Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Foreword Women in many developing countries in sub-Saharan Africa, south and south-east Asia, central and south America have a high risk of cervical cancer, and detection programmes and efficient screening programmes are largely lacking. The facilities, service delivery systems and expertise needed for detection and treatment of both cervical precancerous lesions and invasive cancers in many high-risk developing countries are very deficient. Thus, planned investments in health-care infrastructure and in equipping health care providers with skills in cervical cancer prevention are important components of global cervical cancer control initiatives. Colposcopy is a diagnostic method useful for the diagnosis and evaluation of cervical intraepithelial neoplasia and preclinical invasive cancer. It allows magnified visualization of the site where cervical carcinogenesis occurs. It enables taking directed biopsy and in delineating the extent of lesions on the cervix in screen-positive women, thus avoiding conization. It also helps in directing treatments such as cryotherapy and loop electrosurgical excision procedure for cervical intraepithelial neoplasia. Colposcopy is not widely available and not widely practised in many developing countries where a high incidence of cervical cancer is observed. Similarly, skills and facilities for cryotherapy and loop electrosurgical excision procedure, the two appropriate treatment methods for cervical intraepithelial neoplasia in low-resource settings discussed in this manual, are extremely deficient in many developing countries at high risk for cervical cancer. This introductory manual is intended to simplify the learning of colposcopy and treatment of cervical intraepithelial neoplasia with cryotherapy and loop electrosurgical excision procedure so as to allow dissemination of the skills in low-resource settings. The first draft of the manual was written as a result of an ICRETT fellowship, offered by the International Union Against Cancer (UICC). Subsequently, the manual was used in a number of training courses in developing countries to train health care personnel in colposcopy and treatment of cervical intraepithelial neoplasia, in the context of specific research and demonstration projects in early detection and prevention of cervical cancer. The feedback from those courses, and from users and the reviewers of draft versions of this manual, has been helpful to further improve the contents. It is hoped that this manual will find a range of uses, as a resource for short teaching courses for health-care personnel, as a teaching, as well as a learning, aid for medical and nursing students, medical practitioners, as a field manual in screening programmes or even as a self-learning tool. Availability of simplified learning resources, training mechanisms and trained providers in cervical cancer prevention may help to overcome some of the technical challenges and may prepare the ground for implementing such services in developing countries. We believe that this manual will help to equip health care providers with the necessary skills in detecting and treating cervical intraepithelial neoplasia, thereby preventing invasive cervical cancer in many women world-wide. P. Kleihues, M.D. Director, IARC C. Elias, M.D. President, PATH vii
Acknowledgements The authors gratefully acknowledge the following colleagues who readily agreed to review a draft version of this manual, in spite of short notice, and who provided useful suggestions, advice for revision and encouragement. The manual has greatly benefited from their input. Nevertheless, the sole responsibility for the content remains the authors’ and we wish to impress the fact that the recommendations in this manual have been made based on what we think is feasible and effective in low-resource settings: Dr Parthasarathy Basu, Gynaecological Oncology, Chittaranjan National Cancer Institute, S.P. Mukherjee Road, Calcutta, India Dr Jerome Belinson, Gynecologic Oncology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA. Dr Neerja Bhatla, Associate Professor of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India Dr Paul D. Blumenthal, Director, Contraceptive Research and Programs, Johns Hopkins Bayview Medical Center, Associate Professor, Department of Gynaecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA Dr Nagindra Das, Department of Gynaecological Oncolgy, Northern Gynaecology Oncology Centre, Gateshead, Tyne & Wear, England Dr Lynette Denny, Department of Obstetrics & Gynaecology, Faculty of Health Sciences, Cape Town, South Africa Dr Amadou Dolo, Chef de Service Gynécologie- Obstetrique, Hôpital Gabriel Touré, Bamako, Mali Dr Laurie Elit, Hamilton Regional Cancer Centre, Hamilton, Ontario, Canada Dr Alex Ferenczy, Professor of Pathology and Obstetrics and Gynaecology, The Sir Mortimer B. Davis Jewish General Hospital, Montreal, Canada Dr Daron Ferris, Director, Student Health Service, Associate Professor, Department of Family Medicine Medical College of Georgia, Student Health Center, Augusta, GA, USA Dr Bernard Fontanière, Professor of Cytology, Centre Leon Berard, Lyon, France Dr Silvia Franceschi, Chief of the Unit of Field Intervention Studies, IARC, Lyon, France Dr L. Frappart, Laboratoire d’Anatomie et de Cytologie Pathologiques, Hôpital