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Essay 242 - abnormal smear

Posted by Valerie T.
A 40 year old primigravida has been referred to the gynaecology clinic at 10 weeks gestation. A cervical smear taken 4 weeks earlier has shown severe dyskaryosis. (a) What will you tell her about this finding? [5 marks] (b) Critically evaluate the options for further investigation and treatment [10 marks]. (c) How should she be followed up after treatment? [5 marks].

a) First I will tell the patient that severe dyskaryosis is a type of abnormal cervical smear. It means that there are abnormal changes on the the neck of the womb (cervix) that need to be treated. I will say that she does not have cancer.These changes are precancerous and there is a risk that if these changes are not treated they can develop into cancer. Severe dyskaryosis is caused by a common viral infection with the human papilloma virus. It is transmitted during sexual intercourse but does not require spcific treatment. Most people have this virus. I would offer colposcopy which is a method of taking a detailed look at the cervix using a microscope. Colposcopy is done as a daycase in the clinic and will not harm the fetus or cause miscarriage. Only a speculum is inserted in the vagina and acetic acid is placed on the cervix to help us to see the abnormal areas. I will provide written information on severe dyskaryosis and colposcopy.

b) Severe dyskaryosis is an indication for referral for colposcopy. This is important because it allows a better assessment of the cervix and degree of abnormaility. Colposcopy is also beneficial because it can be done as a day case. In pregnancy colposcopy is more diffficult because of the changes to the cervix caused by pregnancy. The cervix is more vascular and the transformation zone will be larger. Therefore colposcopy should be performed by someone experienced in this procedure and great care taken to identify the entire transformtion zone. Some small areas of CIN may be found in metaplastic areas. Care should be taken not to overdiagnose CIN because of the increased vascularity of the cervix.
After determining the degree of dysplasia, a decision by the colposcopist and patient should be made on further management. If colposcopy confirmed severe dysplasia or moderate dysplasia, then colposcopy should be repeated at the end of the second trimester. The reason for this is that treatment of CIN is not indicated in pregnancy because of the risk of haemorrhage in pregnancy. However, there is a risk that severe dysplasia may progress to cervical cancer and therefore cervical surveillance is necessary. Three months postpartum, if the colposcopy still shows severe dyskaryosis, then treatment should be offered with LLETZ. This will excise the area of dysplasia and provide a specimen to undergo histological examination. It is important to obtain histological diagnosis, since this is more accurate and does not always correspond to colposcopic findings. If initial colposcopy showed mild dysplasia, then colposcopy should be repeated 3 months postpartum. There is a great chance that mild dysplasia will regress. The cervix is easier to assess 3 months postpartum compared with immediately postpatum and in pregnancy itself. If colposcopy had showed invasive cancer, an immediate referral to the gynaecological oncologist for definitive treatment. If the patient would like to continue the pregnancy, a cone wedge biopsy may be performed under a general anaesthetic. If she prefers not to continue the pregnancy, then a total abdominal hysterectomy and bilateral salpinggoohorectomy may be performed.

c) After treatment it is important that the patient is followed up. The histological findings from the LLETZ specimen should be found out and the patient informed. The general practitioner should also be informed. Following the LLETZ, the patient should be reviewed in 6 months for repeat colposcopy and smear. Then further 6 monthly smears should be done. These can b done by the GP or colposcopy nurse specialist. The patient may return to routine 3 year recall system, after three consecutive negative smear reports. If the colposcopy or cytology findings are consistently abnormal during a 24 month period, further treatment such as a repeat LLETZ should be offered. If the LLETZ biopsy showed cervical cancer, then the patient should be followed up immediately by the gynaecology oncology specialist and associated multidisciplinary team.
Posted by Parveen  Q.
I will tell her that it is an abnormal smear report from the neck of the womb. It was performed with the aim to locate for precancerous changes in the cervical epithelium which can be treated to reduce the incidence of cervial cancer. 80 to 90% of severe dyskaryosis have CIN 2-CIN3. About 18to 36% of CIN 3 takes 10 to 20years to develop in to cervical cancer respectively. CIN 3 does not regress spontaneously. She will be referred for colposcopy with the aim to be seen in 4weeks, as per guidelines. I will reassure her that colposcopy does not harm the foetus or cause misscarriage. I will also reassure her that the treatment options will take her views in consideration. I will provide her information leaflets and give further appointment.

