Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Treatment of cervical intraepithelial neoplasia by loop electrosurgical excision procedure (LEEP) FIGURE 13.7: Excision of ectocervical plus endocervical lesions (a) (b) (c) (d) (e) (f) ↑ ↑ ↑ ↑ ↑ FIGURE 13.8: Excision of an ectocervical lesion extending into the endocervical canal by a two-layer excisional method; (a) appearance of the CIN 3 lesion after 5% acetic acid application; (b) appearance after Lugol’s iodine application; (c) excision of the ectocervical lesion in progress; (d) ectocervical cut completed; (e) endocervical cut completed and the specimen in place (narrow arrows); (f) endocervical cut specimen removed and the bleeding points in the floor of the crater are being fulgurated to achieve haemostasis 109
Chapter 13 in the endocervical canal can be excised using a smaller loop - usually a square loop with a 1.0 x 1.0 cm configuration - but care must be taken not to go any deeper than is necessary to completely excise the lesion and a margin of normal tissue. This type of excision can reach a maximum of 1.6 cm into the endocervical canal (Figure 13.7). Excision of this depth should be attempted only when absolutely necessary, due to increased risk of bleeding and stenosis as the depth of excision increases. LEEP should not be used if the distal or upper extent of the lesion in the canal cannot be seen and if the distal end of the lesion extends more than 1 cm into the canal. Such patients should undergo cold-knife conization. Since this twostep method requires adequate performance of the basic LEEP procedure, it is recommended that it should not be attempted until the operator is comfortable and competent with the basic LEEP. Women with lesions that extend further up into the canal need cold-knife conization to properly assess the endocervical canal. ↑ FIGURE 13.9: Appearance of the cervix three months after LEEP; note the parallel blood vessels in the healed cervix (arrow) Lesions with vaginal extension If the lesion extends onto the vagina, it is preferable to use the ball electrode for electrofulguration on the peripheral, vaginal part of the lesion and LEEP on the central, cervical part of the lesion. The treatment of these vaginal lesions is beyond the scope of this manual and the LEEP treatment referred to here deals only with the type of lesions shown in Figures 13.4, 13.6, 13.7 and 13.8 and described above. Interested readers may refer to standard text books (Wright et al., 1992; Wright et al., 1995). Follow-up care after LEEP Women should receive instructions on self-care and what symptoms to expect after treatment. If appropriate, written instructions should be provided. Women should be advised that they will have a brown or black discharge lasting between a few days and two weeks. They should be advised to promptly report back if the discharge persists for more than two weeks, if discharge becomes malodorous and/or is associated with lower abdominal pain or if profuse bleeding develops. Women should be advised not to use a vaginal douche or tampons, or to have sexual intercourse for one month. The appearance of cervix three months and one year after LEEP is shown in Figures 13.9 and 13.10. The effect of LEEP treatment on the potential transmissibility of HIV (to or from women) during the FIGURE 13.10: Appearance of the cervix one year after LEEP healing phase is not known. HIV-1 shedding in the vaginal secretions after treatment of CIN in HIV-positive women has been demonstrated (Wright et al., 2001). Therefore, the authors suggest advising all women that LEEP treatment may increase the transmissibility of HIV and that using condoms is an effective means of prevention. Condoms should be used for period of 6-8 weeks. Ideally, a supply of condoms should be available, free of charge, at colposcopy clinics in settings where HIV infection is endemic. A follow-up appointment should be made for review at 9-12 months after treatment; the management plan 110
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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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Chapter 2 An introduction to cervic
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An introduction to cervical intraep
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Chapter 3 An introduction to invasi
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An introduction to invasive cancer
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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
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Chapter 5 between the two ocular le
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Chapter 5 Obtain specimens for labo
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Chapter 5 FIGURE 5.2: Biopsy techni
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Chapter 5 tissue tends to mimic inv
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Chapter 6 invasive carcinoma. Even
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Chapter 6 ages (Figures 1.7d, 1.7e,
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Chapter 6 FIGURE 6.7: The colour ch
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Chapter 6 Crypt openings Immature s
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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 and 106: Chapter 12 involvement increases wi
Page 107 and 108: Chapter 12 Table 12.1: Eligibility
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: Chapter 13 Once the specimen has be
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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