European consensus statement on expert colposcopy

BACKGROUND

Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease.

AIMS

To provide expert guidance on complex colposcopy cases through published evidence and expert consensus.

MATERIAL & METHODS

Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics.

RESULTS & DISCUSSION

The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

European consensus statement on essential colposcopy

This European consensus statement on essential colposcopy provides standards for the general colposcopist seeing women referred for colposcopy with an abnormal cervical screening test (including cytology and HPV tests) or with a clinically suspicious cervix. The article gives guidance regarding the aims and conduct of colposcopy. Recommendations are provided on colposcopy technique, the management of common colposcopy issues, treatment and follow-up of after treatment of CIN or early stage cervical. Colposcopists should make an informed decision on the management of each individual that is referred and organize appropriate follow-up. Cervical cancer is still a major health issue and the quality of care can only improve if there is a structured guidance for women with an abnormal smear or suspicious cervix.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Fertility after the treatment of gynecologic tumors

In a young woman with gynecologic cancer, preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian cancer of certain histological subtypes such as ovarian tumors of low malignant potential, malignant ovarian germ cell tumors, and ovarian sex cord stromal tumors. For women with invasive epithelial ovarian cancer who have early-stage disease, fertility-sparing surgery may be an option. In some cases, fertility-sparing surgery may be followed by postoperative chemotherapy. The concept of fertility-preserving surgery in early cervical cancer has been adopted by several leading centers worldwide as an option for stage Ia and small Ib disease without the presence of lymphovascular involvement. Nonsurgical options such as hormonal therapy may be considered for women with early-stage, low-grade endometrial cancer. Improvements in cancer cure rates and the development of conservative treatments mean that many young women with early gynecologic cancer can hope to start a new pregnancy after the treatment. Patients are generally advised to wait 2 years after treatment for any malignancy before attempting pregnancy, but the optimal interval between cure and conception must be carefully determined by a multidisciplinary team including oncologist and obstetrician. Gynecologic surgery and hemotherapy can have an impact not only on fertility, but also on the course of a next pregnancy (increased risk of miscarriage and premature delivery, etc.) These risks must be taken into account by the obstetrician. Management of young women diagnosed with gynecologic cancer should be individualized, with the risk of conservative therapy balanced against the disadvantages of more radical treatment. The patient and the family should be extensively counseled. The alternatives to the traditional and standard radical procedures should be discussed, and the limitation of data regarding many conservative treatment options should be explained. The patients should be aware that by accepting fertility-sparing treatment they are assuming a small but undefined risk for recurrence of the disease. They need to know that these conservative therapeutic approaches are yet not considered "standard." Furthermore, patients need to be assessed for the realistic probabilities of achieving conception on the basis on their age, history, and infertility evaluation. Some of them will require assisted reproduction technology (ARTS) to help achieve a pregnancy, especially in vitro fertilization (IVF). They may also consider ovarian tissue, oocyte, or embryo cryopreservation before definitive cancer therapies. And, finally, patients also need to understand the risk of premature delivery and the consequences of prematurity. The care of the young patient with gynecologic malignancy is extremely complex and challenging. It necessarily requires a multidisciplinary approach with the close collaboration of gynecologist-oncologist, reproductive endocrinologist, and perinatologist.

Treatment of cervical intraepithelial neoplasia reverses CD4/CD8 lymphocyte abnormalities in peripheral venous blood

Immunosuppressed patients have an increased prevalence of cervical intraepithelial neoplasia (CIN) and apparently normal subjects with CIN have evidence of immunosuppression. The immunosuppression may antedate the cervical lesion or be a result of the CIN. One index of an impaired immune response is a reduced ratio of CD4/CD8 peripheral blood lymphocytes. This study sought to confirm that patients with CIN had a reduced CD4/CD8 ratio and to determine whether local treatment of the cervical lesion affected the abnormality. Patients with CIN had a lower mean CD4/CD8 ratio than controls (1.19 vs. 1.83, P < 0.01) and more of the patients with CIN had a ratio less than 1.0 [14/38 (37%) vs. 1/30 (3%), P < 0.01]. After laser treatment of CIN, the mean CD4/CD8 ratio was higher than before treatment (1.76 vs. 1.19, P < 0.01). Paired pre- and post-treatment values in 11 patients confirmed this improvement (mean CD4/CD8: 1.14 vs. 2.08, P < 0.01). These findings confirm an association between CIN and a reduced CD4/CD8 ratio. The effect on lymphocytes of treating CIN suggests that the altered ratio is a result of the disease rather than a pre-existing etiologic factor.