Recommendation for referral for colposcopy is same as that of nonpregnant woman, with the aim to be seen in 4weeks.Colposcopy is technically difficult in pregnancy, should be performed by an experienced person in the procedure. Poor correlation exists between cytology, colposcopy and histology findings. At colposcopy either see and treat or colposcopy and biopsy can be undertaken. Care must be undertaken to visualise the whole of transformation zone as small area of CIN may be seen among wide area of metaplasia. Correlation between colposcopy and histology impression is 85%. Punch biopsy is unrealible, also there is a risk of haemorrhage and unsatisfactory sample in pregnancy. If there is suspicion of invasion , wedge biopsy of the most abnormal area of cervix done. The treatment options depends on her choice . LLETZ(large loop excision of the transformation zone) is the widely used treatment for grossly visible lesion . Specimen for histology can obtained, however there are diathermal artifacts, and the tissue comes out in fragments, making orientation difficult. there are adverse pregnancy outcome , like preterm labour, preterm premature rupture of membranes, hemorrahage, and vaginal discharge. The cervical incompetence is less than cone biopsy. The modification of LLETZ is needle diathermy excision, where the shape of tissue obtained is under operator control. The conservative mangement involves regular colposcopy at 6 to 8weeks interval through out prenancy without biopsy if the lesion does not look suspcious of invasion.

The recurrence rate after treated CIN is about 5% at 2years. Treated CIN remains higher risk of invasive cancer than general population, so regular follow up done to identify new , or resdiual disease and to ressure her. Repeat smear with or wthout colposcopy done at 6 months, 12 months, and then yearly smears for 5years, if negative, then return to routinue recall at 3years. There is difficulty in sampling the transformation zone after treatment, so endocervical brush should be used in conjunction with ayer\'s spatula. Colposcopy is not necessay, but increase the detenction of residual disease.
Posted by Parveen  Q.
Please add in my 2paragraph-

In conservative management , treatment is undertaken in postpartum ,by an experienced colposcopist.
thanks.
Posted by Malar R.
She should be told that the smear shows changes which need to be investigated further. This is to exclude pre cancerous changes. Colposcopy is recommended where a magnifier is used to visualise her cervix.The procedure will be very similar to her smear test.This will enable a thorough asessment of her cervix and treatment will be according to findings.This test will be safe to her pregnancy.Her previous smear history and any previous cervical treatment will be enquired for.

Options for investigation include examination of her cervix in a colposcopy clinic and repeating a smear.This will enable visualisation of any suspicious cervical lesions and ensuring that the previous smear result was accurate.

Colposcopy is the next step. It is safe in pregnancy. It allows correlation of the smear with the cervical findings after magnification.However it requires a skilled colposcopist as the cervical changes in pregnancy due to hormones may make interpretation difficult.

In the presence of low grade colposcopy (CIN1) changes, conservative management may be chosen. However she must be colposcoped in each trimester to ensure that the lesion remains low grade.This minimises the risks of treatment(infections, bleeding, miscarriage) to the pregnancy.It also allows follow up of any lesions especially as the intial smear result and the colposcopy changes do not correlate.

If colposcopy shows high grade lesion (CIN2-3) with no features of invasion, there are 2 options. She may have conservative management with repeat colposcopy in each trimester or treatment with LLETZ in theatre under regional or general anaesthetic.The benefits of conservative management are the avoidance of risks of surgery as mentioned above. The disadvantages are the need to colposcope regularly in pregnancy.

Treatment with LLETZ will remove the CIN changes but is associated with bleeding, infections and risks of miscarriage, which may not be acceptable in a 40 yr old primip.The procedure will have to be done in theare due to the risk of bleeding heavily from a pregnant vascular cervix.

In the presence of an invasive lesion, she must be referred to gynaecological oncology specialist for a knife cone biopsy. This may be curative but has to be done in theatre under regional or general anaesthetic due to the risk of bleeding. This is associated with the risk of infections, miscarriage and cervical incompetence later.

If the colposcopy is normal then she maybe colposcoped again in 3 months to check for an new lesions and then have a smear and colposcopy 3 months postpartum. She shoud then have mapping biopsies if the smear is high grade and the colposcopy normal.This will allow diagnosis of lesions not seen on colposcopy.

Follow up after treatment depends on the histological grading of the CIN.However is is important to reassure the mother that the baby is not compromised as well. She should have a USS to check for viability after treatment.
She should also be reviewed after 2 -4 weeks to give her histology results, check adequate healing and check fetal heart.
In low grade CIN, she should have a repeat smear 6,12 ,24 months after treatment and return to routine recall if all normal.
In high grade CIN, she should have a smear 6,12,18 months and yearly afterwards for 10 years and then go back to routine recall if all normal.


