Clinically Suspicious cervix

Aboubakr Elnashar Benha university Hospital, Egypt
Aboubakr Elnashar

Contents
1.Terminology & Definition
2.Causes
3.Evaluation
4.Treatment
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Abnormal-looking cervix
Unhealthy looking cervix
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DEFINE It is the cervix which has one or more of the following:
1.White or red patches
2.Polyps
3.Nodular cervix with retention cyst
4.Hypertophied cervix
5.Ulcer
6.Purulent, or persistent discharge
7.Bleeding on touch or PCB (Sammour et al, 1985; Aboloyoun et al, 1990; Abdelshafy,1997; Chong, 2003; Milingos et al, 2010; Darwish et al, 2013)
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Women presented with suspicious cervix during routine pelvic examination should be referred for appropriate diagnosis mainly to exclude underling preinvasive or invasive cervical lesions.
Proper diagnoses and management of cervical lesions are the cornerstone for cervical cancer prevention in settings where there is no or disorganized cervical cancer screening program, like Egypt
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CAUSES
1.Inflammatory: Mechanical Traumatic Infections. 2. Dystrophic: Hormonal or Nutritional 3. Neoplastic: Benign Premalignant Malignant
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Clinically suspicious cervix does not mean CIN, but mostly, it is caused by benign and inflammatory conditions: Cervicitis Ectopy, Ectropion infected Nabothian cysts polyp, or true ulcers (Chong, 2003)
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Ectopy
Ectropion, erythroplakia, macula rubra , erosion.
single-layered secreting columnar epithelium (which usually covers the cervical canal, i.e. the endocervix), beyond the external cervical orifi ce.
multilayered squamous epithelium typically found in the vagina and exocervix are replaced.
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1.sex hormones (particularly oestrogen) that encourage the growth of columnar epithelium over the ectocervix
2.common in pregnant
3.taking the COC
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PCB Causes (Sahu etal,2007)
Ectopy: 34%
Cervical polyp: 5-13%
Chlamydia infection: 2%
CIN: 7-17%
Invasive cervical cancer: 0.6-4%.
No specific cause: 50% .
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Cervical
Polyps
Carcinoma
Ectropion
Trauma
Cervicitis
Genital warts
Vaginal
Carcinoma
Vaginitis
* Atrophic
* Infective
Endometrial
Polyps
Carcinoma
Usually, the bleeding originates from the vagina, or cervix, rather than the endometrium.
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Cervical polyps can also bleed and can also normally be visualised on examination.
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Cervicitis : vaginal discharge, bleeding. STI: Chlamydia gonorrhoea occasionally herpes.
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Invasive cancer
CIN
Total
Year
19 (0.9%)
244 (11.9%)
2049
2000
Elnashar
4 (4%)
15 (16%)
95
2010
Milingos et al
Pre invasive and Invasive cancers
PCB asymptomatic
speculum examination and refer urgently if suspicious
Patients with a clinically suspicious cervix are more likely to develop CIN and should have priority in any extended screening programs. CIN & invasive cancer in suspicious cervices
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Diagnosis
History
Speculum examination
Laboratory Tests: Infection screen
Nucleic acid amplification testing (NAAT) for N.G, C.T, and T. V
Wet mount: most cost-effective means of diagnosing TV, the overall sensitivity is low and is dependent on the inoculum size; thus, NAAT testing has become popular due to its relatively high sensitivity and specificity.
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 Cytology.
 HPV.
 VIA
 Colposcopy
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Pap smear
 used for ≥50 y all across the globe.
widely used for in most developed countries Meets all the requirements for mass screening:.
• Fairly tolerated by patients, Easy to administer
• Reasonable sensitivity & specificity.
•Detection of endocervical lesions.
•It has resulted in a substantial reduction in both the morbidity & mortality of cervical cancer.
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In developed countries:
Continue to be the mainstay of cervical cancer
organized program settings
adequate coverage
optimal frequency.
refresher training
continued supplies
Infrastructure
laboratory quality assurance
In developing countries:
impractical approach
Not appropriate or adequate

