dr.maninder ahuja director ahuja nursing home & infertility centre faridabad vice presindet...

DR.MANINDER AHUJADirector AHUJA NURSING HOME & INFERTILITY CENTREFARIDABAD

• VICE PRESINDET FOGSI• PRESIDENT ELECT INDIAN MENOPAUSE SOCIETY• DEPUTY SECRETARY GENERAL SAFOMS • BOOK “STEP BY STEP MANAGEMENT OF MENOPAUSE”• THREE CHAPTERS IN JEFFCAOTE BOOK OF GYNAECOLOGY

UPDATED IN 2008• CHAPTERS IN “ 3RD EDITION OF FOGSI’S Priciples& Practice Of

Obstetrics &Gynaecology for Post Graduates”• Three Chapters in “Operative Obst.&Gynaecology”editors dr.Randhir

Puri&Dr.Narendra Malhotra • Editor of Manual on “ Prevention of Cervical Cancer”

• DVD ON “PRESCRIPTION OF EXERCISE FROM ADOLESCENT

TO MENOPAUSE”• Dvd on “EXERCISE IN PREGNANCY”• EDUCATIONAL CD ON MENOPAUSE• PRESIDENT FARIDABAD OBST&GYNAE SOCIETY• CHAPTER SECRETARY INDIAN MENOPAUSE SOCIETY

(FARIDABAD)• CHAIRPERSON PUBLIC AWARENESS COMMITTEE OF IMS• CHAIRPERSON GERIATRIC GYNAECOLOGICAL COMMITTEE

OF FOGSI

04/19/231DR.Maninder Ahuja VP FOGSI

04/19/23DR.Maninder Ahuja VP FOGSI2

DVDs ONEXERCISE

Mid lifeNew Beginnings

North ZoneYuva FOGSI2 0 1 3

22nd Nov to 24th Nov Venue- Hotel Radisson Amritsar

04/19/233 DR.Maninder Ahuja VP FOGSI

SCREENING TESTS PRERUISITES

The ultimate proof of success of cervical screening is its ability to reduce the incidence of and deaths from cervical cancer in a cost-effective manner.

One of the prerequisites for effective screening is the availability of a suitable cervical screening test that has adequate sensitivity and specificity for detection of precancerous lesions and that yields reproducible results.

Such a test should be cheap, simple, and easy to apply; without side effects or complications; as painless as possible; and socio culturally acceptable.

R. Sankaranarayanana,T, L. Gaffikin , M. Jacobc , J. Sellorsd , S. Roblesea International Agency for Research on Cancer (IARC), 150 cours Albert Thomas, 69372 Lyon Cedex 08, France b JHPIEGO, Baltimore, MD, USAcEngenderHealth, New York, NY, USA dPATH (Program for Appropriate Technology in Health), Seattle, WA, USA e PAHO (Pan American Health Organization), Washington, DC, USA


EARLY DIAGNOSIS AND MANAGEMENT OF PRECANCEROUS LESIONS IS GOING

TO SAVE MANY LIVES!

Every seven min one woman is dying of cervical cancer in

India.


Mother and daughter dyad

Every seven minute one mother is dying of Cervical cancer !


Cervical cancer screening –Indian perspective

India is a diverse country with varied scenarios

A uniform strategy can not be implemented75% of population is in rural or low resource

setting25% of population is in urban high resource

settingAny new program needs to be integrated in

the existing healthcare services

AOGIN guidelines04/19/238 DR.Maninder Ahuja VP FOGSI

Spectrum of Changes in Cervical Squamous Epithelium Caused by HPV

Infection1

Normal Normal CervixCervix

HPV Infection /HPV Infection /CIN* 1CIN* 1

CIN 2 / CIN 3 /CIN 2 / CIN 3 /Cervical CancerCervical Cancer

*CIN = cervical intraepithelial neoplasia

1. Adapted from Goodman A, Wilbur DC. N Engl J Med. 2003;349:1555–1564. Copyright © 2003 Massachusetts Medical Society. All rights reserved. Adapted with permission.