Posted by Saad A.
(a) It is explained to the patient that severe dyskaryosis is not a malignancy. It is a pre malignat stage of cervical cancer. She will be told about the natural history of the disease. It takes 10years for the disease to progress from CIN III to invasive disease in 18% and 36% progress to invasive disease in 20 years. IT is also explained that the relatioship between cytology, histopathology, colposcopic findings are not definite and that the women might have invasive or microinvasive disease and that cervical screening and treatment of abnormal cervical smear is needed to prevent the development of cervical cancer. She should be re-assured that severe dyskaryosis will not affect the pregnancy. She requires colposcopy which should be done ideally within 4 weeks of the refferal(according to NHSCSP guidelines) and the procedure will be explained to her in a simple language and that it is not harmful to her pregnancy . Written information and hospital contact details are provided.
b. The investigations are needed for diagnosis and planning the treatment. The colposcopy is required to identify the extent of lesion and whole of transformation zone is visualized. The procedure is undertaken by applying 3% acetic acid and biopsy is taken from the most abnormal area. Usually pathology is detected in 85% of cases. The treament options are ablative/excision techniques. The treatment can be taken during colposcopy i.e see and treat method or it can be taken afterwards i.e colposcopyand biopsy and treatment later on. The see and treat option is associated with psychological satisfaction but is associated with over treatment. Whereas in the second option the biopsy report is available and hence treatment can be taken accordingly in next visit. Both options are discussed with the patient and her wishes are taken. DLE(Diathermy loop excision) is the most commonly excision technique used. The aim of treatment is that the excised margins should be free of the disease. It is very effective and not associated with side effects like infection haemmorage, cervical stenosis/incompetence and infertility. Thermal artefacts at the excision margin are the potential disadvantage. The ablative techniques(LASER/Cryotherapy and cold coagulation) donot provide adequate tissue for the histopathology and should be done after the biopsy. The knife cone biopsy is now rarely done only done in CGIN ,if the lesion is very high in the canal and if the lesion is not detected under colposcopy satisfactorily. It is associated with infection,haemmorage(primary and secondary),cervical stenosis/incompetence.The last option is for invasive disease by hysterectomy /traceolectomy depending upon the stage of the disease while detected on examination If there is suspected invasive disease wedge biopsy is also essential in pregnacy as punch biopy is unreliable and there is risk of haemmorage and unsatisfactory sample in pregnancy. The patient wishes are taken and documented on the notes. Provide written information and hospital contact details.
c. Through out pregnacy regular colposcopic examination (6-8 weeks biopsy) is needed and if the lesion does not look invasive the lesion is treated post partum if colposcopist advise.She should be followed up by 6 monthly cytological surveillance +/- colposcopy for 2 yearsand then yearly for 5 years and then 3 yearly. In case of carcinoma more frequent follow up is needed. If the cervical smear is positive after the treatment then she might require repeat colposcopy +/- further excision. Patient is provided written information and name of support groups.
Posted by Dr Mamta D.

a) I will tell her that as her smear shows severe dyskaryosis, it is a abnormal cervical smear and needs to be investigated further. There is a abnormality in the neck of womb (cervix). I would reassure her that it is not a cancer but a precancerous condition and she requires colposcopic examination within 4 weeks to identify the abnormality. Colposcopic examination requires magnification to visualize the cervix, it is safe and not associated with risk of miscarriage.
I will tell her that severe dyskaryosis may have CIN 2 or CIN 3. CIN 3 does not regress spontaneously and risk of CIN 3 to progress to invasive cancer is 18% at 10 years and 36% at 20 years. I will reassure her that treatment options will take her wishes into consideration and provide her information leaflets about CIN and arrange further appointment.