Edouard Herriot, Lyon, France Dr K. Geethanjali Amin, Department of Preventive Oncology, Tata Memorial Center, Mumbai, India Dr José Jeronimo Guibovich, Ginecologia Oncologia, Patalogia Mamaria, Colposcopia, Instituto de Enfermedades Neoplasicas, Lima, Peru Dr Robert D. Hilgers, Executive Director, International Gynecologic Cancer Society, Louiseville KY, USA Dr Martha Jacob, EngenderHealth, New York, NY, USA Dr Namory Keita, Chef de Service de Gynécologie - Obstétrique, Université de Conakry, CHU Donka, Conakry, Guinée Dr Peter H. Kilmarx, U.S.Centers for Disease Control and Prevention, USA Dr Suphannee Koonsaeng, Gynecologic Oncology Unit, National Cancer Institute, Bangkok, Thailand Dr R. Lambert, Unit of Descriptive Epidemiology, IARC, Lyon, France Dr Jean Liaras, Caluire, Lyon, France Dr Pisake Lumbiganon, Professor and Chairman, Department of Obstetrics & Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand Dr Monique Marien, Department of Obstetrics & Gynaecology, Hôpital Edouard Herriot, Lyon, France Dr Patrice Mathevet, Department of Obstetrics & Gynaecology, Hôpital Edouard Herriot, Lyon, France Dr Paulo Naud, Co-ordinator, Programme on Detection of Precursor Lesions of Cervical Cancer and HPV Infection, Porte Alegre, RS - Brazil ix
Page 1 and 2: Colposcopy and Treatment of Cervica
Page 3 and 4: INTERNATIONAL AGENCY FOR RESEARCH O
Page 5 and 6: Published by the International Agen
Page 7: Contents 11 Management that provide
Page 11 and 12: Preface Health care providers have
Page 13 and 14: Chapter 1 An introduction to the an
Page 15 and 16: An introduction to the anatomy of t
Page 25 and 26: Chapter 2 An introduction to cervic
Page 27 and 28: An introduction to cervical intraep
Page 33 and 34: Chapter 3 An introduction to invasi
Page 35 and 36: An introduction to invasive cancer
Page 41 and 42: Chapter 4 Table 4.1: Indications fo
Page 43 and 44: Chapter 4 FIGURE 4.2: Colposcope wi
Page 45 and 46: Chapter 4 FIGURE 4.6: Endocervical
Page 47 and 48: 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
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Chapter 6 a FIGURE 6.17: An area of
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Chapter 7 The colposcopic diagnosis
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Chapter 7 appears as individual sma
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Chapter 7 acid stain is correlated
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Chapter 7 FIGURE 7.15: Moderately d
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Chapter 7 FIGURE 7.23: A dense acet
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Chapter 7 FIGURE 7.30: Mustard yell
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Chapter 7 We recommend that the stu
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Chapter 8 highlights this responsib
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Chapter 8 Appearance before applica
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Chapter 8 diagnosis of AIS and aden
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Chapter 8 a ↑ FIGURE 8.10: Adenoc
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Chapter 9 Inflammatory lesions of t
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Inflammatory lesions of the uterine
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Inflammatory lesions of the uterine
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Chapter 10 Table 10.1: Common sourc
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Chapter 10 Table 10.2 (cont.): A su
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Chapter 11 FIGURE 11.1: Flow chart
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Chapter 11 treatment policies for p
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Chapter 11 Vaginal delivery can be
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Chapter 12 involvement increases wi
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Chapter 12 Table 12.1: Eligibility
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Chapter 12 a b c d e f FIGURE 12.6:
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Chapter 12 during the follow-up in
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Chapter 13 (2) (1) FIGURE 13.2: Ele
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Chapter 13 (1) (2) (3) (4) (5) (8)
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Chapter 13 Once the specimen has be
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Chapter 13 in the endocervical cana
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Chapter 14 Decontamination, cleanin
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Decontamination, cleaning, high-lev
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References Herrero, R. (1997) Preva
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Further reading Suggestions on furt
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Appendix Leukoplakia Condylom
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Appendix regardless of your pregnan
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Appendix Monsel’s paste Ingredien
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Appendix 5 The modified Reid colpos
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Index Acetowhitening . . . . . . .
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