CERVICAL

INTRAEPITHELIAL NEOPLASIA and

CERVICAL CARCINOMA

Cytology: Normal

Superficial Cells

Intermediate Cells

Parabasal Cells

Metaplastic Cells

The Bethesda System of Repor2ng Cervical

Cytology

ADEQUACY OF SAMPLE
Sa@sfactory
Unsa@sfactory

The Bethesda System of Repor2ng Cervical

Cytology
SQUAMOUS CELL ABNORMALITIES
Atypical squamous cells ( ASC )
ASC of undetermined signicance ( ASC US )
ASC, cannot exclude high grade lesion ( ASC H )

Low grade squamous intraepithelial lesion ( LSIL )

High grade squamous intraepithelial lesion ( HSIL )
Squamous cell carcinoma

The Bethesda System of

Repor2ng Cervical Cytology
GLANDULAR CELL ABNORMALITIES
Atypical glandular cells, specify site of origin, if
possible
Atypical glandular cells, favor neoplas@c
Adenocarcinoma in situ
Adenocarcinoma
OTHER CANCERS ( e.g. lymphoma, metasta@c,
sarcoma )

q Incidence: 22.5/100,000 unchanged

since the 1970s
q 7,277 es@mated new cases yearly
q 3,807 deaths yearly
}
}
}
}

56% of Filipino women with cervical cancer will die

within 5 years
About 2/3 of cervical cancer is diagnosed in the
advanced stage, where mortality is high
Median survival 76 months
Five year survival 51.7%

Incidence starts rising steeply at age 35

2005 Philippine Cancer Society Cancer Facts and Es8mates

Uterine cervix
Es@mated New cases
QuickTime and a
TIFF (LZW) decompressor
are needed to see this picture.

11,070 cases of invasive

cervical cancer are expected to
be diagnosed in 2008

Es@mated Deaths
3,870 deaths from cervical
cancer are expected in 2008

Natural History of Cervical Ca

HPV
Infection

Low grade
Cervical SIL

High Grade
Cervical SIL
5-10 years

Long interval from viral infection to cancer

development

Invasive
Cervical
Ca
15-20 yrs

( page 747 ) FIGURE 28. 4 Diagram of cervical epithelium showing various

terminologies used to characterize progressive degrees of cervical neoplasia

Koilocyte

Risk Factors

RISK FACTOR
HIV
Moderate Dysplasia on Pap Smear within past 5 years
Intercourse within 1 year of menarche
No prior screening
HPV (depending on subtype)
Six or more lifetime sexual partners
Low socioeconomic class
Race (black vs. white)
Smoking
Current smoker
Previous smoker of 5 pack years
OCP use
Barrier contraception

Relative Risk
Very High
Very High
16
10
2.5 3.0
5
5
2.5
2
3.42
2.81
1.2 1.5
0.6

Majority of cases are associated with

infection of one or more types of HPV
which is sexually transmitted.
Walboomers et al 1999

The most common HPV types in decreasing frequency among cases were
HPVs 16, 18, 45, 52, 58 (95% CI OR = 31392). In squamous cell
carcinoma, common types were HPVs 16, 18, 45, 52 and 58; whereas it
was HPVs 16, 18 and 45 in adenocarcinomas; in contrast to normal
cervices, HPVs 16, X, 18, 45, 6, MM4, 31, 52, 11, 54 and IS39 (27).
The prevalence of antibodies to HPV 16 virus-like particles (VLP) is higher
in squamous cancers (47%) than in controls (25%) and it is higher in cases
where HPV 16 DNA is detectable in cervical cells (62%). However, the
sensitivity and specificity of the serological assay are lower than that of
HPV DNA (29).
Prevalence of HPV in cervical cancer in 22 countries including the
Philippines indicated that HPV DNA was detected in 93% of tumors, with
no significant variation in HPV positivity, with common HPVs 16, 18, 45
and 31. HPV 16 predominated in squamous cell tumors and HPV 18 in
adenocarcinoma and adenosquamous tumors. HPV 16 was the
predominant type in all countries except for Indonesia, where HPV 18
predominated. A clustering of HPV 45 was apparent in western Africa,
while HPVs 39 and 59 were almost entirely confined to Central and South
America (31).

