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Screening in Gynaecological Cancers

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Prof. HYS Ngan Department of Obstetrics & Gynaecology University of Hong Kong Queen Mary Hospital Screening Cervical cancer Ovarian cancer Endometrial cancer ... – PowerPoint PPT presentation

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Title: Screening in Gynaecological Cancers


1
Screening in Gynaecological Cancers
  • Prof. HYS Ngan
  • Department of Obstetrics Gynaecology University
    of Hong Kong
  • Queen Mary Hospital

2
Fallopion tube
Uterus
Endometrium
Ovary
Cervix
Vagina
3
(No Transcript)
4
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5
Screening
  • Cervical cancer
  • Ovarian cancer
  • Endometrial cancer

6
Screening
  • To detect disease among
  • healthy
  • population
  • Without symptoms of disease
  • Purpose decrease mortality due to the disease
    screened

7
Disease appropriate for screening
  • High prevalence of disease
  • Known natural history, precursor lesion and
    course of progression
  • Detection of early stage disease, amenable to
    cure
  • Method used is simple, cheap, specific and
    sensitive, acceptable, risk-free and accessible

8
Carcinoma of the cervix
  • commonest lower genital tract cancer
  • about 500 new cases per year in HK
  • about 140 deaths per year in HK
  • median age 50 years

9
Natural history of low-grade HPV cervical lesion
  • Cervical HPV is very common, related to sexual
    behaviour
  • High spontaneous remission rate
  • lower remission rate in CIN
  • LSIL progress to HSIL in 70 in 10 yrs

10
Natural history of CIN 1-2
  • regress persist CIN3 Ca
  • CIN I 57 32 11 lt1
  • CIN2 43 35 22 5
  • (100 prospective studies)

11
Cervical cytologySensitivity and Specificity
  • Overall sensitivity 61-64, cervical cancer
    82-95
  • Overall specificity 99 - 99.4
  • Quantin.C 1992, Soost.HJ 1991

12
Cervical cytologyPositive predictive value
  • Low-moderate dysplasia 73-76
  • severe dysplasia 85-90
  • Invasive cancer 95
  • Quantin.C 1992, Soost.HJ 1991

13
False negative rate of cervical cytology in
detecting cervical cancer
  • Depends on the quality of the smear taking and
    the laboratory
  • estimated to be 3-30

14
New technology
  • automation for cervical cancer screening
  • liquid-based cytology - thin layer preparation

15
Advantages of LBC
  • Eliminate
  • air-dried artifact
  • inflammatory cells
  • blood
  • mucus
  • Increase
  • detection of abnormal cytology

16
Cervical cancer screening - new methods under
exploration
  • cervicography
  • polar probe
  • HPV typing

17
HPV DNA testing - potential use
  • HPV based instead of cytology based screening
  • triage of patients with equivocal or ASCUS
  • external quality control of cytology
  • high risk HPV predicts high grade SIL in the
    absence of cytology abnormality
  • molecular variant predicts carcinoma

18
Organized screening vs Opportunistic screening
  • Finland and Sweden
  • decrease in indicence and mortality of cervical
    cancer
  • concentrate resources
  • wide coverage
  • Policy decision

19
European and American recommendation
  • Age
  • Europe 35-60 yrs for invasive ca
  • 25-65 yrs for preinvasive lesions
  • USA 18 yrs old
  • Interval
  • Europe 3-5 years
  • USA annual
  • low risk, 3 consecutive negative, space out

20
Hong Kong College of Obstetricians and
Gynaecologists
  • Age sexually active to 65
  • Interval 2 consecutive annual normal smears, 3
    yearly

21
How to take a cervical smear?
  • Speculum
  • adequate exposure
  • light source
  • sampling device - Ayres spatula, brush or broom
  • transformation zone

22
Speculum
23
Ayres spatula, endocervical brush
24
Broom type sampler
25
When not to take a cervical smear
  • Blood in vagina, on the cervix - usually because
    of menstruation
  • Obvious or gross growth on the cervix - a biopsy
    is more appropriate
  • Cervix cannot be seen

26
  • How to interpret a cytology report?

27
  • Reports of cervical smear should be interpreted
    together with the clinical picture of the
    patient.
  • Some physiological or medical conditions may lead
    to difficulty in the interpretation of a smear.