b) Colposcopy examination of cervix is the first step in investigation and evaluation of cervix as it is safe, allows magnification of cervical findings and allows a correlation between smear and cervical findings. However it requires a skilled colposcopist as due to cervical changes in pregnancy, squamocolumnar junction is everted with areas of metaplasia, transformation zone is wide and cervix is more vascular.
If colposcopy findings are suggestive of low grade abnormality (CIN 1) changes conservative management may be chosen. However she should have a colposcopy examination in each trimester to ensure that the lesions remain low grade. It minimises the risks of treatment (infection, bleeding and miscarriage) and allows follow up.
If colposcopy examination is suggestive of high grade lesion (CIN 2-3) with no features of micro invasion or invasion then the option include either conservative management with repeat colposcopy every 8 weeks antenatelly and to be repeated in postpartum or treatment with LLETZ in operation theatre under anaesthesia (regional or general).
Treatment with LLETZ will remove the CIN changes but is associated with bleeding, infection and miscarriage and may not be acceptable in a 40 years old primigravida.
In the presence of invasive lesion, she should be referred for conization. Cold knife cone biopsy may be curative but has to be done in theatre under regional or general anaesthesia and is associated with risk of bleeding (both primary and secondary), infection, miscarriage, cervical incompetence and stenosis. r. Risk of these complications are less with laser conization.
If the colposcopy examination is normal she should have colposcopy examination 3 months postpartum.


c) Adequately treated CIN has a recurrence rate of 5% at 2 years and woman with treated CIN remains at high risk of invasive cervical cancer compared to general population so she should be closely followed up to identify residual/ new disease and to reassure her. I would advise her repeat smears at 6 and 12 month, if negative it should be repeated yearly for 4 years and if still negative she should return to routine recall system i.e. every 3 years (as her age is 40 years). As the sampling of transformation zone may be difficult after treatment so an endocervical brush should be used in addition to a spatula. Colposcopy is not essential but may enhance detection of residual disease.
Posted by Shahla  K.
)Report of sever dyskaryosis generate considerable anxiety in 40 year old primigravida . I will inform her that sever dyskariosis does not means she is having cancer. Cervical screening programe helps to identify premalignant conditions.Early treatment prevent invasive cervical cancer
With sever dyskariosis.risk of premalignantCIN III is 50% , I would refer her for colposcopy ,this is an out patient procedure,involve examination of cervix under microscope. Biopsy done if suspicious areas found .
colposcopy does not affect pregnancy,it will not cause miscarriage or teratogenicity
Carcinoma of cervix has long natural history.it takes many years for premalignant condition to become invasive.
Cervical smear is prone to false positive,
During pregnancy owing to physiological changes at cervix it shows more false positive results.It has been seen that there is poor relation between screening cytology,colposcopy and histology.I will give her written information,and contact number of support group.
B)she should be refer for colposcopy and should be seen with in four weeks of referral.It will create anxiety
Pregnancy makes interpretation of finding difficult therefore it should be conducted by an expert colposcopist.
Colposcopy is binocular microscope which allow close examination of cervix.
Presence of punctuation,mosaicism.abnormal vessels,aceto white area at cervix and failure to take brown color if lugol iodine applied are suspicious of malignancy .Directed biopsy should be done.Visualization of transformation zone is not a problem during pregnancy.
In the presence of suspicion ,\"See and treat\" is not good choice, as such choice lead to excessive haemorrhage (>500ml) and overtreatment. .
If histology shows CIN II,CINIII then treatment defer to post partum period concordance of punch biopsy and final diagnosis is 95%,then followed up with repeated colposcopy every 8 week during antenatal period.
However if colposcopy unsatisfactory,microinvasion can not be ruled out then Cone biopsy may be necessary,
There are variety of options one is ablative technique and other is excisional
Ablative technique will not provide specimen for histology whereas excisional technique (cold knife excision) provide material for histology.But there are concern of miscarriage, preterm labour ,chorioamnitis and premature rupture of
membrane. There is theoretical risk of haemorrage from cervix during labour and delivery hence planed caeserian section should be done
C)Lesion may progress regress or remain the same after pregnancy .Therefore smear and colposcopy should be done to identify residual disease.
In case of persistant abnormal smear during antenatal period or presence of CIN II CINIII in histology excision of transformation zone is mandatory.
,Followed up with smear every 6 month until 3 smear negative then discharge to routine recall.
Posted by Mohammad H.
A 40 year old primigravida has been referred to the gynaecology clinic at 10

weeks gestation. A cervical smear taken 4 weeks earlier has shown severe

dyskaryosis. (a) What will you tell her about this finding? [5 marks] (b)

Critically evaluate the options for further investigation and treatment [10

marks]. (c) How should she be followed up after treatment? [5 marks

I will tell the patient thta her smear shows a severe dyskaryosis which is not

a cancer and I will explain to her that this is ann abnormality that needs

further investigations.I will tell her that she should undergo urgent colposcopic

examination and I will reasssure her that this colposcopic examination will not

cause a harm to her fetus.She should knoe that a biopsy may be taken at the

time of colposcopy and types of biopsies (bunch , LLETZ, conization) and the

possibility of hemorrahage,miscarriage and preterm delivery should be discussed

with her .I will tell her that she is expected to have CIN3 in ~80%of cases with

severe dyskaryosis and it may takes years before this lesion becomes an

invasive one and conservative treatment can be considered in CIN3 .Information

leaflets should be provided to the patient.



