Treatment of choice of stage III CIN in 40 year old female is :
Correct Answer: Hysterectomy
Description: Ans. is a i.e. Hysterectomy Before discussing the answer to this questions lets first have a look at the treatment modalities available in case of CIN Modalities for management of CIN Ablative procedures Cryotherapy * Loop electro surgical * Hysterectomy Laser Vaporisation Therapy excision (LEEP) * Conisation Ablative Procedures : They are performed in out patient setting (OPD procedures). They must only be performed when the following conditions exist : There is no evidence of micro invasion or invasive cancer (on cytology, colposcopy or ECC). The lesion is located on the ectocervix (as determined by colposcopy and ECC). There is no involvement of the endocervix (as determined by colposcopy and ECC). Cytology and histology correspond with each other Modalities available in Ablative procedure : Cryotherapy It destroys the surface epithelium of the cervix by crystallizing the intra cellular water, resulting in eventual destruction of the cell. Major advantage is its ability to control exactly the depth and width of destruction by It is useful when : It is paicularly useful in : - Small lesions - Larger lesions that cryoprobe cannot cover - CIN Grade I & II - Irregular cervix with a Fish Mouth appearance. - When lesion is located in ectocervix - Extension of the disease to vagina or satellite lesions on Vagina Lesions with extensive glandular involvement Depth of destruction = 4-5 mm * Depth of destruction = 7mm Complications : - Discharge (M/C) * Complications : - Slight discharge Bleeding (Rare) - Pain - Cervical Stenosis (Rare) - Bleeding - Infection (Rare) drawback of Ablative procedures : it destroys the tissue and so no tissue specimen is available for additional histological evaluation.deg Excici'InI Procedures :They can be used LEEP (Loop electrosurgical excision Cold Knife Conization procedure) or LLETZ= (Large loop excision of transformation zone) It is both diagnostic as well as therapeutic. It is an OPD procedure & requires LA. Now it has become the procedure of choice for treating CIN II & CIN III. Complications are less & include : - Slight bleeding - Infection It is both diagnosis and therapeutic (Indications-given earlier) It is performed in 0.T and requires GA It refers to the excision of a cone shaped pa of cervix using a scalpel. Complications are more : - Paindeg - Bleedingdeg - Infectiondeg when Endocervix is involved as well Disadvantages of Excisional procedures : All Excisional procedures produce - Pregnancy complication. Cervical stenosisdeg Incompetent osdeg Aboiondeg Premature labourdeg Dystociadeg Advantage of excision procedures over ablative methods is tissue is available after excision method for fuher histological studies and Transformation zone is visible. Remember : In both ablative and excision methods patient should be followed with Pap smears every 3-4 months and by endocervical curettage (ECC), if endocervix is involved. As far as hysterectomy is concerned : "Hysterectomy is unacceptable as primary therapy for C1N1,2 or 3. However it may be considered when treating recurrent high grade cervical disease if childbearing has been completed or when a repeat cervical exicison is strongly indicated but technically not feasible." But most of the other books say that : Large Loop excision of transformation zone has become the procedure of choice for management of CIN in many developed countries. But in developing countries where women are likely to default from follow up, hysterectomy is still the best option. According to Shaw 14/e, p 365 ? Hysterectomy is desirable in : * Older and parous women When a woman cannot comply with follow-up If uterus is associated with fibroids, DUB or prolapse. If micro invasion exists. If recurrence occurs following conservative therapy. According to Jeffocate 7/e, p 421 ? "If smear remains or becomes positive after conservative surgery, total hysterectomy is indicated, but the ovaries need not be removed if the woman is premenopausal. There is also a place for totarhysterectomy as an elective procedure when micro-invasion is found on biopsy, or when the patient is more than 40 years of age." Indications of Hysterectomy in CIN according to are : Microinvasion. CIN III at limits of conization specimen in selected patients. Poor compliance with follow up. Other gynaecologic problems requiring hysterectomy such as fibroids, prolapse, endometriosis and PID.
Category:
Gynaecology & Obstetrics
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