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Cin managment


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CIN - managment

CIN - managment

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  • 1. Management of CIN A. Alobaid, MBBS, FRCS(C), FACOG Consultant, Gynecologic Oncology Assistant professor, KSU Medical Director, Women s Specialized Hospital King Fahad Medical City
  • 2. —  Who to treat? —  When to treat? —  Treatment options —  Treatment principles —  Complications
  • 3. CIN I —  CIN I preceded by LGSIL —  CIN I preceded by HGSIL
  • 4. CIN I preceded by LGSIL —  Spontaneous regression is observed in most women (80%) —  Expectant follow up is warranted —  Treatment acceptable if: 1.  CIN I persists for more than 24 months 2.  Relieve patient s anxiety 3.  Patient at very high risk to follow-up
  • 5. CIN I preceded by HGSIL —  There is 70% chance of having underlying CIN II, III or worse —  Excisional diagnostic procedure Is generally recommended —  An alternative approach is expectant management with intensive monitoring
  • 6. Adolescent women with CIN I —  Undetected high grade disease is uncommon, invasive cancer is rare, regression to normal is common —  Expectant management is preferred
  • 7. Pregnant women —  high rate of postpartum regression of CIN I to normal —  Follow up is deferred until 6 weeks postpartum
  • 8. CIN 2,3 —  Prompt treatment is recommended with some exceptions of pregnant women and adolescents
  • 9. Treatment options —  Cryosurgery —  CO2 Laser Vaporization —  Electrocoagulation —  Sharp Conization —  Laser Excisional Conization —  Electrical Loop Excision —  Hysterectomy
  • 10. Candidates for ablative therapy —  Satisfactory colposcopy —  Negative ECC —  Cytology and histology that correspond to each other —  Should be avoided in pregnant women and those with previous treatment
  • 11. Ablative techniques —  The principal disadvantage of these techniques is that they do not provide a specimen for pathologic evaluation —  The endocervical canal cannot be studied effectively —  Ill-defined and ill-controlled tissue destruction —  Simpler, faster, and more hemostatic than excisional techniques —  Greater late complications like reduced cervical volume and cervical stenosis
  • 12. Cryotherapy —  Office procedure using local anesthesia and NSAID s —  Using refrigerant gas (CO2 or N2O) —  The ectocervix must be cooled to -20 C to cause crystallization of intracellular water and destroy the lesion —  It is achieved by forming an ice ball in the cervical tissue that is at least 5 mm from the tip of the probe
  • 13. Cryosurgery —  A thin layer of water-soluble lubricant is applied over the tip of the probe to allow more uniform and rapid freeze of the cervix —  The probe should cover the entire lesion, and a 4-5 mm ice ball around the probe is required for an adequate freeze —  Repeat freeze thaw cycles will produce greater tissue volume destruction than single freeze cycles for the same amount of time provided
  • 14. Cryosurgery —  There is usually a watery discharge for 10-14 days —  The patient is re-evaluated after 4 months of the treatment —  If the pap smear remains positive 6 months after therapy, then cryosurgery is considered a failure and the patient should be reevaluated and retreated
  • 15. Criocirugia-YouTube.flv
  • 16. CO2 laser —  Laser is directed at the lesion under colposcopic guidance —  Water in the tissue absorbs the laser energy which destroys the tissue by vaporization —  The lesion is ablated to a depth of 5 mm on the ectocervix and 8-9 mm around the endocervix
  • 17. Excisional therapy —  Cold knife conization —  Laser conization —  LEEP (LLETZ)
  • 18. Treatment specifications —  Perform colposcopy during treatment phase to obtain accurate view of the entire TFZ —  3 mm margin is obtained around the abnormal TFZ to allow for glandular involvement —  Obtain 1 cm endocervical margin for LGSIL —  Obtain 1.5 cm endocervical margin for HGSIL
  • 19. Indications for excisional therapy —  Unsatisfactory colposcopy —  Lesions extending into the endocervical canal —  +ve ECC —  Discrepancy between the cytology and biopsy results —  Suspected microinvasion —  Suspected AIS —  Invasive disease suspected —  Recurrence after previous treatment
  • 20. Sharp Conization —  One of the oldest techniques —  Recommended for women with suspected microinvasion and AIS —  The margins of the cone are plotted colposcopically using acetic acid or Lugol s solution —  The configuration of the specimen is based on the extent of disease —  Complications include: bleeding (immediate or delayed), cervical stenosis, cervical incompetence
  • 21. Laser Excisional Conization —  More precise than the cold knife cone —  Less blood loss but more thermal artifact —  Requires advanced training and skill
  • 22. Colposcop?aCono-l?ser-YouTube.flv
  • 23. Electrical Loop Excision —  Appears to be the current treatment of choice —  Done on an outpatient basis —  Advantages include: simplicity, low expense, short learning curve —  Does not increase the risk of preterm deliveries —  Complications may include bleeding and large excisions
  • 24. Electrical Loop Excision —  Should be performed under colposcopic guidance to the peripheral extent of the abnormal TFZ —  The patient is grounded —  Local anesthetic is injected just beneath and lateral to the lesion —  The cutting current is set at 35-60W —  The diameter of the loop must be large enough to encompass the entire lesion —  A second excision of the endocervical canal using a smaller loop may be used for high grade lesions —  Ball coagulation is set at 60W —  The base is coagulated even if there is no bleeding (non-touch coagulation)
  • 25. Colposcop?a-ConodeCÈrvix-YouTube.flv
  • 26. Conizacion cervical v final - YouTube.flv
  • 27. Complications —  Intraoperative bleeding —  Postoperative bleeding: early or delayed —  Infection —  Cervical stenosis
  • 28. Hysterectomy —  If there is coexistent gynecologic conditions requiring hysterectomy —  Patient request and persistent or recurrent CIN 2,3
  • 29. Reproductive outcome —  Cold knife conization is the only treatment modality that increases the risk of perinatal mortality and preterm delivery —  During pregnancy, surveillance with serial TV ultrasound for cervical length measurement is recommended for patients who had CKC
  • 30. Prognosis —  The rate of recurrent or persistent CIN is 5-17% following any treatment modality —  Higher rates of persistent disease are associated with: 1.  Large lesion size 2.  Endocervical gland involvement 3.  Positive margin status 4.  Positive HPV DNA positivity after treatment
  • 31. Thank you