1) A 30-year-old lady is referred for colposcopic examination as her Pap smear report has been in
favor of high grade squamous intraepithelial lesion (HSIL).
a) What are the other indications for colposcopic referral? (10 marks)
b) Describe the colposcopic features of high-grade lesion (10 marks)
c) How would you counsel her for a LLETZ biopsy? (40 marks)
d) Discuss the management of this patient, if her LLETZ biopsy reveals squamous cell carcinoma
with stromal invasion depth ≤3mm and clear surgical margins. (40 marks)
a)
I. atypical squamous cells of undetermined significance
II. 2 times Low grade squamous intraepithelial lesion
III. atypical squamous cells of undetermined significance L 6 months apart
IV. Glandular cell atypia
V. Low grade squamous intraepithelial lesion with positive HPV DNA
VI. atypical squamous cells of undetermined significance L with positive HPV DNA
VII. Repeatedly Unsatisfactory/Inflammatory smear
b)
I. Dense acetowhite area
II. Coarse Mosaic
III. Coarse punctuation
IV. Ridge Sign
V. Cuffed crypt opening
VI. Inner boarder sign
VII. Non staining by Lugols iodine
c)
- It is a simple and safe way of removing a small part of the cervix that contains the
abnormal cells. - This procedure takes 15-30 minutes and is usually done under local anesthetic as a day
procedure. - An electrical wire is used to take a small ‘scoop’ from the cervix in order to remove the
tissue containing the abnormal cells. - There is a small chance of complications with the procedure.
I. Primary haemorrhage
II. secondary Haemorrhage
III. Infection
IV. Cervical stenosis
V. Increase risk of preterm delivery (less than cone biopsy) - To minimize risk of infection after the LLETZ procedure, it is recommended to avoid
swimming, baths, spas, intercourse and tampons for at least 3 – 4 weeks until the cervix
is healed. - Patient may have bloody vaginal discharge after the procedure, but this should settle
within 1-2 weeks. - The recovery period after a LLETZ procedure is very minimal with most women able to
return to work the following day. - Follow up after the LLETZ procedure is very important to ensure that all abnormal cells
have been removed and there are no further cell changes. Usually this requires a further
Cervical Screening Test 6 months after the LLETZ.
d)
I. Refer to cancer centre
II. Case will be discussed at Multi- disciplinary meeting
III. As it is stage 1A1 – look for lympho-vascular space invasion( LVSI) +
IV. Ask for fertility wishes
V. If Fertility wishes and no LVSI – re-excision by cone biopsy and no need of further
surgery (Chance of pelvic node positivity is less than 1 %)
VI. If LVSI +ve she needs laparoscopic B/L pelvic node dissection
VII. No fertility wishes – simple hysterectomy and B/L salpingectomy +/- B/L PND
dependent on LVSI state
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