Human Papilloma Virus

Low risk (HPV 6, 11, 40, 41, 42) seen in CIN I or
condyloma acuminata

Intermediate (HPV 31, 33, 35, 51, 52) seen in
HSIL (CIN II/III)

High risk (HPV 16, 18, 45, 56) seen in invasive
CA

Transforma@on Zone

How does HPV causes carcinoma?

Integra@on of DNA of cancer associated HPV
into the host cell genome
HPV viral genomes encodes
6 early openings ( E1,E2,E3,E4, E6, E7 )
2 late openings ( L1, L2 )

How does HPV causes carcinoma?

Low risk HPV -maintained as extrachromosomal DNA
episomes
High Risk HPV - integrated into the host cellular DNA
E7 binds and inac@vates Rb protein
E6 binds p53
Func@onal loss of p53 and Rb protein leads to
resistance to apoptosis, causing uncensored cell
growth

DIAGNOSIS OF PREMALIGNANT
LESIONS OF THE CERVIX

SCREENING and DIAGNOSTIC TESTS

The Cervical Cytology ( Pap test )

HPV DNA tes@ng
Colposcopy and Colpo guided biopsy
Excisional - Coniza@on, LEEP, LEETZ, Laser

Pap smear

Quick Tim e an d a
T IFF (Unco mpr esse d) de com pr esso r
ar e n eed ed to se e this p ictur e.

Conventional vs Liquid Based Cytology

Quick Time an d a
TIFF (Unco mp re ssed) dec ompressor
are n eed ed to se e this picture.

Conven@onal vs Liquid Based Cytology

Require special care to
avoid drying of cells
Fixa@on is carried out
immediately by spriay
or immersion
can be obscured by
blood, mucus, and
inamma@on

Sampling and cell transfer

to a liquid medium
preserves the cells and
minimizes cell overlap,
blood, mucus, and
inamma@on. It creates a
mono-layer, a layer one cell
thick, with no overlapping
cells

Conven@onal vs Liquid Based Cytology

The conven@onal Pap smear The ThinPrep Pap Test makes
Pap smear slides by an
is made by hand; the
automated slide prepara@on unit,
physician "smears" the
the ThinPrep 2000 Processor,
sampling device across a
that produces uniform thin-layer
microscope slide to spread a
slides, a one-cell thick monolayer,
layer of cells. Each
virtually free of obscuring
physician may do it
ar@facts such as blood, mucous,
dierently, leading to some
and inamma@on
slides with thick lumps and
clumps, and some slides
with clear areas of no cells

Conven@onal vs Liquid Based Cytology

Up to 90% of those
False Nega@ves are due
to limita@ons of
sampling or slide
prepara@on
Discarded amer a single
conven@onal smear is
done

Return of visits and

repeat Pap smears is
diminished.
Residual LBC can
undergo tes@ng for HPV,
herpes simplex virus, N.
gonorrhea, C.
trachoma@s

Solu@ons Used in Colposcopy

Normal Saline Solu@on
3 - 5 % Ace@c Acid
Lugols Iodine

Results of Colposcopy
Sa@sfactory colposcopy:
the margins of the lesion(s) and the en@re
squamocolumnar junc@on are visible

Acetowhite
Leukoplakia
Puncta@on
Mosacism
Atypical Blood vessels

Principles of Ace@c Acid Test

3-5% Ace@c Acid
Swelling of epithelial
@ssues
Reversible coagula@on
of nuclear proteins
and cytokera@ns

Colposcopic Features
COLOR tone & INTENSITY of acetowhitening

MARGINS and SURFACE CONTOUR

VASCULAR features

COLOR CHANGES amer iodine applica@on (Schillers test)

Principles of Ace@c Acid Test

Acetowhitening is NOT
UNIQUE to CIN
Condi2ons with AW
Immature sq
metaplasia
Inamma@on
Leukoplakia
Condyloma

Principles of Ace@c Acid Test

Normal Squamous Epith.
Lesser coagula@on
Supercial cells are
sparsely nucleated
Coagula@on insucient
to block color of
underlying stroma

Principles of Ace@c Acid Test

Cervical Intraepithelial Neoplasia
(CIN)
Cells have high nuclear content
Maximal coagula@on
Sub-epithelial vessel
parern is obliterated

Principles of Ace@c Acid Test

LSIL (CIN I)
Small amount of
nuclear protein, lower
1/3 epith.
Appearance of
whiteness is
delayed and less
intense

