Penanganan

Lesi Pra Kanker Serviks

I Nyoman Bayu Mahendra

Konsultan Onkologi-Ginekologi
Divisi Onkologi-Ginekologi Bagian/SMF Obgin FK Unud/RSUP Sanglah
CIN 1 is the histologic manifestation of HPV
infection.

• Although most CIN 1 lesions are associated with

oncogenic HPV, HPV-16 is less common in CIN 1
than in CIN 3, and nononcogenic HPV types are also
commonly found in CIN 1 lesions (82, 83).
• The natural history of CIN 1 is similar to that of HPV-
positive ASC-US and LSIL in the absence of CIN,
suggesting similar management.
• Regression rates are high, especially in younger
women (32, 64), and progression to CIN 2+ is
uncommon (64, 84).
If CIN 1 persists for at least 2 years, either continued
follow-up or treatment is acceptable (CII).

• If treatment is selected, either excision or ablation is

acceptable (AI).
• A diagnostic excisional procedure is recommended if the
colposcopic examination is inadequate;
• In patients with CIN 1 and an inadequate colposcopic
examination, ablative procedures are unacceptable (EI).
• Podophyllin or podophyllinrelated products are
unacceptable for use in the vagina and Cervix
• Hysterectomy as the primary and principal treatment for
histologically diagnosed CIN 1 is unacceptable (EII).
CIN 1 in Special Populations

• Women Aged 21-24 Years (Fig. 15). For women aged

21-24 years with CIN 1 after ASC-US or LSIL
cytology, repeat cytology at 12-month intervals is
recommended.
• For women aged 21-24 years with CIN 1 after ASC-H
or HSIL cytology, observation for up to 24 months
using both colposcopy and cytology at 6-month
intervals is recommended,
• Treatment of CIN 1 in women aged 21-24 years is
not recommended
Pregnant Women.

•For pregnant women with a histologic

diagnosis of CIN 1, follow-up without
treatment is recommended (BII).
•Treatment of pregnant women for CIN 1 is
unacceptable.
Follow up

• After treatment for CIN 2+, recurrence risk remains

well above that of women with negative co-test
results throughout observation periods that have
been reported to date (89).
• After two negative co-tests in the first 2 years after
treatment, risk is similar to that of women with a
negative Pap test
CIN 3 in pregnancy

• Cervical intraepithelial neoplasia 3 does not pose a

risk to the pregnancy and poses no immediate risk
to the mother. Treatment during pregnancy carries
substantial risk for hemorrhage and pregnancy loss.
 Panduan Tata Laksana Lesi Pra Kanker Serviks
Lesi Pra Kanker Serviks
(Cervical Intraepithel Neoplasia)

CIN I CIN II / III

Didahului Ablatif Trakelektomi/

Didahului Usia 21-24 tahun Hamil Eksisional Konisasi
oleh riwayat (krioterapi) Histerektomi
oleh riwayat
tes pap
tes pap
dengan hasil
dengan hasil
abnormal (di
ASC-H atau
luar ASC-H
HSIL
atau HSIL)

Kolposkopi · Follow up
ulang jika Ablatif/ dengan pap Follow
Co-testing
ditemukan Eksisional smear rutin up
1 tahun
hasil prosedur tiap tahun teratur
abnormal · Kolposkopi 1
tahun
kemudian
pada riwayat
hasil pap
smear ASC-
H, HSIL
 Perbandingan Modalitas Terapi Lesi Pra Kanker Serviks

Procedure Rates Technical Equipment Complication Primary

Ease Cost Rates Cure
Cryosurgery +++ +++ ++ 80%

Loop electrosurgical +++ ++ +++ 95%

excision procedures
Laser ablation + + +++ 95%

Laser excision + + ++ 95%

Cold-knife conization ++ +++ + 98%

+, low; ++, medium; +++, high

KRIOTERAPI dan ELEKTROKAUTER
KRIOTERAPI dan ELEKTROKAUTER

Crisp 1967
Destruction of tissue –200 to –300 C
CO2 (-600C)
N2O (-900C)
KRIOTERAPI

