TEALE FENNING

juliprakash · Joined: 08 May 2008 Posts: 29

25 year old parous lady whose cervical smear showed moderate and then severe dyskaryocytosis but colposcopy is normal.The following are appropriate

1.Knife conisation -T
2.repeat smear in 3 months -F
3.laser vaporisation ?
The NHS colposcopy guide and cervical screening says that persistent high grade smear even if colposcopy is normal needs treatment.Any one can u please give opinion

Shinelkimo · Joined: 25 Apr 2007 Posts: 55

FTF
sorry cannot give you reference.
For my opinion, we should do endocervical curettage to exclude endocervical malignancy. but not in choice

juliprakash · Joined: 08 May 2008 Posts: 29

Hi why cant it be any tretment procedure.NICE says persistent dyskaryocytosis even with normal colposcopy needs treatment.

NHS COLPOSCPY GUIDE
Women referred with moderate or severe dyskaryosis (high grade) on
their test result are at significant risk of CIN 2 or 3, even in the presence
of normal colposcopy. Biopsy should be undertaken in > 95% of
women with high grade abnormalities (see section 6.3). If treatment is not
undertaken, close surveillance with colposcopy and cytology every six
months is advised. If at follow-up a high grade cytological abnormality
persists, excisional treatment is recommended (90%).

salihabduallah · Century Club Joined: 04 Sep 2007 Posts: 120

This mean we have 2 options:
either conservative = follow up / 6 months by smear + colposcopy

or excional treatment >> then also follow up / 6 months if tissue examination is normal.

Is this the case ?

juliprakash · Joined: 08 May 2008 Posts: 29

YES.but about the answers for mcq?

salihabduallah · Century Club Joined: 04 Sep 2007 Posts: 120

Nick Raine-Fenning · Posted: Sat Aug 02, 2008 12:47 pm Post subject:

You need to get the knife out - nothing else will do other than a bowler hat LLETZ.

You need to sample up the canal.

A smear is only done to determine who does and who does not need colposcopy. This woman obviously needs colposcopy.

Once you colposcope someone you then need to decide if it is normal or not and if abnormal whether you need to biopsy or 'see and treat'.

The question is not very well written as you really want to know if the SCJ was seen. It says normal so one would presume it was.

Xerxes I · Posted: Tue Aug 12, 2008 7:01 pm Post subject:

Salihabdullah,

In this scenario we don't have the option of conservative mx as somebody has waited already for the mod dyskaryosis to become severe. I'd go for excisional, definitely not ablative or waiting.

Nick Raine-Fenning · Posted: Wed Aug 13, 2008 7:59 am Post subject:

Yes I agree.

We discussed this question and the background to it i.e. persistently abnormal smears with normal colposcopy, the indications for knife cone etc on the recent ABC and EMCQ Courses and agreed that this was one indication for the knife.

There is very little about persistently abnormal smears actually and the BSCCP Guidelines do not address the scenario given here which I think we would all agree is rare. If we are thinking CIGN or equivalent then one would expect some glandular cells at least! Confused

docsubhi · Joined: 03 Sep 2007 Posts: 59 Location: london

Accoding to the colposcopy guideline (Page 39)

If she presents with moderate dyskaryosis or higher but normal colposcopy , ideally a biopsy should be taken as progression to CIN 2/3 is high. A conservative approach might be followed and she can be managed with 6 monthly colposcopy, wherein if the abnormality persists (or gets worse - as in this case), excisional treatment (ie knife cone or LLETZ) is recommended

Nick Raine-Fenning · Posted: Thu Aug 14, 2008 7:06 pm Post subject:

Biopsy what? Normal Cx? I do not think this makes sense and would not support this if the colposcopy is normal. Random biopsies of normal appearing Cx are likely to reassure.

The question specifically refers to a normal colposcopy with high grade smears. Not common and difficult to address but I do not think random biopsies of normal appearing Cx and ignoring the endocervix can be right.

N

docsubhi · Joined: 03 Sep 2007 Posts: 59 Location: london

I agree with you Nick

But maybe I am interpreting this wrong -

" Women referred with moderate or severe dyskaryosis (high grade) on
their test result are at significant risk of CIN 2 or 3, even in the presence
of normal colposcopy. Biopsy should be undertaken in > 95% of
women with high grade abnormalities (see section 6.3). If treatment is not
undertaken, close surveillance with colposcopy and cytology every six
months is advised. If at follow-up a high grade cytological abnormality
persists, excisional treatment is recommended (90%).[/b]"

Evidence: The overall specificity for distinguishing normal from
abnormal tissue at colposcopy in a meta-analysis was only 48%.156
The specificity of high grade cytology is over 90% in several
studies.157,158 This evidence suggests that high grade cytological
abnormalities have a high likelihood of being associated with CIN
2 or CIN 3. Follow-up studies159,160 also support the relatively high
likelihood of CIN 2 or CIN 3 in this group, and thus the presence
of persistent high grade abnormalities, even in the face of normal
colposcopy, warrants treatment.