Principles of Ace@c Acid Test

HSIL (CIN II-III)
Greater amount of
nuclear protein, 1/3 to full
thickness of the
epithelium
Appearance of
whiteness is densely
white, opaque and
immediate

Principles of Schillers Test

Applica@on of Lugols Iodine
Uptake of Iodine by glycogen-
rich epithelium
Color: Mahogany brown or
black
Mature Squamous
Epithelium

Principles of Schillers Test

Glycogen - decient
epithelium
Color: Par@al staining
or thick mustard
yellow
Immature squamous
epithelium, columnar,
leukoplakia, CIN,
cervical cancer

Principles of Observed Vascular Features

Vasculature parerns observed amer applica@on of saline solu@on. Use

green lter.
Mosaic and Puncta@ons, vessels of abnormal caliber

Principles of Observed Vascular Features

Colpo Guided Cervical Biopsy

Excisional

Coniza@on
LEEP
LEETZ
Laser

Cold Knife Conization

Loop Electrosurgical Procedure

CO2 Laser

LEETZ

Guidelines For Pap Smear Screening

2002 American Cancer Society Guideline for the Early Detec2on of Cervical Neoplasia and Cancer, Smith, Harmon J. Eyre and Carmel C Debbie Saslow, Carolyn D. Runowicz,
Diane Solomon, Anna-Barbara Moscicki, Robert A., 2002;52;342-36 CA Cancer J Clin "

When to start screening

Approximately 3 years amer onset of sexual ac@vity
When to discon2nue screening
Age 70 years with an intact cervix plus a history of
3 consecu@ve normal smears & no history of
abnormal cytology within the 10-year period prior to
age 70

Guidelines For Pap Smear Screening

2002 American Cancer Society Guideline for the Early Detec2on of Cervical Neoplasia and Cancer, Smith, Harmon J. Eyre and Carmel C Debbie Saslow, Carolyn D. Runowicz,
Diane Solomon, Anna-Barbara Moscicki, Robert A., 2002;52;342-36 CA Cancer J Clin "

Screening aYer hysterectomy

Not indicated following hysterectomy for benign
disease
1. CIN 2/3 are excep@ons to these benign condi@ons
and warrant screening even amer hysterectomy.
2. For post-hysterectomy (for a benign disease) high-
risk pa@ents, annual Pap smear is s@ll recommended
to screen for vaginal intra-epithelial neoplasia (VAIN)

Guidelines For Pap Smear Screening

2002 American Cancer Society Guideline for the Early Detec2on of Cervical Neoplasia and Cancer, Smith, Harmon J. Eyre and Carmel C Debbie Saslow, Carolyn D. Runowicz,
Diane Solomon, Anna-Barbara Moscicki, Robert A., 2002;52;342-36 CA Cancer J Clin "

Screening interval
Annual with conven@onal cytology OR Every 2 years
with liquid-based cytology,
THEN
At or amer age 30, amer 3 consecu@ve N smears, may
decrease screening interval every 2-3 years
Note: 1. For high-risk pa@ents (> 1 risk factor),
annual Pap smear is recommended

 Result of LSIL is a good indicator of HPV infec@on

Pooled es@mate of high risk (oncogenic) HPV DNA posi@vity
among women with LSIL was 76.6 %
Prevalence of CIN 2 or greater iden@ed at ini@al colposcopy
among women with LSIL is 12-16 %
Risk of CIN 2,3 is the same in women with LSIL and those with
ASC-US who are high-risk (oncogenic) HPV DNA (+)
Colposcopy recommended except in special popula@ons (A
II)
Endocervical sampling for non pregnant in whom no lesions
are iden@ed (B II) and those with an unsa@sfactory
colposcopy (A II) but is acceptable for those with sa@sfactory
colposcopy & a lesion iden@ed in the transforma@on zone (C
II)

 Immediate LEEP is ACCEPTABLE. When CIN 2,3 is not iden@ed

histologically
1. Dx excisional procedure OR
2. observa@on with colposcopy and
3. cytology at 6 months intervals for 1 year is acceptable
PROVIDED: colposcopy is sa@sfactory and endocervical sampling is
nega@ve (B III)
Acceptable to review the cytological, histological and colposcopic
ndings
If the review yields a revised interpreta@on, mgt shld follow
guidelines for the revised interpreta@on
If observa@on with colposcopy & cytology a Dx excisional
procedure is recommended for women with repeat HSIL
cytological results at either 6 or 12 month visit
Amer 1 yr of observa@on, women with 2 consecu@ve NILM results
can return to rou2ne cytological screening

 BECAUSE OF THE SPECTRUM LINKED TO AGC, INITIAL EVALUATION

MUST INCLUDE MULTIPLE TESTING MODALITIES.

