Case ConferenceMarch 8th 2017

08-Mar-2017, Divisi Ginekologi Onkologi RSCM

Mrs X

Management of ASC-H with Human Papilloma Virus Positive after LLETZ
Excision in Women with Cervical Intraepithelial Lesion

 

 

CASE DESCRIPTION

 

Patient Mrs. 65 yo, P2 came to gynecology outpatient clinic department Cipto Mangunkusumo Hospital on October 16^th, 2015 referred from Cengkareng Hospital due to High grade squamuous Intraepitelial lession. Patient complained of abdominal since 2 months prior admission, the patient didn’t realize about vaginal bleeding, didn’t complained about post coital bleeding. Denied dyspareunia, Micturition and stool was within normal limit. Based on the Fetomaternal US examination, uterus was normal, reguler stratum basalis, endometrial thickness <2 mm, both ovary was normal, portio and endocervix was normal, there was no abnormal mass or new neovascularization at cervix.

On October 17^th 2016 the patient underwent colposcopy, LBC, HPV genotyping. The colposcopy was unsatisfied finding, LBC was atypical squamous cell can not exclude HSIL (ASC-H), HPV genotyping High risk Negative  , Low risk type 43/44.

On October 31^st 2016 do Large Loop Electrosurgical Trasformation Zone. The result was CIN III (Cervical Intraepitelial Neoplasia III) with free margin.

After three months on February 13rd 2017, we did colposcopy, LBC, and HPV genotyping. From colposcopy, we found unsatisfied appearance.

On February 27 2017 patient came to out outpatient clinic bought her examinations; atypical squamous cell can not exclude HSIL (ASC-H), HPV genotyping High risk Positive type 16.

 

CLINICAL QUESTION

 What is the best management in patient with recurrance or persistance ASC-H and HPV positive?

 

DISCUSSION

 

ASC is used to describe “cellular abnormalities that were more marked than those attributable to reactive changes but that fell short of a definitive diagnosis of ‘squamous intraepithelial lesion’. This interpretation is by far the most common cytologic abnormality, and as a consequence, it precedes the diagnoses of CIN 2-3+ more often than any other cytology result. However, aggressive investigation should be avoided because the ASC diagnosis is poorly reproducible, the risk of cancer is very low (0.1 to 0.2 percent), and the risk of CIN 2-3+ for any individual patient is also low (6.4 to 11.9 percent).

Women whose test results are HPV positive have a 15 to 27 percent chance of having CIN 2-3+ and should be referred for colposcopy. CIN 2-3+ has been detected in 24 to 94 percent of patients with cytology results of “ASC—cannot exclude high-grade intraepithelial lesions” (ASC-H). This suggests that colposcopy is an appropriate initial diagnostic intervention.

HPV has been detected in 86 percent of women with ASC-H monolayer cytology and in 70 percent of women with ASC-H conventional cytology. CIN 2 or CIN 3 has been reported in at least 70 percent of women with cytology results of high-grade squamous intraepithelial lesions (HSIL), and 1 to 2 percent have invasive cancer.

CIN 2 and CIN 3 are recognized potential cancer precursors, although CIN 2 is associated with significant spontaneous regression. Evidence suggests that approximately 40 percent of CIN 2 cases regress over two years, whereas regression of CIN 3 is too rare to measure accurately.

            Both excision and ablation are acceptable treatment modalities for women with a histological diagnosis of CIN 2,3 and satisfactory colposcopy, except in special circumstances. A diagnostic excisional procedure is recommended for women with recurrent CIN 2,3. Ablation is unacceptable and a diagnostic excisional procedure is recommended for women with a histological diagnosis CIN 2,3 and unsatisfactory colposcopy. Observation of CIN 2,3 with sequential cytology and colposcopy is unacceptable, except in special circumstances.

Hysterectomy is unacceptable as primary therapy for CIN 2,3. Acceptable post treatment management options for women with CIN 2,3 include HPV DNA testing at 6-12 months. Follow-up using either cytology alone or a combination of cytology and colposcopy at 6 month intervals is also acceptable. Colposcopy with endocervical sampling is recommended for women who are HPV DNA positive or have a repeat cytology result of ASC-US or greater.  If the HPV DNA test is negative or if 2 consecutive repeat cytology tests are “negative for intraepithelial lesion or malignancy,” routine screening for at least 20 years commencing at 12 months is recommended. Repeat treatment or hysterectomy based on a positive HPV DNA test is unacceptable. If CIN 2,3 is identified at the margins of a diagnostic excisional procedure or in an endocervical sample obtained immediately after the procedure, reassessment using cytology with endocervical sampling at 4-6 months after treatment is preferred. Performing a repeat diagnostic excisional procedure is acceptable. Hysterectomy is acceptable if a repeat diagnostic procedure is not feasible. A repeat diagnostic excision or hysterectomy is acceptable for women with a histological diagnosis of recurrent or persistent CIN 2,3.

In the absence of other indications, hysterectomy is not the initial treatment of choice for patients with CIN 2 or CIN 3. Hysterectomy may be considered for treatment of persistent or recurrent CIN 2 or CIN 3 or when a repeat excision is indicated but technically unfeasible. If excision is indicated, it should be performed (where possible) before hysterectomy to rule out invasive cancer.

 

Adequate colposcopy, is an accurate method to rule out invasive cervical cancer and abdominal or vaginal hysterectomy is an effective therapeutic procedure in women with CIN III who have completed reproductive function.

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