• Prosedur Relatif Mudah

• Menghancurkan Sel Prakanker
• Pendinginan dengan Gas Co2, N2o
• Menciptakan Bola Es 4-5 mm Lateral
Cryoprobe
• Waktu 15 Menit
• Tanpa Anestesi
• Rawat Jalan
• Oleh Dokter Umum/Paramedis
KRIOTERAPI

Kerugian : merusak jaringan → PA (-)

Peralatan :
• PISTOL PENDINGIN
• FROBE
• GAS CAIR : CO2 DAN N2O
• JELY PELICIN YANG LARUT AIR
• DESINFEKSI
• SPEKULUM VAGINA
• ASAM ASETAT 3-5 %
KRIOTERAPI

KRITERIA :
 Lokasi lesi di serviks, tanpa perluasan ke
vagina/endoserviks
 Lesi tertutup oleh probe (2 mm dari tepi probe)
 Tidak menderita kanker serviks
 Tidak dalam keadaan hamil
 Tidak menderita PID
 Tidak sedang menstruasi
KRIOTERAPI

TEKNIK :
⇝ LITOTOMI DORSAL
⇝ MASUKKAN SPEKULUM
⇝ GUNAKAN VAGINAL SIDEWALL RETRACTOR ATAU
KONDOM (bila perlu)
⇝ GUNAKAN JELY PELUMAS PADA UJUNG CRYOPROBE
⇝ MASUKKAN CRYOPROBE KE DALAM VAGINA
⇝ TEKAN PEMICUNYA UNTUK MENGAKTIFKAN PISTOL
⇝ BERITAHU PASIEN BAHWA TINDAKAN SUDAH DIMULAI
Penempatan ujung probe cryo pada ektoserviks
KRIOTERAPI

• ⇝ PERTAHANKAN SAMPAI TERBENTUK BOLA ES YANG

• TERLIHAT 4-5 MM DILUAR PROBE. BIASANYA
• MEMERLUKAN WAKTU 3-5 MENIT
• ⇝ DEAKTIVASI PISTOL KRIO DENGAN MENEKAN TANDA
• DEFROST, TUNGGU 5 MENIT KEMUDIAN ULANGI SEKALI
LAGI
• PENDINGINAN SEPERTI PROSEDUR SEBELUMNYA
(double-
• freeze technique = 3 – 5 – 3)
• ⇝ TUNGGU SAMPAI PROBE TERLEPAS DARI SERVIKS,
KEMUDIAN
• DILEPASKAN DAN DIKELUARKAN DARI VAGINA
 2 mm

cervix 5 mm

- 20 0C Recovery zone
0 0C Lethal zone

- 85 0C

Recovery zone
probe

Ice ball thickness 7 mm

< 200C lethal Cannot destroy

0 ~ - 20 0C : recovery zone Lesion > 5mm deep

- 20 ~ - 85 0C : lethal zone
KRIOTERAPI

• PASCA TINDAKAN :
• ⇝ DEKONTAMINASI
• ⇝ JARINGAN GRANULASI 2 - 3 MINGGU →
• REEPITELISASI
• ⇝ PENYEMBUHAN TOTAL 6 - 8 MINGGU
• ⇝ PEMERIKSAAN IVA ULANG 6 – 12 BULAN
KRIOTERAPI

EFEK SAMPING :
⇝ NYERI/KRAM SELAMA 2-3 HARI
⇝ PUSING, TIDAK SADAR
⇝ DISCHARGE YANG PROFUSE SELAMA
LEBIH KURANG 4 MINGGU
⇝ PERDARAHAN BERAT & PID (< 1%)
⇝ STENOSIS SERVIKS ?
 KRIOTERAPI
ADVANTAGE DISADVANTAGE
Effective on CIN 1/2 Les effective on CIN 3

Technical ease PA Specimen (-)