INITIAL WORK-UP
Colposcopy with endocervical sampling for women with all subcategories of
AGC & AIS (A II)
Endometrial sampling in conjunc@on with colposcopy and endocervical
sampling in women 35 y/o with clinical indica@ons sugges@ng they may be at
risk for neoplas@c endometrial lesions (unexplained vaginal bleeding or
condi@ons sugges@ng chronic anovula@on)
HPV DNA tes@ng at the @me of colposcopy is preferred in women with ATYP
EC , EM or GLAndular cells NOS.

UNACCEPTABLE:
HPV DNA Tes@ng alone OR Program of repeat cervical cytology for the ini@al
triage of all subcategories of AGC and AIS (EII)

 Colposcopy is recommended
When CIN 2,3 is not iden@ed histologically observa@on for
upto 24 months using both colposcopy and cytology at 6-
month intervals is preferred
PROVIDED: Colposcopy is sa@sfactory and endocervical
sampling is (-)
UNACCEPTABLE:
Immediate LEEP

In excep@onal circumstances Dx excisional procedure is

acceptable (B III)
If during a up a high grade colposcopic lesion is iden@ed or
HSIL cytology persists for 1 year Biopsy is recommended
If CIN 2,3 is iden@ed histologically Mgt shld follow 2006
Consensus
If HSIL persists for 24 months w/o iden@ca@on of CIN 2,3
Dx excisional procedure is recommended (B III)

CASE 1 PAP SMEAR

A 54 year old, grandmultipara, came in at
FEU OB OPD with pap test result of ASC US.
What is /are your treatment option/s
a.repeat cytology after 6 months
b.colposcopy
c.HPV DNA testing
d.ABC
e. AC

CASE 2 PAP SMEAR

A 19 year old, Nulligravied, married for 2 years, came in at FEU
OB OPD with pap test result of LSIL. What is /are your
treatment option/s ?
a. Cytology after 12 months
b.Colposcopy
c. Endocervical Curettage
d.ABC
e. BC

CASE 3 PAP SMEAR

A 49 year old, G2P2, menopause for 2 years, came in at FEU OB
OPD with pap test result of ASC H. What is /are your
treatment option/s ?
a. Cytology after 6 months
b. Colposcopy
c. ECC
d. ABC
e. BC

CERVICAL INTRAEPITHELIAL
NEOPLASIA ( CIN )

Cytology: Koilocytes

Eosinophilic squamous cells with

perinuclear empty cavity
Cytoplasmic thickening
Moderate nuclear enlargement

CIN 1: Histopathology

CIN 2

CIN

( page 747 ) FIGURE 28. 4 Diagram of cervical epithelium showing various

terminologies used to characterize progressive degrees of cervical neoplasia

Koilocyte

Natural History of CIN ( From Ostor , 1993 )

CIN 1
CIN 2
CIN 3

Regression (%)
57
43
32

Persistence (%)
32
35
< 56

Progression to CIS (%)

11
22
-

Progression to Invasion (%)

1
5
> 12

MANAGEMENT
Cervical Intraepithelial Neoplasia
( CIN )

 RECOMMENDED MANAGEMENT OF WOMEN WITH CIN 2,3

Adolescent & Young women
Either Treatment or Observa@on, provided colposcopy is
sa@sfactory
1. Treatment
Excision or Abla@on
2. Observa@on

Both colposcopy & cytology at 6 months intervals for up to 24 months (B III)

When CIN 2 is specied, observa@on is preferred.