28
History on request form
  • contraceptive history
  • menopausal status
  • date of last menstrual period
  • prior radiotherapy or current chemotherapy
  • hysterectomy
  • drugs or hormones
  • parity

29
Bethesda System 2001
  • Negative
  • Squamous cell - ASCUS, ASC-H (cannot exclude
    HSIL)
  • - LSIL
  • - HSIL, HSIL with features suspicious of
    invasion
  • - SCC

30
Bethesda System 2001
  • Glandular cell
  • - Atypical endocervical cells, endometrial
    cells, glandular cells
  • - Atypical, favor neoplastic endocervical
    cells, glandular cells
  • - Endocervical adenocarcinoma in-situ
  • - Adenocarcinoma endocervical, endometrial,
    extrauterine, NOS

31
Cytology screening
No. Unsat. ASCUS AGUS LG HG
Inv Conven 95874 0.44 4.36 0.1
1.24 0.29 0.02 1999 Thin Prep 100420
0.32 4.78 0.1 1.6 0.3
0.001 2000 (4800) (1600)
A Cheung
32
  • How to manage abnormal smear?

33
Histological grading of pre-invasive cervical
lesion
  • Koilocytes human papillomaviral changes
  • Cervical intraepithelial neoplasia (CIN)
  • 1 dysplastic cells in lower one third of
    epithelium
  • 2 lower two third
  • 3 almost the whole thickness

34
Inflammatory changes with atypia
  • could be due to vaginitis or infection such as
    monilia, trichomonas, herpes or condyloma.
  • Treat the cause and repeat the smear 4 to 6
    months later to ensure that dysplastic cells were
    not masked by the previous inflammatory cells.

35
Management of ASCUS
  • 5 of smears reported as ASCUS
  • Majority of ASCUS turn out to be normal or of low
    grade CIN
  • Less than 1 associated with cancer

36
Management of LSIL
  • 1.5-2.5 of smears screened were of LGIL
  • 15-30 associated with HG CIN
  • about 1 associated with cancer
  • 2 options
  • repeat smear 4-6 months interval
  • refer for colposcopic assessment (HKCOG guideline)

37
Management of HSIL
  • Gross examination showed a growth - biopsy
  • Grossly normal - refer colposcopy

38
Outcome of AGUS
  • Normal 19-34
  • Significant pathology 15-37
  • CIN 16-54
  • AIS 3-5
  • Ca cervix 2-3
  • Ca corpus 1-4

39
Recommendation
  • AGUS- favor neoplasia, co-existing with squamous
    neoplasia, previous hx of cervical lesion refer
    colposcopy, DC and cone
  • AGUS- favor reactive, not otherwise specified
    repeat cytology with adequate endocervical
    sampling

40
Colposcopy services in Hong Kong
  • Department of Obs Gyn of major hospitals of the
    Hospital Authority
  • Lady Helen Woo Womens Diagnostic and Treatment
    Centre at Tsan Yuk Hospital
  • Private gynaecologist with colposcopy training

41
Colposcope
42
Treatment of high grade CIN
  • ablative therapy
  • cryotherapy
  • cold coagulation
  • diathermy
  • laser evaporisation
  • excision therapy
  • cone (knife, laser, loop excision)
  • hysterectomy is rarely indicated

43
Management of abnormal smear
Hong Kong College of Obstetricians
Gynaecologists - Guidelines on The Management of
An Abnormal Cervical Smear
44
Ovarian Cancer in HK
  • New Cases 220
  • Death 95
  • Median age 51
  • (1992)

45
Ovarian cancer
  • High mortality due to late diagnosis
  • 75 of ca ovary at diagnosis were at late stage
    with a 28 5 yr survival
  • Stage I ca ovary has 95 5 yr survival

46
Ovarian Cancer
  • Symptoms of ovarian cancer
  • asymptomatic
  • Lower abdominal pain/pressure
  • mass
  • Abdominal enlargement
  • Vaginal bleeding
  • Urinary/bowel symptoms

47
Ovarian Cancer
  • Risk factors
  • 1) majority has no risk factor
  • 2) family history 10
  • - familial ovarian syndrome
  • 2) nulliparous
  • 3) racial and social