Electric source (-) SQJ changes

Anastesi (-) Vaginal discharge

 KRIOTERAPI
 The temperature
 Freezing time
 Type of probe
 Extend of probe
 Size & grade of cervical lesion
 KRIOTERAPI
• EFEKTIFITAS
• CIN 1: 86 – 96 %; CIN 2 – 3: < 80 % (WHO)
• CIN 1: 86 %; CIN 2 – 3: 77 % (ACCP)
• CIN 1: 96,4 %; CIN 2 – 3: 82,1 % (INDIA)
 One quadrant : 6,8%
  Two quadrant : 14,1%
Cryotherapy. Probe krio menutupi lesi (a,b). Pembentukan bola es (c,d
dan e). Penampakan setelah defrost (f).
(a) Bola es pada serviks segera setelah krioterapi, (b) Penampakan 2
minggu setelah krioterapi. (c) 3 bulan setelah krioterapi. (d) 1 tahun
setelah krioterapi.
ELEKTROKAUTER
Destruction of tissue 4000 F to 15000 F
 93% (Gordon and Duncan, 1628 CIN 3)
 95,4% (Loobuyck and Duncan, 1165 CIN 2)
 98% (ECD, Chanen, 2990, CIN 3)
 Unsatisfactory colposcopy
 Lesion extend to endocervix
 Lesion size (two quadrant or more)
 Competency level of the surgeon
 Pain during procedure
 Bleeding
 Vaginal discharge
 Infection
 Cervical stenosis
LEEP / LLETZ
Electro surgery

A surgery method to destroy tissue by

manipulating electrons of alternating
current through living tissue to create heat
within tissue cell

Electrocautery is a method to
destroy tissue by touching hot
metal produced by direct
electrical current through high
impedance conductor
• LEEP: Loop Electrosurgical Excision Procedure
• LLETZ: Large Loop Excision of the
• Transformation Zone

• An excision method, using a thin electric wire to

remove a part or the entire TZ and therefore
removes the affected tissue which can be
examined further
CIN: HOW TO TREAT??

• The more recent conservative methods of Tx

– Destructive (electrocoagulation, cryotherapy, laser
ablation)
– Excisional (laser conization & electrosurgical
excision {LLETZ/ LEEP}

• Destructive techniques
– Rather easier to perform
– Destroy the transformation zone epithelium
– Specimen is not provided
• Marginal status can not be evaluated
• Precise grade of the treated lesion – not
guarantied
LEEP—Adverse Effects

• Possible side effects of LEEP are similar to

cryotherapy, but chance of severe bleeding
is slightly higher.

• Less than 2% of women have moderate to

severe post procedure bleeding.

• Women may have a brown or black

discharge for up to two weeks after LEEP.

• Infection
LEEP/LEETZ equipment

ESU
Hand piece electrode
Ground pad
Speculum; bivalve & lateral vaginal
Smoke evacuator
Tissue forceps, Gauze
NaCl 0,9%, Aceto-acetate 3-5%, Lugol sol
Colposcope
LEEP Technique

• Lithotomic position
• Insert vaginal speculum
• Local anesthesia
• Turn on smoke evacuator
• Place electrode close to cervix
• Press switch pad while swinging electrode
• Collect tissue specimen
• Hemostasis
Movement of the electrode

• Just after switch pad has been turned on

• Lateral - lateral or posterior - anterior direction

Slightly deeper at the middle to get doom shape specimen

LEEP Technique
LEEP Technique
Surgical Steps
1. Anesthesia and Patient Positioning
2. Single-Pass Excision
• The correct loop diameter should incorporate
the entire lesion diameter to a depth of 5 to 8
mm
•Multiple-Pass Excision
• Less commonly, bulky lesions may require multiple
passes using a combination of loop electrode sizes
•4. Control of Bleeding Sites
- 3-5 mm ball elecrode and the electrosurgical unit
switched to coagulation mode
- Monsel
Bleeding

• Usually occurred at lateral, posterior cervix

• Can be managed by:

electro-coagulation
Monsel solution
vaginal tampon
suture
Post procedure advice

• Abstinence for about 1 mo

• Avoid heavy work fo 3 days
• Be alert for bleeding, foul smell discharge
COLD KNIFE CONIZATION

