1. Cervical Cancer Colposcopy & Treatment
Philippe De Sutter
Gynaecology - Oncology

2. Colposcopy & Treatment
Colposcopy has a central place in the management of abnormal cervical cytology
Colpo- cyto- histological correlation is the key to an adequate triage for treatment
Never perform a treatment without prior colposcopic assessment
Perform any treatment technique under colposcopic guidance and control
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

3. Colpo- cyto- histological Triage Conclusion for clinical management
Treatment
Ablation / destruction
Excision / conization
Colpo-cytological follow-up
3 - 6 months
Cytological control with earlier interval
months
Return to screening with normal interval
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

4. Cervical Intraepithelial Neoplasia Principles of treatment
High grade lesions; CIN 2-3
Are true precursors of invasive cervical cancer
Should be treated to prevent progression
CIN is a squamous intraepithelial disease
Removal of the stromal tissue is not necessary
Removal of the glandular epithelium is not necessary
CIN is located at the Transformation Zone
The TZ can be assessed by colposcopy
No treatment without prior colposcopic assessment !
Surgical removal of the TZ remains the standard
The surface squamous epithelium
CIN in crypts
Ablation
Excision
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

5. Historical review on treatment techniques
All provide therapeutically comparable results
Any method is acceptable
More "conservative" colposcopic guided methods
Hysterectomy > Conization > Ablation
Invasive cancer after treatment by ablation
Incorrect triage by colposcopy
Specimen for pathology!
Exclusion of occult (micro)invasion
Assessment of margins
Ablation > Excision
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

6. Standard of treatment = LEEP conisation “Loop Electrosurgical Excision Procedure”
Triage for treatment by Colpo- cyto- histological correlation
High grade lesions (CIN 2-3) are true precursors of invasive cervical cancer and should be treated to prevent progression
Obtain an adequate specimen for histologic evaluation
Excise CIN and whole TZ with free margins
Exclusion of (micro-)invasion
Avoid thermal artefacts
Cause minimal damage to the cervix
Preserve endocervical glands and stromal tissue
Avoid haemorrhagic complications
Avoid fertility and pregnancy disorders

7. Electrosurgery Tissue effects
Use high power level
Maintain efficient cutting at maximum depth
High current density
Vaporisation of cells
Steam interface
Current arcs
Adequate speed
Start current before touching tissue
Continuous movement
No contact or force
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

8. LEEP Local anaesthesia
Potocky needle 27g x 31”
Or dental needle 30g
Dental syringe
1 - 2 x 1.8ml Lidocaine 2% + Noradrenaline
Circumferential submucosal cervical infiltration (4-6x)
Apply tampon and wait till bleeding stops
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

9. Margin involvement Larger cone size is related to:
Less involved margins
Higher cure rate
More complications !
Adjust cone size for optimal therapeutic efficiency
Provide good access to cervix
LEEP treatment under colposcopic control !!!
Locate TZ, SCJ and extension of lesion(s)
Use adequate Loop size and excision technique
Crater base is vaporized with blend current
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

10. Margin involvement Adequate interpretation / review of pathology
Limited involvement
10-20% acceptable
Follow-up sufficient
Deep involvement CIN3 or possible invasion
< 1-5%
Second LEEP
Hysterectomy
Beware occult invasion !
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

11. Recurrence ~ 20 % remains HR-HPV positive
Is predictive risk factor for recurrence
No recurrence without HPV (?)
~ ½ will develop cytological SIL
~ ½ will need second treatment for CIN2+
> 5% true recurrences
More in younger women ?!
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

12. Follow-up Post-op control at 1 month
Optional
Pathology result
First follow-up visit earliest at 4-6 months
Cytology + HPV
Colposcopy optional
Every 6 months for 1-2 years
Yearly
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

13. "See and treat" Principle
Diagnosis and treatment in one session
By excision !
Consider if intention to treat irrespective of result of punch biopsy
Cytology HSIL (or LSIL)
and colposcopy suggestive of HGL
Cytology HSIL (reliable or confirmed)
and colposcopy negative or only suggestive of LGL
Colposcopic suspected early invasion
Ph. De Sutter Cervical cancer: screening, colposcopy & treatment, HPV vaccination

14. Excessive cervical treatment? … for the prevention of cervical cancer…
HPV+ / LSIL - Any cytologic or colposcopic abnormality
Young women < 20-25y
Usefulness of screening in the prevention of cancer?
Frequent HR-HPV + with ASC-US / LSIL
Mostly transient / reversible
Sometimes “acute” HR-HPV infection with HSIL
Impressive colposcopic image / CIN 2-3
Often transient / reversible
Follow up after treatment
20% HR-HPV+
5-10% recurrences  second treatment
 Selection for surgical treatment!

15. Safeguarding women’s reproductive health
Cervical treatment = cervical trauma
Increased risk for adverse pregnancy outcome
Avoid unnecessary cervical treatment
Especially in young women
Treat only progressive disease
“Do no harm”
Treatment worse than risk of severe disease
If treatment is inevitably
Quality of colposcopic assessment!
Limited excision / ablation