Options for further investigation and treatment:
Urgent colposcopic examination will allow direct vizualization of the cervix but

to be satisfactory the whole transformation zone (TZ) should be visualized which

may not be possible in pregnancy.There is a need for expert personnel to the

colposcopic findings and to differentiate different types af abnormalities.
Biopsy should be taken from suspected lesion and it can be punch biopsy which

is diagnostic and there will be a need for furthr treatment .Long Loop

Excision of the T Z (LLETZ) will offer both diagnostic and therapeutic tool at

the same seting .
Conization of the cervix can be done but is assovated with risk of bleeding,

infection ,fetal loss and preterm delivery due to incomptent cervix .
If CIN1 is diagnosed repeat the smear after 6 months as spontaneous regression

ca occur.
Destructive methods will not give adequate tissue for histological examination.
If invasive lesion is found ,temination of pregnancy(TOP) or if (TOP) was

denied wait for the earliest maturity then deliver the baby and treat as a non

pregnant patient.

Afetr treatment the patient should be followed by clinical examination and

cervical smears every 6 months for 3 years and then yearly for 10 years .

Information leaflets should be provided to the patient.












Posted by Idris O.
a) I would explain to her the smear is abnormal but cancer has not being diagnosed. The smear is a screening test to detect pre cancer stages before cancer develops. I would inform her she would need diagnosis with colposcopic evaluation within 4weeks to confirm the findings and exclude invasive disease. I would reassure her that colposcopy will not harm the fetus or cause miscarriage. I would inform her that the incidence of invasive cervical cancer in pregnancy is low and pregnancy itself does not have an adverse effect on the prognosis,only about 30% of CIN 111 will develop invasion within 20years.

b) The options for investigation and treatment would include , repeat cervical smear. There is however, a poor correlation between cytology and histological findings and invasive disease may be missed. The next option is referral for an expert colposcopic examination. This correlates with histolopathology in about 85% of cases. It can confirm the cytological finding and exclude invasive disease. It requires expertise to visualize the whole of the transformation zone as a small area of CIN may be missed. If invasive disease has been excluded , she would be offered a wait and see with regular colposcopic examination
( every 6-8wks) without biopsy throughout pregnancy. The lesion would be treated postpartum and this is usually reserved for the expert colposcopist. This is because excisional biopsies in pregnancy are not usually therapeutic and some lesions may still be missed.The alternative management would be a large loop excision of the transformation zone (LLETZ) if the whole cervical lesion was visible. This is associated with a risk of haemorrhage and this biopsy would be undertaken in a centre with facilities to deal with the haemorrhage. This allows diagnosis and treatment to be offered at the same time. This would be associated with a lot of anxiety and stress in this patient and she would be appropriately counselled and managed according to her choice.
If however invasive disease is suspected clinically or colposcopically, I would obtain a wedge biopsy of the most abnormal area. This is acceptable in pregnancy and unlike the cone biopsy, this is not associated with major morbidity such as haemorrhage, infection and miscarriage. A punch biopsies are unreliable in the diagnosis of invasive disease because associated with higher risk of haemorrhage and unsatisfactory sample in pregnancy.

c) She would be followed up with cervical smear every 6months for the first year and annually for the next 9years( total of 10years). Any abnormal smear would be referred for colposcopy. This is because persistent or recurrent disease is usually detected within 2years and the long term risk of invasive cancer persist up to 10 years or even beyond after treatment. If the smears are normal over a 10 year period she would be followed up with routine recall.l

Posted by Jancy V.
I will inform her that the smear report shows some abnormal cell changes in the neck of the womb, which is known as dyskaryosis, which is a pre cancerous condition. 80- 90 % of women with severe dyskaryosis have a cellular change called CIN3, which if not treated properly can lead on to cancer of the cervix in 20 ? 35% cases in 10 to 20 years. Hence I would tell her that she requires further tests, which involves referral to a colposcopy centre, where there is a specialist who uses an equipment to see the the cervix under magnification and take sample of tissue from the suspicious areas of cervix for microscopic tests. The results of these would provide more definitive diagnosis and help us to decide on treatment plans. Colposcopy is usually done as a day case surgery, does not involve pain and hence doesn?t require anesthesia. She should be re assured that colposcopy is not an invasive procedure and will in no way harm the on going pregnancy. There can be considerable anxiety to the woman, so she should be carefully counseled. Information leaflets should be provided .

