OVER KANSERLERİ TEDAVİSİNDE LENFADENEKTOMİNİN YERİ ÇUKUROVA ÜNİVERSİTESİ TIP FAKÜLTESİ ADANA
1953 - 1984 YILLARI ARASINDA SERVİKS CONVENTIONAL SMEAR(CS) False negative errors%6-55? KANSERİ İNSİDANSI Epidermoid ca Adeno ca
CONVENTIONAL SMEAR(CS) False negative errors • Sampling errors (62%) • 18% of total harvested cells • Excess blood • Inflamation, mucus • Epithelial cells, debris • Air-drying artifact • Experience %20!!!!
The new technologies for cervical screening • Liquid based cervical cytologic smears(TP) • HPV DNA testing Self collection • AutoPap primary screening • Cervicography
TERMINOLOGY Atypical squamous cells ASC-US ASC-H Low-grade squamous intraepithelial lesion (LSIL) High grade squamous intraepithelial lesion (HSIL) AGC-NOS AGC-favor neoplasia Adenocarcinoma in situ (AIS) Unsatisfactory Satisfactory but limited
Can TP reduce the unsatisfactory rate? • The TP method reduced the "satisfactory but limited by" rate by 97% and the unsatisfactory rate by 63%.), No Conventional smears (CS)5,423 (36.1%) Thin Prep slides (TP)9,583 (63.9%) Guidos BJ, Selvaggi SM. Diagn Cytopathol 1999
Can the TP method reduce the unsatisfactory rate? • The TP method reduces " the unsatisfactory rate . unsatisfactory rate Conventional smears (CS) 58 (11.6%) Thin Prep slides (TP) 4 (0.8%) Bergeron C,ActaCytologica, 2001
LGSIL TP CS Ataoğlu Ö, Arşiv, 2003
The false negative rate in cervical cytology. Comparison of TP to CS. FNR(%) 9.416.74 5.7 CS TP EC+ EC- EC+ EC- • The TP method reduces " the false negative rate . Sprenger E, Acta Cytol
DETECTION RATE OF SIL AND CANCER • 8000 women TP CS HSIL 92.9% 77.8% Ca 100% 90.9% ThinPrep cytology demonstrated significantly increased sensitivity for detecting HSIL and carcinoma Hutchinson ML Cancer 1999-
Does TP have superior sensitivity for SILs? TP CS % % ASCUS 9.5 6.3 LSIL 7.8 5.3 HSIL 3.3 3.3 J Reprod Med 2002 Jan;47(1):9-13Biscotti CV
Does TP have superior sensitivity for SILs? • SIL 85.0 58.5 • Sensitivity 86.7 63.6 • Spesificity 99.1 99.7 TP(%) CS(%) TP produce excellent cellular presentations with standardized quality, superior sensitivity and improved adequacy as compared to the conventional method. Bishop JW Acta Cytologica, 1997 2032 women, multicenter, blind .
HGSIL TP CS Ataoğlu Ö, Arşiv, 2003
MISSING ENDOCERVİCAL CELLs TP CS NO Bergeron,2001 500 34( 6.8%) 31( 6.2%) Sprenger,1996* 2.863 709(24.8%) 937(43.5%) Bishop,1998 9.212 1.345(14.6%) 1.168(12.7%)
MISSING ENDOCERVİCAL CELLs TP CS No 112.058 83.464 AGUS-Adenoca 86 (0.17%) 77(0.09%) Sensitivity Overall 72.0 % 41.5 % Endometrium 65.2 % 38.6 % Cervix 87.1 % 55.5 % TP is a more sensitive method of detecting cervical and endometrial adenocarcinomas than the conventional Pap smear. Schorge,Cancer2002
SYSTEMATIC REVİEWDifferent TPs TP beta 15.145 2.272 2.085 9.0 TP 2000 68.402 3.054 2.583 18.2 Overall 83.547 5.326 4.668 14.1 Toplam LSIL LSIL Increased TP CS (%)
A metaanalysis of prospective studies comparing cytologic diagnosis and sample adequacy. The TP improved sample adequacy and led to improved diagnosis of LSIL and HSIL. However, there is no difference in the rate of ASCUS diagnosis between TP and CS groups. CONCLUSION Bernstein SJAm J Obstet Gynecol 2001
Cross sectional study of CS,TP, and HPV DNA testing for cervical cancer screening(2585 cases) • CS is superior in terms of low and high grade lesions and in populations with a low or a high incidence of abnormalities • TP is less reliable and should not replace CS. CONCLUSION Coste J
Significance of high-risk HPV detection in primary cervical cancer screening. HPV DNA % Normal 8/1144 0.7 ASCUS 9/86 10.5 LSIL 7/28 25.0 HSIL 26/33 78.8 SCC 3/3 100 Oh YL, Cytopathology 2001
DIAGNOSTIC METHODS FOR HPVDNA • İn Situ hibridzasyon * • PCR ** • Hybrid capture I *** • Hybrid capture II **** Sensitivity
HPVDNA Sensitivity in HGSIL • CS %51-77.7 • TP %93-94 • TP+HPVDNA %96.9-99.7 • Austin RM, Cancer Cytopathology, 2003 Manos MM, JAMA, 1999
HPVDNA TEST and SIL 1-Does HPV (human papillomavirus)-DNA testing using the presently available technology offer any advantage over the utilization of the CS as a screening tool for women at risk for cervical pre-cancers? 2- Is the HPV-DNA test is a valuable intermediate triage method for patients with CSs demonstrating ASCUS or LSIL in order to better select those patients who would maximally benefit from colposcopy, thus, using clinical resources in an efficient way
Evaluation of human papillomavirus testing in primary screening for cervical abnormalities • 4075 healthy women Sensitivity(%) Specifity TP 61 82.4 HPVDNA PCR 88.2 78.8 Hibrid 90.8 72.6 Testing for HPV has higher sensitivity but lower specificity than TP screening Kulasingam SL JAMA 2002
Comparison of HPV DNA testing and repeat Pap test in women with LSIL • A total of 159 women . Sensitivity Loss to follow-up HPVDNA 87.5% 17.1% Repeat CS 11.1% 32.7% The incremental cost of HPV testing was calculated to be $3003 per additional case of CIN identified.
At present available evidence indicates that the best reason for performing HPV-DNA testing is the triage of selected patients with ASCUS and in specific settings with LSIL.
Combined Pap smear(CS), cervicography(CER) and HPV DNA testing in the detection of cervical intraepithelial neoplasia PPV Sensitivity Specifity CS 45 82 57 HPVDNA 48 64 70 CER 51 74 69 CS+HPV 43 94 46 CS+CER 43 95 44 CS+CER+HPV 40 99 37 Costa S Acta Cytol 2000
HPVDNA TESTING • The incidence in Turkish women • The role in the pathogenesis of cervical carcinoma in Turkish Woman
PAP-NET Screening • 20.000 slides, negative on two manual screenings. • 195 abnormal smears Identified abn. 212 (1%) PAP-NET Screening 75% abnormal 14 HSIL 33 LSIL Identified abn. 44%
TÜRKİYE’mizde ne yapalım...... ÇUKUROVA ÜNİVERSİTESİ TIP FAKÜLTESİ • Önce klasik smear taramasını bir başlatalım...... Kadın Hastalıkları ve Doğum ABD
? CONCLUSION: HPV testing does not appear to add significantly to cytology in terms of positive predictive value or detection rate, if extended cytologic indications for colposcopy are used. Paraskevaidis E Gynecol Oncol 2001