Visual inspection with acetic acid (VIA)
Effects of acetic acid: .It coagulates the proteins of the nucleus & cytoplasm & makes the protein opaque & white. .It dehydrates the cells, the cytoplasmic volume is reduced & the reflection is increased.
Duration: appears after 20 seconds disappears after 2 minutes.
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Procedure
1.Wash the cervix with a 3%–5% acetic acid solution.
2.Carefully inspect the cervix, especially the TZ, with the naked eye.
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Category
Clinical Findings
Negative
No acetowhite lesions or
faint acetowhite lesions;
polyp,
cervicitis, inflammation,
Nabothian cysts.
Positive
Sharp, distinct, well-defined,
dense (opaque/dull or oyster white) acetowhite with or without raised margins touching SCJ; leukoplakia and
warts.
Suspicious for cancer
ulcerative, cauliflower-like growth or
ulcer; oozing and/or bleeding on touch.
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Negative
Positive
Suspicious for cancer
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VIA Performance:
Source: Adapted from Gaffikin, 2003
Sensitivity
Specificity
Pap
47-62
60-95
VIA
76-84
79-83
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Management:
VIA: Negative:
follow-up after 3-5 ys acc to the decided policy.
VIA test: positive
Offer to treat immediately. or
Refer for colposcopy and biopsy and then offer tt if a precancerous lesion is confirmed.
VIA : suspicious for cancer:
Refer for colposcopy and biopsy and further management
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WHO guidelines for screening and tt of CIN, 2013
In developing counteries, where screening with an HPV test is not feasible: screen with VIA and treat.
Use a strategy of screen with VIA and treat, over a strategy of screen with cytology followed by colposcopy (with or without biopsy) and treat.
Screen-and-treat strategies involve tt with cryotherapy, or LEEP when the patient is not eligible for cryotherapy.
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Colposcopy Indications 1. Part of any gynecologic examination 2. Primary screening for cervical cancer. 3. Clinically suspicious cervix. 4. Abnormal Pap smear 5. Evaluation & treatment of CIN. 6. Follow up after conservative therapy of CIN. 7. Postcoital bleeding. 8. Patients with external vulval warts 9. Evaluation of sexual assault victims. 10. Patients with history of DES exposure
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Swede score
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Swede score of 4 and above: Punch biopsies of the cervix
Swede score 6 and above:
immediate treatment with cold coagulation under visualisation with the Gynocular and local anaesthesia.
patients not suitable for cold coagulation or with biopsies revealing microinvasive cervical disease or worse: appropriate diagnostic workup and management protocol.
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TREATMENT Of the cause
Cervicitis
Ectopy, Ectropion
Infected Nabothian cysts
Polyp
True ulcers
CIN
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Cervicitis. CT: Doxycycline 100mg twice daily for 7 days or Azithromycin 1gm orally stat dose. Gonorrhoea Ceftriaxone 250mg IM stat dose or Cefixime 400mg oral stat dose.
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Cervical Ectropion.
Indications: Routine tt is not recommended
To relieve symptoms
No tt unless PCB is persistent
Further studies to test that tt: protection against cervical cancer
Prior tt, ruled out underlying malignancy
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Methods:
1.Cervical ablation: with either
Cryotherapy Electrocautery microwave tissue coagulation laser cauterisation
Side effects:
copious vaginal discharge until healing is complete
cervical stenosis
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2. An alternative therapy
Acidifying agents: boric acid suppositories 600mg vaginally at bedtime
Alpha interferon suppository
Polydeoxyribonucleotide vaginal suppositories.
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Polyps.
Removal
1.Symptomatic
2.Suspicious
Often performed in the office without sedation {Most are pedunculated and detach easily and painlessly).
more persistant, or larger polyps, which are more likely to bleed
electrosurgical excision
hysteroscopic polypectomy if they appear to be coming from the endocervix or higher.
should be sent to pathology to be evaluated for malignancy
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Vaginal Atrophy.
1.Vaginal moisturizers and lubricants prior to and during intercourse (Avetrix gel) not have any direct effect on improving atrophic changes. 2. Vaginal estrogen therapy. PCB despite lubricants most effective: thickens the vaginal epithelium and decreases dryness. 1st line tt for postmenopausal women.
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CIN: WHO Recommendation 2014.
CIN 1:
(i)immediate tt
(ii)follow the woman and then tt if the lesion is persistent or progressive after 18 to 24 months.
CIN 2 and CIN 3: cryotherapy or LEEP.
AIS (adenocarcinoma in situ) CKC
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Cryotherapy
Cryotherapy relies on a steady supply of compressed refrigerant gases (N2O or CO2) in transportable cylinders.
Cryotherapy is not adequate to treat lesions involving the endocervix.
If excellent contact between the cryoprobe tip and the ectocervix is achieved, N2O-based cryotherapy will achieve –89°C and CO2-based system will achieve –68°C at the core of the ice ball and temperatures around –20°C at the edges. Cells reduced to –20°C for one or more minutes will undergo cryonecrosis.
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Cryotherapy should consist of two sequential freeze-thaw cycles, each cycle consisting of 3 min of freezing followed by 5 minutes of thawing (3min freeze-5 min thaw-3 min freezethaw).
Adequate freezing has been achieved when the margin of the ice ball extends 4-5 mm past the outer edge of the cryotip. This will ensure that cryonecrosis occurs down to at least 5 mm depth.
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Advantages Favorable safety profile Outpatient procedure No anesthetic requirements Ease of procedure Low-cost equipment with minimal maintenance Bleeding complications rare No proven adverse reproductive effects Acceptable primary cure rate
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Disadvantages No tissue specimen for histopathology evaluation Cannot treat lesions with unfavorable sizes or shapes Uterine cramping Potential for vasovagal reaction Profuse vaginal discharge postprocedure Cephalad migration of squamocolumnar junction Adapted from Martin-Hirsch, 2010, with permission. Video
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LEEP Technique
• Colposcopy & lesion outlined
• Patient grounded with pad return electrode
•Inject anaesthetic just beneath & lateral to the lesion
•Set cut/blend to 25-50 watts & excise lesion using the LEEP
•Coagulate the base of the cone by the ball electrode(60 W) even if no apparent bleeding
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Advantages Favorable safety profile Ease of procedure Outpatient procedure using local anesthesia Low costs of equipment Tissue specimen for histopathology evaluation Disadvantages Thermal damage may obscure specimen margin status Special training required Risk of postprocedure bleeding Theoretical risk of vapor plume inhalation
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Clinically Suspicious cervix

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Clinically Suspicious cervix