When CIN 3 is specied or colposcopy is unsa@sfactory,
treatment is recommended (B III)
FOLLOW UP COLPOSCOPY & CYTOLOGY

TWO consecu@ve nega@ve intraepithelial lesion or malignancy and

Normal Colpo rou@ne cytological SCREENING
Colposcopic appearance worsens or if HSIL cytology or colposcopic
lesion persists for 1 year Repeat biopsy is recommended (B III)
CIN3 is subsequently iden@ed or if CIN 2,3 persists for 24 months (B
II) TREATMENT

 Hysterectomy preferred for women who have

completed child-bearing and have histological
diagnosis of AIS on a specimen from a Dx
excisional procedure (C III)
Conserva2ve mgt acceptable if future
fer@lity is desired (A II)

If conserva@ve mgt, but the margins of

specimen are involved or endocervical
sampling obtained at the @me of excision
contains CIN or AIS reexcision to increase
the likelihood of complete excision is
preferred

CASE 1 CIN
1. A 49 year old, G2P2, menopause for 2 years, came in at FEU
OB OPD with pap test result of ASC H. She underwent colpo
guided biopsy. Histopath revealed CIN 1. What is the most
appropriate management?
a. hysterectomy
b. observe
c. conization
d.HPV DNA testing
e. ECC

CASE 2 CIN
2. A 54 year old, grandmultipara, came in at FEU OB
OPD with pap test result of ASC US. Colpo guided
biopsy revealed CIN 3. What is the subsequent
management?
a.
hysterectomy
b.
LEEP
c.
Conization
d.
ABC
e.
BC

Treatment Methods in
Cervical Intraepithelial Neoplasia
( CIN )

Goal of Treatment in CIN

To remove the lesion
Hysterectomy is not recommended
ABLATION METHODS
Cryotherapy
Thermoabla@on
CO2 laser abla@on

EXCISION METHODS
LEEP or LEETZ
Cold Knife Coniza@on

CO2 Laser Vaporization

Electrofulguration
Cryotherapy

ABLATIVE
PROCEDURE

Cervical Carcinoma

MAJOR CATEGORIES OF CERVICAL CARCINOMA

SQUAMOUS CELL CARCINOMA
Large cell ( kera@nizing or non kera@nizing )
Small cell
Verrucous
ADENOCARCINOMA
Typical ( endocervical )
Endometrioid
Clear cell
Adenoid cys@c ( basaloid cylindroma )
Adenoma malignum ( minimal devia@on adenocarcinoma )
MIXED CARCINOMA
Adenosquamous
Glassy cell

SCCA, Kera@nizing and Non kera@nizing

Micoinvasive carcinoma (MICA)

2009 FIGO Staging

Case: Diagnosis
A 32 year old, G5P4 ( 4014 ) came in at the OB OPD for pap smear. On
speculum examina@on, a funga@ng mass was noted at the anterior lip of
the cervix with scanty clear discharge. Per@nent pelvic examina@on
revealed normal external genitalia, parous vagina, Cervix measured 5 x 4
cm nodular, with no forniceal involvement, corpus was small, no adnexal
mass and tenderness, both parametria were smooth and pliable. What is
the best diagnos@c procedure for her?
a. Pap smear
b. colposcopy
c. biopsy
d. ABC
e. BC

Case: Diagnosis
A 48 year old G7P6 ( 6015), came in for pap smear. Speculum
examina@on revealed a funga@ng mass at 2 oclock to 5
oclock posi@on of the exocervix. IE revealed a nodular cervix
measuring 4x4cm , Corpus was small, (-)AMT, Both
parametrium were smooth and pliable.
Will you perform pap smear? Yes / no
If no, what is the BEST op@on for this lady?

Cervical Mass

Cervical biopsy

Cervical Carcinoma
FIGO STAGING

Guidelines for Clinical Staging

ACCEPTED
Biopsy (direct, colpo-guided, cone)
Recto-Vaginal examina@on
AFTER CONFIRMATION OF BIOPSY:
CBC, Renal Func@on tests, LFTs
Chest X-ray
KUB-IVP
Proctosigmoidoscopy

Cystoscopy
Skeletal survey

FIGO Committee on Gynecologic Malignancy Manual 2006

The following examina@ons are permired:

Intravenous urography
X-ray examina2on of the lungs and skeleton
Suspected bladder or rectal involvement
should be conrmed by biopsy and histologic
evidence.
Coniza@on or amputa@on of the cervix

Guidelines For Clinical Staging

Performed as INDICATED BUT NOT ESSENTIAL to
complete staging procedures
Barium enema
CT scan
Ultrasonography
MRI



PET Scan
Lymphangiography
Angiography
Laparoscopy
FIGO Committee on Gynecologic Malignancy Manual 2006

Guidelines For Clinical Staging

No need for Pap smear

No need for frac@onal curerage
Cervical cancer is clinically staged!
Once invasive cancer is diagnosed, the pa@ent
should be referred to a gynecologic
oncologist.
SGOP Clinical Practice Guidelines 2008