Since women with severe dyskaryosis can have CIN 3 in 80 -90% cases, colposcopy is definitely indicated in order to get the histological diagnosis. Pregnancy should not be considered as a contraindication for colposcopy referral . Considering her age, there is chance that she can have microinvasive or invasive disease and hence early referral to colposcopy is needed. Incidence of invasive cancer of cervix in pregnancy is rare and pregnancy itself can have no adverse effect on the prognosis. If colposcopy is suggestive of CIN 1, she should be reassessed 3 months postpartum. If suspected CIN2 or 3, re assessment in second trimester and 3 months postpartum is needed and if it persists, LLETZ or cold knife conisation is done. Biopsy may be avoided in pregnancy in suspected CIN. But in cases with suspected invasive disease at colposcopy, biopsy is essential. It should be cone or wedge or diathermy biopsy because punch biopsy cannot rule out invasion. However biopsy in pregnancy carries a risk of hemorrhage. If cone biopsy shows margins free of disease, no further surgery is necessary. If invasive cancer is diagnosed and patient wishes to continue her pregnancy, she should be informed of the risks of metastasis and cone biopsy should be done. If she agrees, termination of pregnancy and referral to oncology center for definitve therapy should be offered.

Women who had conisation for CIN 2 and 3 should have follow up at 6 months and 12 months and annually for at least 10 years before returing to normal recall. Patients with treated CIN 1 can return to normal recall 2 years after achieving normal cytology. In women with CIN who underwent hysterectomy, vault smears at 6 months and 18 motnhs post surgery is needed. If incomplete or uncertain excision of CIN at TAH, follow up should be as if the cervix was in situ.
Posted by Fahima A.
a) First of all I will reassure her that it is not a cancer but it is a precancerous condition. It can turn in to cancer in 18% 0f women in 10 years and 36% of women in 20% years if not treated properly. However pregnancy has role in disease progression. She should be referred to colposcopy clinic. There may not be correlation between cytology, colposcopy and histological findings.. Information leaflet should be given.
b) She should be referred urgently to colposcopic examination to exclude microinvasive disease as in a few cases it may be present. Expert colposcopist is needed in this case because it is difficult to interpret colposcopic findings during pregnancy. If invasiveness is absent there are several options for treatment.
First she can be followed up with colposcopy in her pregnancy at the end of second trimester and treatment can be done after delivery.
Secondly if she is very anxious treatment can be done either with DLE or wedge biopsy. Cone biopsy is usually not recommended because of increased risk if miscarriage. Treatment should be done in a center where blood transfusion facilities available as there is a risk of haemorrhage due to increased vascularity in pregnancy. Punch biopsy is unreliable in pregnancy.
Whether excision done or not patient should be women should be seen with colposcopy in postpartum because excision biopsy can not be considered therapeutic in pregnancy.
If invasive lesion is found either hysterectomy or radiotherapy is the treatment of choice. Patient should be offered termination of pregnancy for that. If patient refuses TOP treatment can be waited up to fetal maturity and delivery. But there is a risk of progression of the disease.
c) She should be followed up closely as there is increased risk of developing cervical cancer than general population. Her first follow up visit should be in that colposcopy clinic and should be done with both cervical smear and colposcopic examination. If this is normal in high grade CIN her smear test should be done again at 12 month then at 24 month then yearly up to total 10 years. However in low grade CIN If 3 smear test is negative (at 6, 12, & 24 month ) she can go to her routine 3 yearly re call.
Posted by Reena M.
a] I will tell her that her smear report has come , and it shows cells with changes . She needs further tests . I will tell her dyskaryosis doesn\'t mean cancer , but the cervix needs to be examined through colposcope . I will tell her coplposcopy is not painful , and it is visualisation of cervix through microscope, with magnification. There is no clear correlation between smear which is cytological study and histology . There is inter observer variation.I will also tell her coplposcopic examination is not teratogenic or causes abortion. Written information will be given to her and support group introduced.