FOR DEVELOPMENT OF PRECANCEROUS LESIONS

OF CXWe need infection with HPVPersistence of virusLeads to precancerous lesionsIf they don’t clear then invasive cancerThere is no viremia of natural infectionIt is only from local tissue changes that

we can diagnose premalignant lesionsSo screening involves exfoliated cells

from TZ, from endocervical glands, and HPV DNA Presenct in tissue


Screening methods available

VISUAL INSPECTION: VIA and VILLI (subjective visual inspection with acetic acid &lugol’s iodine

Cytology : Pap Smear, LBC (Liquid based cytology)

HPV DNA Test: High Risk HPV DNA Test / HPV Typing

Follow up with colposcopy or directed biopsy or treat with ablative methods or excisional methods



When to start screening?

Till What Age?

Population†

USPSTF ( us preventive task force) ACS/ASCCP/ASCP( ameirican cancer

society, american socieity of colposcopy and cervical pathology, american society for clinical pathology)

Younger than 21 years

Recommends against screening.Grade: D recommendation.

Women should not be screened regardless of the age of sexual initiation or other risk factors.?

21–29 years

Recommends screening with cytology every 3 years. Grade: A recommendation.

Screening with cytology alone every 3 years is recommended.

30–65 years

Recommends screening with cytology every 3 years or for women who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years. Grade: A recommendation.

Screening with cytology and HPV testing (“co-testing”) every 5 years (preferred) or cytology alone every 3 years (acceptable) is recommended.

HPV vaccinated

Women who have been vaccinated should continue to be screened.

Recommended screening practices should not change on the basis of HPV vaccination status.

MARCH 14 2012 Recommendations for Cx. Cancer screening

Modified from CA Cancer J Clin. 2012;62:147-172 .


Older than 65 years

Recommends against screening women who have had adequate prior screening¶ and are not otherwise at high risk for cervical cancer. Grade: D recommendation.

Women with evidence of adequate negative prior screening¶ and no history of CIN2+ within the last 20 years should not be screened. Screening should not be resumed for any reason, even if a woman reports having a new sexual partner.

After hysterectomy

Recommends against screening in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (ie, CIN 2 or 3) or cervical cancer.Grade: D recommendation

Women of any age following a hysterectomy with removal of the cervix who have no history of CIN2+ should not be screened for vaginal cancer. Evidence of adequate negative prior screening is not required. Screening should not be resumed for any reason, including if a woman reports having a new sexual partner.

high-risk populations who may need more intensive or alternative screenin.

These special populations include women 1) with a history of cervical cancer, 2) who were exposed in utero to diethylstilbestrol (DES), and 3) who are immune-compromised (eg, infection with human immunodeficiency virus).

04/19/2315DR.Maninder Ahuja VP FOGSI

WHO Guidelines for screening cancer cervix

•New programmes should start screening women aged 30 years or more, and include younger women only when the highest-risk group has been covered.

•Existing organized programmes should not include women less than 25 years of age in their target populations.

•If a woman can be screened only once in her lifetime, the best age is between 35 and 45 years.

contd……


Contd….

•For women over 50 years, a five-year screening interval is appropriate.• In the age group 25-49 years, a three-year interval can be considered if resources are available.•Annual screening is not recommended at any age.• Screening is not necessary for women over 65 years, provided the last two previous smears were negative. 04/19/2317 DR.Maninder Ahuja VP FOGSI

What is critical for Pap smear:

•Accurate sampling.

•Adequate preservation.

•Complete evaluation.

•Meaningful interpretation.


WHEN?8th – 12th DAY OF MC

CERVICAL MUCUS IS ABUNDANT

EXT. OS IS WIDE OPEN

NO RECENT CERVICAL EXAM. / EXPLORATION / NO VAGINAL EXAM. WITH A LUBRICANT.


