Colposcopy and treatment of CIN/CGIN — structured SAQ (15 marks)

(a) Structured colposcopic assessment and recorded information (3 marks)

Up to one mark per point, maximum three. [4]

• Magnified assessment of the transformation zone after acetic acid; state that most cervical cancers develop in the transformation zone, so seeing the squamocolumnar junction (SCJ) is the first question.[4]
• Record the transformation zone type using the IFCPC 2011 terminology — here the SCJ is fully visible (type 1 or 2), making colposcopy satisfactory.[4]
• Record the lesion — site, size, and the worst colposcopic feature (here dense acetowhite with abnormal vessels) — and obtain a directed biopsy before any destructive treatment, because histology is the standard.[3]

(b) Management decision and the ablation-vs-excision principle (4 marks)

One mark for the decision with rationale; up to three for the eligibility principle and its components. [3]

• Decision: with biopsy-confirmed high-grade CIN and a fully visible lesion and SCJ, excision (LLETZ) is appropriate here; ablation would also be eligible but she consents to LLETZ which gives histology.[3]
• The eligibility principle for ablation: ablation is acceptable only when the entire lesion is visible on the ectocervix, the SCJ is fully seen (transformation zone type 1 or 2), there is no suspicion of invasion, there is no glandular disease, and cytology and colposcopy are concordant with a biopsy that excludes invasion.[3][4]
• Contraindication to ablation: a type 3 zone (SCJ not fully seen) means lesions in the endocervical canal may be missed and ablation risks undertreatment — excise instead.[4]
• Never ablate glandular disease (CGIN/AIS) — excision is essential.[5]

(c) Obstetric outcomes of excision to disclose at consent (4 marks)

One mark per correctly named outcome with its relative risk, maximum four. [1]

• Preterm delivery (under 37 weeks) — cold-knife conisation RR 2.59; LLETZ RR 1.70.[1]
• Low birthweight (under 2500 g) — conisation 2.53; LLETZ 1.82.[1]
• Premature rupture of the membranes — LLETZ RR 2.69.[1]
• Caesarean section — cold-knife conisation RR 3.17; and the Athanasiou network meta-analysis confirms that more radical excisional techniques carry more preterm-birth risk, whereas ablative treatments probably do not increase preterm-birth risk.[2]

(d) Management of possible glandular neoplasia with normal colposcopy (4 marks)

One mark per point, maximum four. [5]

• Excisional biopsy is essential — among women referred with possible glandular neoplasia of endocervical type on cytology, 85.4% had significant pathology (AIS, invasive cancer, or high-grade CIN).[5]
• Colposcopic impression varies significantly for glandular disease, and AIS is a histological diagnosis — complete excision of the abnormal lesion should be achieved; ablation is never appropriate.[5]
• Endocervical sampling is required when the SCJ is not seen or cytology is abnormal despite a normal-looking colposcopy; even with normal colposcopy, CIN 2/3 or AIS may be found in about 16% on endocervical curettage.[7]
• Residual disease risk after AIS excision is high even with clear margins (about 32% in one series), so close surveillance follows fertility-sparing cone, and hysterectomy is recommended once fertility is no longer desired.[6]