b]Since there is no corelation between cytolgy and colposcopy , she needs colposcopy . 80-90% of severe dyskaryosis have cin II-III. I will refer her for colposcopy , and to be planned within 4wks .Colposcopy should be done by experienced colposcopist , as there will be difficulty in interpretation due to pregnancy changes.ie increased vascularity. Further plan will be according to colposcopic findings , directed biopsy from suspicious areas . Ca cervix has long natural history , which enables to treat , it in precancerous stage itself. Colposcopy revealing CIN I-II . can be followed with pap smear and repeat colposcopy during pregnancy and definite treatment offered postpartum . But if invasion is suspected , cone biopsy is advised to be done in second trimester . There is increased risk of hemorrahage , choriamnionitis , pre term labor and delivery with cone biopsy.So it should be done in theatre by senior obstetrician . This has to be followed by repaet smear surveillance during pregnancy, to ensure that progression has not taken place, and plan treatment postpartum 36% of CIN III progress to invasive carcinoma in 20 yrs . . CIN 1 will progress to CIN III in 2yrs in about 26% . Any further queries should be explained to her and partner

c] Follow up smear is advised to patients who have undergone treatment . smear at 6 months, annually till 10yrs Clear written information will be given to the patient and her GP will also be informed
Posted by Natalie P C.
A
The first thing I will do is to explain what severe dyskariosis means and what are its implications. I will explain that these are cells that look abnormal due to its shape, increased mitosis or increased nuclear to cytoplasm ratio. I will explain that this means that she may have CIN or even microinvasive cancer. I will explain that the point of the smear is to pick up these CIN pre-cancerous lesions and treat them before they develop into cancer.

I will explain that she needs furthur investigations. I will offer to refer her to colposcopy and explain that colposcopy is looking at the cervix with a microscope to allow investigation and biopsy of the cervix. I will explain that there is no risk to the pregnancy wth a basic colposcopy. I will give her written information leaflets.

B
Colposcopy is a good test used to investigate for vascular changes and changes in response to acetic acid and iodine. It is fairly sensitive. The gold standard is the histology on the biopsy that is taken. It is not 100% sensitive as some lesons look quite mild and can turn out to be severe and it is not 100% specific as some lesions may look like CIN and turn out just to be koilocytic changes of HPV infection. It is a subjective assessment and operator dependent which is why colposcopists must maintain a minimum work load to maintain their skill.

Histology is the gold standard and requires that the sample of tissue be large enough to not all be too close to the edge and have electrocautery artefacts. I must be placed in an appropriate fixative like formalin, appropriately labelled and transported and processed. Examination of the tissue is also partially subjective but there a specific criteria that are applied making it less operator dependant.

A cone biopsy as LLETZ is the best way to biopsy lesions and treat them at the same time. This allows production of tissue for a definitive histologic diagnosis while also allowing it to be checked that the margins are clear of disease. Repeat cone biopsis are though associated with cervical incompetence or stenosis. Cryocautery or diathermy allows treatment of the disease but without allowing tissue diagnosis. Treatment is equally good but you are unable to say if all disease has been treated of to make sure that microinvasive disease has not been missed. Cold knife is equally as good as LLETZ. Its benefit is for CGIN or glandular disease is this can be higher up the canal and it has a greater risk of cervical stenosis and incompetence. Cone biopsy is often sufficient to treat CIN, CGIN and even grade 1a cervical cancer with only additional lymph node dissection for 1a2 disease. A biopsy though may risk a miscarriage for her pregnancy and bleeding may be more.