Instruments and Materials Required

Sterile Cusco’s speculum

Good light source

Pair of gloves

Ayre’s spatula / endocervical brush

Glass Slides / pencil

Coplin’s Jar

95% ethly alcohol

Cytology form


collection devices Plastic or wooden Ayre’s spatula

Cervix brush

Plastic broom

Ordinary wooden tongue blade

Cotton swab not to be used


SAMPLING DEVICES


CUSCO’S SPECULUM AND CERVICAL BIOPSY FORCEP


• Cervix is visualized using a Cusco’s speculum

• Obscuring elements like blood or mucus is gently removed

• The long arm of the spatula or mid part of the brush is inserted into the cervical canal and is gently rotated 360o so that the entire TZ is sampled.

• The device is removed and the material obtained is immediately transferred onto a numbered glass slide taking care to cover 75% of the surface area and on one side only.

• The slide is immediately put into a coplin jar containing the fixative 95% ethanol. Alternatively use spray fixative at a distance of 12 inches, to avoid disrupting the cells.

• Fixation time: Atleast 30 minutes.

How to take a Conventional pap Smear

04/19/23 27DR.Maninder Ahuja VP FOGSI

Option 1 Option 2 Option 3

No.

No.

No.



It is better to have two slides one with brush and one with spatula


Preservative

95% ethinyl Alcohol or 80% Isopropanol

Collection of Liquid based Cytology Samples

The cervex brush is used to collect the sample and the manufacturer’s instructions are to be followed.Rotated 5-9times

Central bristles inserted into cervical canal and lateral bristles fully bend against Ectocervix

No smear needs to be prepared and the entire sample collected by the brush is transported to the laboratory in the fixative vial after proper labelling

04/19/23 31DR.Maninder Ahuja VP FOGSI

SAMPLE COLLECTION PROCEDURE – LIQUID BASED CYTOLOGY


SAMPLE COLLECTION - HPV HR HYBRID CAPTURE 2


What is TZ


Comparison Of LBC and PAP

CONVENTIONAL SMEAR

Heterogeneous Graphic cell

localization 300-500 k cells/slide Variable fixation Thick uneven groups need frequent

focusing Dirty background Variable preservation

LIQUID BASED SMEARHomogeneous Random cell

presentation 50-70 k cells/slide Uniform fixation Uniform thin layerNot single cell

monolayers Clean background Well preserved cells


Correlation between different terminologies

Dysplasia terminology(reagar,1953)

Original CIN terminology(richart,1968)

TBS(SIL) terminology,1991

Modified CIN terminology

normal normal With in normal limis.Benign cellular changes

normal

Atypia Koilocytic atypia,flat condyloma without epithelial changes

ASCUS/AGUS/LSIL

Low grade CIN

Mild dysplasia or mild dyskaryosis

CIN-1 LSIL Low grade CIN

Moderate dysplasia or moderate dyskaryosis

CIN-2 HSIL High grade CIN

Severe dysplasia or severe dyskaryosis


Carcinoma in situ


Invasive carcinoma

Invasive Invasive Invasive


Screening test

Sensitivity Specificity characteristics

Cytology Low to moderate44-78%

high 91-96% Requires health based infrastructure,laboratory , training, subjective

HPV DNA High(66-100%) Moderate (61-90%)

Lab based, objective,repruducible, expensive

Visual inspection

Low technology, low cost ,linkage to immediate treatment

VIA Moderate 67-79%

Low 49-86% Suitable for low resource settings

VILLI Moderate high 78-98%

Moderate 73-93%

Properties and charactristics of different screening methods


Poor-Moderate Sensitivity of Poor-Moderate Sensitivity of CytologyCytology


Sensitivity of a single HPV test


Cyto. Dx & Associated High Grade Lesions

Incidence CIN 2/3 Invasive Ca

ASC-CU 2.5 to 5.0% 5-10% <0.1%

LSIL 1.5 to 2.0% 15-30% 0.1-0.2%

HSIL 0.5 % 70% 1-2%

Glandular abnormalities: Colposcopy+ ECC is recommended


Disadvantages of CytologySensitivity of single smear is 51% & specificity is 98%.

Expensive, Requires infrastructure and training2/3rd of false negatives are due to errors of sampling. 40-50% cancers in cases screened within 5 years . 15-42% fail to obtain evaluation. 10-18% are never notified.


dr.maninder ahuja director ahuja nursing home & infertility centre faridabad vice presindet...

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