Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Treatment of cervical intraepithelial neoplasia by cryotherapy FIGURE 12.1: Cryoprobes, the cryogun, pressure gauge and stop watch FIGURE 12.2: Cryotherapy equipment 10 1. Probe 2. Trigger 3. Handle grip (fibreglass) 4. Yoke 5. Instrument inlet of gas from cylinder 6. Tightening knob 7. Pressure gauge showing cylinder pressure 8. Silencer (outlet) 9. Gas-conveying tube 10. Probe tip 7 1 3 2 8 6 4 5 8 9 FIGURE 12.3: Components of cryotherapy equipment cryotherapy gun through a flexible gas-conveying tube, a pressure gauge showing the cylinder gas pressure, an outlet silencer, a cryotherapy gun with handle grip, a gas trigger to allow the gas to be released to the cryotherapy probe at high pressure and the cryotherapy probe. In most equipment, the pressure gauge shows three colour zones: yellow, green and red. When the gas cylinder is opened, if the pressure indicator in the gauge moves to the green zone, there is adequate gas pressure for treatment; if the needle remains in the yellow zone, the pressure is too low and the gas cylinder should be changed before commencing treatment; if the needle moves to the red zone, excess pressure is indicated and this excess pressure should be released. One should consult the manual provided by the manufacturer thoroughly for operational instructions. Cryotherapy for ectocervical lesions Eligibility criteria that must be met for cryotherapy are given in Table 12.1. If the woman is suffering from cervicitis, trichomoniasis or bacterial vaginosis, she may be offered a choice of having either cryotherapy immediately with simultaneous antimicrobial treatment or antimicrobial treatment and returning two to three weeks later for cryotherapy (see Chapter 11, Table 11.1). If there is evidence of pelvic inflammatory disease (PID), it is advisable to delay cryotherapy until the infection has been treated and resolved. If there is marked atrophy due to estrogen deficiency in an older woman and staining of the outer margin of a lesion is indistinct, cryotherapy may be carried out after a course of topical estrogen treatment and colposcopic reassessment. The woman must give written consent 97
Chapter 12 Table 12.1: Eligibility criteria for cryotherapy • The entire lesion is located in the ectocervix without extension to the vagina and/or endocervix • The lesion is visible in its entire extent and does not extend more than 2 to 3 mm into the canal • The lesion can be adequately covered by the largest available cryotherapy probe (2.5 cm); the lesion extends less than 2 mm beyond the cryotherapy probe • CIN is confirmed by cervical biopsy/colposcopy • There is no evidence of invasive cancer • The endocervical canal is normal and there is no suggestion of glandular dysplasia • The woman is not pregnant • If the woman has recently delivered, she is at least three months post-partum • There is no evidence of pelvic inflammatory disease • The woman has given informed written consent to have the treatment to have the treatment, after being thoroughly informed as to how it will be performed and the probabilities of its effectiveness, adverse effects, complications, long-term sequelae, and alternative ways that can be used to manage her problem. It is advisable to use the largest cylinder of refrigerant gas possible, so that a sufficient amount of refrigerant is available to complete the treatment and the pressure forcing the refrigerant through the probe tip is maintained at a high level so that the effectiveness of the procedure is maintained. Standard-size tanks only allow adequate pressure to treat three women. A large tank has the advantage of treating more women, but transport from clinic to clinic may pose a problem. FIGURE 12.4: Cryotherapy unit connected to a large gas cylinder (covered with a clean cloth) which is safely placed on a moveable carrier If excellent contact is achieved between the probe tip and the ectocervix (Figures 12.5 and 12.6b), a nitrous oxide-based cryotherapy will achieve temperatures of about -89°C and the carbon dioxidebased system will achieve –68°C at the core of the tissue ice ball. The temperature at the edges of the frozen tissue may be around –20°C. Cells held at –20°C for one minute or more will undergo cryonecrosis. The minimum temperature at the probe tip for effective freezing should be –60°C. It is critical to establish and maintain good contact throughout the procedure between the probe tip and the tissue - poor contact means a relatively large variation in the temperatures achieved within the ice ball and therefore variable effectiveness in the target tissue. 98