48
Why screening for ovarian cancer is so difficult?
  • Anatomic location of the ovary, not easily
    accesible
  • Lack well defined precursor lesion and has poorly
    defined natural history
  • Low prevalence, need exquisite specificity to
    avoid unnecessary intervention
  • Lack of a good method

49
Methods used for ovarian cancer screening
  • Serum CA125
  • Transvaginal ultrasonogram
  • Multimodal
  • New method under investigation - lysophosphatidic
    acid

50
Serum CA125
  • Elevated in 82 of ovarian cancer and lt1 of
    healthy women
  • rising pattern over time preceded ovarian cancer
  • limitations lack of sensitivity in Stage I
    disease, poor specificity (elevated in benign and
    other malignant conditions)

51
TVS in ov ca screening
  • Kentucky study 2000
  • 14,468 postmenopausal women
  • annual TVS
  • total 57,214 scans
  • 180 laparotomies 17 ov ca (stage I11, stage
    II3, stage III3)
  • sensitivity 81 specificity 98.9 PPV 9.4 NPV
    99.97
  • Survival at 2 yr 92.9 and at 5 yr 83.6

52
Ovarian cancer screening
  • Jacobs et al. 1993
  • 22000 women over 45 yrs
  • CA125 and transvaginal ultrasound
  • 125 elevated CA125, FU with CA125 and TVS
  • 41 laparotomies 11 ovarian ca vs 8 in control gp
  • specificity 99.9
  • sensitivity 78.6
  • positive predictive value 26.8

53
Ovarian screening
  • Not cost-effective
  • May be considered in high risk population
  • No place for population screening yet

54
Carcinoma of Endometrium
  • Incidence third commonest malignant tumour
    of genital tract
  • Age 58

55
Endometrial Cancer in H.K.
  • New cases 200
  • Death 50
  • Median age 60
  • (1992)

56
Risk factors
  • nulliparity, anovulation, late menopause
  • exogenous estrogen
  • endogenous estrogen
  • DM, HT, obesity
  • smoking, white
  • tamoxifen
  • familial history

57
Postmenopausal Bleeding
  • 1) carcinoma of endometrium 14
  • 2) other gynecological malignancy 14
  • 3) atrophic endometritis 20
  • 4) endometrial hyperplasia 12
  • 5) cervicitis/erosion 8
  • 6) endometrial polyp 8
  • 7) cervical polyp 8

58
Diagnosis of Carcinoma of Endometrium
  • (f) DC near 100
  • uterine aspirate 90
  • endocervical aspirate vaginal 65 aspirate
  • vaginal aspirate cervical smear 40
  • cervical smear 15

59
Should endometrial cancer be screened?
  • High prevalence in the West, low (same as ovarian
    ca) in Hong Kong
  • precursor lesion, atypical endometrial
    hyperplasia
  • accessibility of endometrium to sampling
  • high cure rate for early disease
  • Cons majority detected at early stage because of
    abnormal bleeding esp PMB

60
Endometrial Cancer Screening
  • Tools explored
  • pelvic ultrasound (gt8mm endometrial thickness in
    postmenopausal women) Karlsson 1995
  • endometrial aspirate (inadequate sampling in
    menopausal women)

61
Endometrial aspirator
62
Endometrial aspirator
63
Endometrial aspiration
  • Sensitivity for endometrial ca 94 in patient
    with symptoms
  • sensitivity for hyperplasia 31
  • Cons discomfort to patient
  • lack of known efficiency in asymtomatic
    patients

64
TVS in endometrial ca screening
  • Croatia study (Kurjak 1994)
  • 5013 asymptomatic women
  • ca endometrium 6 and hyperplasia 18, no false
    positive
  • (low prevalence of ca endometrium in asymptomatic
    patients, ? Advantage)

65
Endometrial cancer screening
  • Not justified in population screening
  • excellent prognosis of majority of ca endometrium
    unlikely will result in decreased mortality rates

66
Conclusions
  • Cervical cancer screening is the most successful
    programme in gynaecological cancers
  • Ovarian cancer screening is not proven to be
    cost-effective yet, may be considered in high
    risk groups
  • Endometrial cancer screening may be consider in
    high risk groups
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