•Cervical conization is the surgical

removal of a
cone-shaped portion of cervix
Indication

• 1. Diagnostic
• 2. Treatment
Anatomy
Diagnostic Indication

• Unsatisfactory colposcopy
• Uncertainty regarding presence of
microinvasaion or invasion following direct
biopsy for CIN
• Inconsistent Pap smear and colposcopy
• Cytology shows atypical glandular cells
• Colposcopy suggest glandular dysplasia or
adenocarcinoma
• Lesion extend to endocervical canal and extent
not possible to confirm
Unsatisfactory Colposcopy

• Satisfactory Colposcopy :
Entire squamocolumnar junction and the margin
of any visible lesion can be visualized with
thecolposcope.
Therapeutic Indication

• HSIL ( CIN II / CIN III )

• Microinvasion (Cervical Cancer Stage IA1)
• Desiring fertility
• Negative LVSI (Lymphvascular space invasion)
• Close follow up after treatment
• Extent exceeds capability of LEEP ( 1.5 cm )
Types of Conization

1. Cold knife Conization

2. Electro surgical loop
LLETZ (Large Loop Excition of
Transformation Zone ) ~ Loop Diathermy
Cone Biopsy
3. Laser Cone Biopsy
 Preperation

• Cold-knife conization must be performed in a fully equipped operating

room under general, epidural, or spinal anesthesia

• Local anesthesia may be adequate in relaxed highly cooperative

patients, but unexpected movements and vaginal tightness may
interfere with an optimal conclusion

• Epinephrine typically is used in combination with lidocaine in a

1:100,000 dilution (Xylocaine 1% with epinephrine)

• Some evidence indicates that conization performed during the first,

rather than the second, half of the menstrual cycle is less likely to be
associated with significant blood loss
Procedures of Conization

8. The endocervical canal is sounded to determine the course and

depth of the endocervical canal.
9. No. 11 or 15 scalpel blade is used to make a continuous
incision
10. The scalpel blade should be directed towards the canal; the
angle will be variable depending on the depth of tissue desired
11. The specimen should be obtained in a single piece with as little
tissue trauma as possible. A suture is placed at 12 o’clock for
pathologic orientation
12. The endocervical canal should be checked for patency with a
uterine sound or small dilator.
Complications

• Intraoperative and postoperative bleeding are the most

common complications of cervical conization
• Delayed bleeding may occurs , usually 7-14 days
postoperatively in approximately 2% of the patients
who undergo cold-knife conization.
• A recent also reported increased risk of preterm

membranes
• Cervical stenosis may occur in a few women
• Women who become pregnant after conization
should be closely monitored for this potential
 Specimen Evaluation

• Marker for 12 o’clock position

• Residual CIN III, ectocervical or
endocervical margins positive for CIN,
and/or positive endocervical curettings on
cold-knife conization have higher incidence
of recurrency
• Persistence of HPV after conization may
Management After Conization

• External cone margin +  ablative procedure to

eradicate the residual CIN
• Internal cone margin +  Endocervical curretage
positive  deeper conisation
negative  conservative
Follow Up

• Conization sites usually heal in 6 weeks

• Reexamination of patients 2 weeks postoperatively is
useful to help determine whether restrictions occur
• A final postoperative examination is recommended at 6
weeks
• Papanicolaou tests (Pap smears) should be performed
every 3 months during the first postoperative year and
every 6 months thereafter
• Recurrence or persistence is significantly more common;
16.5% versus 1.9% according to Felix et al, in patients
who had a positive margin for CIN in the postoperative
specimen
 SIMPULAN

Pentingnya pemahaman perjalanan alamiah

infeksi HPV

Dibutuhkan aplikasi dan interpretasi deteksi

dini lesi pra kanker serviks yang tepat guna
menegakkan diagnosis yang tepat pula

Menggunakan modalitas tata laksana lesi pra

kanker serviks sesuai algoritme dan
memperhatikan aspek seperti umur, paritas,
temuan pada pemeriksaan terdahulu
Thank you