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Colposcopy and Treatment of Cervica
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INTERNATIONAL AGENCY FOR RESEARCH O
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Published by the International Agen
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Contents 11 Management that provide
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Acknowledgements The authors gratef
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Preface Health care providers have
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Chapter 1 An introduction to the an
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An introduction to the anatomy of t
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Page 25 and 26:
Chapter 2 An introduction to cervic
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An introduction to cervical intraep
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Page 31 and 32:
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Chapter 3 An introduction to invasi
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An introduction to invasive cancer
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Page 39 and 40:
Page 41 and 42:
Chapter 4 Table 4.1: Indications fo
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Chapter 4 FIGURE 4.2: Colposcope wi
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Chapter 4 FIGURE 4.6: Endocervical
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Chapter 4 Table 4.2: Preneoplastic
Page 49 and 50:
Chapter 5 between the two ocular le
Page 51 and 52:
Chapter 5 Obtain specimens for labo
Page 53 and 54:
Chapter 5 FIGURE 5.2: Biopsy techni
Page 55 and 56: Chapter 5 tissue tends to mimic inv
Page 57 and 58: Chapter 6 invasive carcinoma. Even
Page 59 and 60: Chapter 6 ages (Figures 1.7d, 1.7e,
Page 61 and 62: Chapter 6 FIGURE 6.7: The colour ch
Page 63 and 64: Chapter 6 Crypt openings Immature s
Page 65 and 66: Chapter 6 a FIGURE 6.17: An area of
Page 67 and 68: Chapter 7 The colposcopic diagnosis
Page 69 and 70: Chapter 7 appears as individual sma
Page 71 and 72: Chapter 7 acid stain is correlated
Page 73 and 74: Chapter 7 FIGURE 7.15: Moderately d
Page 75 and 76: Chapter 7 FIGURE 7.23: A dense acet
Page 77 and 78: Chapter 7 FIGURE 7.30: Mustard yell
Page 79 and 80: Chapter 7 We recommend that the stu
Page 81 and 82: Chapter 8 highlights this responsib
Page 83 and 84: Chapter 8 Appearance before applica
Page 85 and 86: Chapter 8 diagnosis of AIS and aden
Page 87 and 88: Chapter 8 a ↑ FIGURE 8.10: Adenoc
Page 89 and 90: Chapter 9 Inflammatory lesions of t
Page 91 and 92: Inflammatory lesions of the uterine
Page 93 and 94: Inflammatory lesions of the uterine
Page 95 and 96: Chapter 10 Table 10.1: Common sourc
Page 97 and 98: Chapter 10 Table 10.2 (cont.): A su
Page 99 and 100: Chapter 11 FIGURE 11.1: Flow chart
Page 101 and 102: Chapter 11 treatment policies for p
Page 103 and 104: Chapter 11 Vaginal delivery can be
Page 105: Chapter 12 involvement increases wi
Page 109 and 110: Chapter 12 a b c d e f FIGURE 12.6:
Page 111 and 112: Chapter 12 during the follow-up in
Page 113 and 114: Chapter 13 (2) (1) FIGURE 13.2: Ele
Page 115 and 116: Chapter 13 (1) (2) (3) (4) (5) (8)
Page 117 and 118: Chapter 13 Once the specimen has be
Page 119 and 120: Chapter 13 in the endocervical cana
Page 121 and 122: Chapter 14 Decontamination, cleanin
Page 123 and 124: Decontamination, cleaning, high-lev
Page 125 and 126: References Herrero, R. (1997) Preva
Page 127 and 128: Further reading Suggestions on furt
Page 129 and 130: Appendix Leukoplakia Condylom
Page 131 and 132: Appendix regardless of your pregnan
Page 133 and 134: Appendix Monsel’s paste Ingredien
Page 135 and 136: Appendix 5 The modified Reid colpos
Page 137 and 138: Index Acetowhitening . . . . . . .
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Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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