidence of invasive disease (100%) There is no major discrepancy between cytology and histology.
- 36. ‘See and Treat’ policy Treatment at first visit to colposcopy for a referral of borderline or low-grade dyskaryosis should not be offered. All suspected CIN 2 and 3 must be treated
- 37. Local destruction All women must have an established histological diagnosis before undergoing destructive therapy Cryocautery Cryocautery should only be used for low-grade CIN and a double freeze- thaw-freeze technique must be used
- 38. Excision Removal of specimen When excision is used, at least 80% of cases should have the specimen removed as a single sample. Depth of excision Type I cervical transformation zone For treating ectocervical lesions, excisional techniques should remove tissue to a depth/length of more than 7mm , though the aim should be to remove <10mm in women of reproductive age Type II cervical transformation zone: Excisional techniques should remove tissue to depth/length of 10mm to 15mm Type III cervical transformation zone: Excisional techniques should remove tissue to a depth/length of 15mm to 25mm Histological assessment of the depth of crypt involvement by CIN3 has shown a mean depth of 1mm to 2mm with a maximum of 5.22mm
- 39. Excision and risk of preterm Increased risk of preterm delivery after loop treatments >10mm in depth Loop excisions greater than 12mm in depth are associated with a threefold increase in preterm delivery 8% for excisions between 10mm and 14mm, rising to 18% for excisions over 20mm in depth/length.
- 40. Repeat excision CIN3 extending to margins CIN3 extending to the lateral or deep margins of excision (or uncertain margin status) results in a higher incidence of recurrence but does not justify routine repeat excision provided: there is no evidence of glandular abnormality there is no evidence of invasive disease the woman is under 50 years of age
- 41. Clinical management of cervical glandular neoplasia
- 42. CGIN Young/ SCJ visible Cylindrical excisional biopsy Including TZ and 1 cm of endocervix above TZ Older/SCJ not visible Cylindrical excisional biopsy Including visible TZ and 20 to 25 mm of endocervical canal Endometrial biopsy, +/- pelvic imaging should be considered. After Tx, follow TOC
- 43. CGIN TOC Completely excised First or Re-excision TOC 6 months after Rx TOC Cytology Negative, HPV inadequate Repeat at 3 months Cytology,HPV-Negative Second TOC 12 months later(18 months after Rx) Cytology,HPV- Negative Recall in 3 years Cytology abnormal HPV Positive Colposcopy Colposcopy—Normal
- 44. CGIN Incompletely excised / Declined re-excision Cytology at 6 months If Negative 2nd Cytology at 6 months later Annually for 9 years
- 45. Hysterectomy for cervical glandular neoplasia Fertility is not required Positive margins after an adequate excisional procedure Treatment by cone biopsy is followed by further high grade cytological abnormality The patient is unwilling to undergo conservative management Adequate cytological follow up has not been possible, eg because of cervical stenosis The patient has other clinical indications for the procedure Invasive disease has been confidently excluded.
- 47. Pregnant women Cervical screening during pregnancy Should not be delayed Previous Colposcopy was abnormal After tx of CGIN,CIN 2 and 3 for TOC sample During Pregnancy, Colposcopic examination CIN 1 suspected ------ Three months following delivery CIN 2/3 suspected ----- Repeat Colposcopy at end of 2nd trimester Repeat Colposcopy 3 months following delivery Invasive disease suspected----- Adequate biopsy
- 48. Contraception No need to change COC pills if currently use Not necessary to remove IUD to performe local treatment Condom use for 3 months promote HPV clearence and CIN 1 regression
- 49. Women with renal failure requiring dialysis Must have cervical cytology at or shortly after diagnosis All women undergo organ transplantation, should have cervical cytology performed with previous year. Five fold increase risk 40% women acquiring virus within 6 months of transplant
- 50. Women who are HIV positive Intially Colposcopy examination Annual cytology Recurrent rate after treatment of CIN is 87% vs 10% in immunocompetent women
- 51. Women exposed in Utero to DES Exposure to DES Colposcopy Negative Routine screening program Positive Annual Colposcopy of vagina, cervix
- 52. Follow up after Stage Ia 2/Ib 1 conservative Tx Stage Ia 2/ Ib 1 Only cytology 6 and 18 months after Tx Annually * 9 years NO HPV Test
- 53. Hysterectomy Routine call + No CIN NO further FU No routine call + NO CIN 6 months smear No FU Completely excised CIN 6 & 18 months No FU Incompletely excised CIN CIN I 6,12 and 24 months after TX CIN 2/3 Annually for nine year upto 65 years or 10 years after Surgery
- 56. HPV Primary screening HPV-based screening offers a 60e70% greater protection against invasive cervical cancer when compared to cytology. Improved accuracy may permit the prolongation of screening intervals from three to five years. Sensitivity of 96.1% and specificity of 90.7% for HPV testing versus cytology which had a sensitivity of 53% and specificity of 96.3%. Disadv: Many women testing positive will have just transient HPV infections. Triage tests are required to better identify the women who would benefit most from colposcopic referrals and minimise overload of colposcopy clinics
- 57. Thank You