CASE 1
A 24 year old G5P3 ( 3023), came in for post coital bleeding. She consulted
at our OB OPD. Per@nent PE ndings revealed (-) SCLN, Speculum exam
revealed funga@ng necro@c mass, IE revealed that the cervix was
converted to 5 x 6cm mass with extension to the lower third of the vagina,
corpus was small, (-) AMT, Lem parametrium was nodular xed to pelvic
side wall, Right parametrium was smooth and pliable. Biopsy of the mass
revealed SCCA , LCNK, Cervix. What is the stage of the disease?
a. IIA
b. IIB
c. IIIA
d. IIIB

CASE 2
A 44 year old G7P6 ( 6015), came in for an abnormal pap
smear. Speculum examina@on revealed a clean looking cervix.
Colpo guided biopsy was done which revealed CIN3. Cone
biopsy was done which revealed SCCA LCK with stromal
invasion measured 5 mm width, 3mm depth. What is the
stage of the disease?
a. IA1
b. IA2
c. IIA
d. IIB

CASE 3
A 29 year old G6P5 ( 5014 ), came in for post coital bleeding. She consulted
at our OB OPD. Per@nent PE ndings revealed (-) SCLN, Speculum exam
revealed funga@ng necro@c mass, IE revealed that the cervix was
converted to 8 x 6cm mass with extension to the upper third of the vagina,
corpus was small, (-) AMT, Lem parametrium was nodular and free, Right
parametrium was smooth and pliable. Biopsy of the mass revealed SCCA ,
LCK, Cervix. What is the stage of the disease?
a. IIA
b. IIB
c. IIIA
d. IIIB

ROUTE OF SPREAD
Growth Parern
Endophy@c
Exophy@c

Lympha@c spread
Primary nodes
Secondary nodes
Distal nodes

Hematogenous

Frequency of lymph node metastases in cervical

carcinoma
parametrial
77%
common iliac
31%
hypogastric iliac
31%
eXternal iliac
27%
obturator
27%
Aortic
27%

Treatment according to
FIGO Staging

TREATMENT
1. Concurrent Chemoradia@on
2. Surgery

TREATMENT
CONCURRENT CHEMORADIATION
current standard of care and mainstay of
treatment
Overall survival advantage for cispla@n based
therapy
Risk of death was decreased by 30 - 50 %

RADIATION
External Beam RT/ Teletherapy ( Cobalt or
LINAC )
40 - 50Gy in 25 to 30 days
Cispla@n 40mg/m2 given weekly

Complica@ons: Anemia, electrolyte irregulari@es

External Beam RT/ Teletherapy

RADIATION
Internal RT / Brachytherapy
Intrauterine tandem and intravaginal ovoid
Done under general anesthesia
Reference Points
Point A
Point B
Bladder point
Rectal point

RADIATION ( Internal RT)

HDR
Out pa@ent sezng
Eliminate exposure to
hospital personnel
Uses Iridium 192

LDR
Lem in place for 2 - 3
days
Uses Cesium 137

BRACHYTHERAPY

Complica@ons of Radia@on
Acute
GI eects, Cystourethri@s, UTI, Skin erythema

Late
Rectal or vaginal stenosis, small bowel
obstruc@on, malabsorp@on, chronic cys@@s,
radia@on proc@@s, stula forma@on

SURGERY
Cone Biopsy and Radical trachelectomy
(if desirous of pregnancy) for stage IA1

SURGERY
Extended Hysterectomy
Class I Extrafascial Hysterectomy
Class II Modied Radical hysterectomy
Class III ( Radical Hysterectomy - Meigs Wertheim
Hysterectomy )
Class IV
Class V ( pelvic exentera@on )

Radical hysterectomy specimen

Black line - Simple hysterectomy

Red line - RH

Radical hysterectomy specimen

Radical vs. simple hysterectomy specimen

FOLLOW-UP
CERVICAL CANCER
POST-TREATMENT SURVEILLANCE

Follow-up post cura@ve treatment

Every 3 months for 1st 2 years, every 6 months from
years 3-5, then annually
Pap smear every 3 months for 1st 2 years, then pap
smear every 6 months for years 3-5, then annual pap
smear
Chest X-ray annually or as indicated
Annual MRI or CT scan for 1st 3 years
HRT may be given to alleviate menopausal symptoms