If colposcopy was normal or mild disease, then a biopsy may not be done and a colposcopy repeated in the 3rd trimester and then 3 months post partum allowing biopsy as then, the cervix would be back to normal then in terms of vascularity and assessment as pregnancy can cause some changes on it?s own. If the disease was CIN and completely excised then she can have a postnatal smear after 3-6months and then 6 months later. If she has 3 normal smears she can return to normal recall. If she had cervical cancer stage 1a that was excised then she needs colposcopy 3 months postpartum and regular smears. If it was stage 1a2 then she needs lymph node dissection postpartum. If she has 1b disease then she may consider trachelectomy with lymphadenectomy postpartum which can be done via laparoscopy or laparotomy.
Posted by Sabahat S.
a) I will tell the patient, that the findings are suggestive of premalignent changes in her cervix i.e the neck of the womb. They do not mean cancer. But the risk of malignant progression is high ( 18 % & 36 % at 10 yrs & 20 yrs ) so the need for investigation & treatment. The first is colposcopy, which should be done with in 4 wks. Colposcopy involves visualizing the cervix under magnification & identifying any abnormal changes suggestive of malignancy. Colposcopy will not endanger her pregnancy, and she should be reassured. If in case any abnormal findings are found during colposcopy, treatment could be undertaken, after taking the patients wishes into consideration. Written information on cervical cancer, precancer & Colposcopy is provided to her. Followup appointment is given, when she can clear her doubts.
b) Colposcopy should be done at the earliest, preferably by an experienced coloposcopist. The physiological changes of pregnancy make interpretation of findings difficult. If the colposcopic findings suggest mild dyskaryosis, she should be followed up with repeat colposcopy every trimester, to ensure the decrease is not progressing. The patient should be involved in the decision making process at all stages & her preference is paramount. But with conservative followup, there is a risk of the desease silently progressing, as the correlation between colposcopic, cytologic & histologic findings is poor.
If colposcopy suggests moderate to severe disease, the options are still conservative followup(if patient desires) with repeat colposcopy at regular intervals. This will be the case when the patient does not want to endanger her pregnancy (considering her advanced age & primigravidity ) and refuses surgical intervention. Tretment could be undertaken in the postpartum period after repeat colposcopy
LLETZ could be done to remove a cervical cone, including at least lower 1.5 cm of the cervix & the TZ. LLETZ entails the risk of miscarriage, bleeding ( primary & secondary ) infection, cervical incompetence/ stenosis. But the advantage is that it provides a histological specimen for analysis & it could be curative if adequate specimen is taken.
Cervical cone could also be taken by knife ( cold knife ) or laser. The advantages are the same i.e provides a histological sample for definitive diagnosis, with the added advantage of no thermal artifacts in the cone margin, enhancing accuracy of desease free margins.Risks involve, severe bleeding due to the increased vascularity of the cervix, infection, miscarriage due to incompetence of the cervix, or cervical stenosis. If in case the findings on colposcopy indicate invasion, TAH could be undertaken followed by chemo and / radiotherapy in a cancer center. The patient may be reluctant for this, considering her age & first pregnancy.
Trachelectomy could be tried, but the experience in its use is still not widespread.
c) Repeat smear should be done at 6 months. Two such smears should be negative at 6 months interval & then at 1 year interval (5 such ) before she returns to routine recall (3 yearly ).
In case if any smear turns out to be suspicious colposcopy should be undertaken with repeat cone if findings are suspicious.
The followup smears will be done by an endocervical brush along with a spatula.
If she is still pregnant the smears will be done ( along with colposcopy ) every 6 ? 8 wks till delivery.
Posted by Sangeetha S.
yes
Posted by Sangeetha S.
I will explain the patient the findings of the smear that she has got abnormal cells on the neck of her woomb which are precancerous but not cancer. If not further investigated and treated can progress to cancer in 10 years . I will refer her to Colposcopy clinic explaining that it is a special clinic where in which specialist doctor will examine the cervix under high magnification and with acetic acid, lugols iodine which help in further diagnosis and depending on colposcopic examination findings she will be discussed different options of manageme
nt. I will give her leaflet regarding Colposcopy and severe dyskaryosis.
The options available for her after colposcopic examination are,
if colposcopic examination suggests low grade CIN all that she needs is colposcopic examination every timister with further evaluation postnatally. If colposcopic examination suggests
high grade lesion CIN2-3, (more than 80% of severe dyskryosis
can have) she can be given the option of directed punch biopsy
and regular coloscopy every 8 weeks antenatally to monitor disease progression and further evaluation postnatally for definitive treatment.. This option has got the advantage of pregnancy being unaffected with increased risk of disease progression and missing microinvasive and invasive cancer even though missed lesions are extremely uncommon.
Second option is LLETZ, Cone biopsy which has got the advantage of definive treatment but at the same time has got increased risk of blood loss, miscarriage,PPROM, preterm labour and Chorioamnionitis.
If histology is microinvasive or invasive cancer the patient is given the first option of cone biopsy and to continue pregnancy and then caesarean hysterectomy. This option has got the advantage of continuing pregnancy but has the risk of disease progression.
Other option is termination of pregnancy and Hysterectomy. This has got the disadvantage of this lady being not having children.
All these options merits and demerits needs to be discussed in detail with patient.
Follow up after treatment: If histology no CIN the needs cervical smear at 6 and 12 months, if all normal the for routine recall. If low grade CIN the smear at 6, 12 and 24 months if all normal then routine recall. If high grade CIN, then smear at 6 and 12 months and the smear annually, if all normal the for routine recall.
If CGIN the smear every 6 months for 5 years and then annually
for 5 years, if all normal for routine recall. If invasive cancer follow up as if carcinoma in situ.