This document discusses the management of cervical intraepithelial neoplasia (CIN). It defines CIN and describes its grading from CIN1 to CIN3 based on the level of involvement of the cervical epithelium. For CIN1, observation or treatment are accepted depending on factors like age and lesion characteristics. CIN2/3 should be treated as regression is only 30-40% and progression risk is higher. Accepted treatment modalities include ablation methods like cryotherapy or laser vaporization and excisional methods like LEEP. Follow up is important after treatment to monitor for regression or recurrence.
2. Cervical Intra-epithelial Neoplasia (CIN)
A histopathological condition where part or
whole of cervical sqamous epithelium is
replaced by cells showing varying degree of
atypia (undifferentiated cells)
3. According to Pathologist
Criteria for diagnosis of Intra-epithelial
neoplasia
-Cellular Immaturity
-Cellular disorganization
-Nuclear abnormalities
-Increase mitotic activities
4. Degree of Neoplasia
CIN 1- Involvement of lower (Basal) 1/3rdof
epithelium by atypical cells
CIN 2- Involvement upto middle third
( Basal ½ to 2/3rd)
CIN 3- Involvement of upper third of epithelium
( Whole thickness)
8. Regression, Persistence and progression probabilities of
CIN
CIN
type
Regression Persistence Progression
to CIS
Progression to
inv.cancer
CIN I 57% 32% 11% 1%
CIN II 43% 35% 22% 1.5%
CIN III 32% 56% - 12%
Natural History of Cervical
Intra-epithelial Neoplasia
Oster et al ,1993:Int J Gyne Path ;12:186-92
9. Management of CIN1
We have 2 option
-Observation: Follow up without treatment
-Treatment : Ablative/ Excisional Procedure
As spontaneous regression in >50% in 1-2 years
so both options are accepted for CIN with satisfactory
colposcopy.
10. Follow up without Treatment
CIN 1: Satisfactory Colposcopy
Based on : Age,parity,Education of patient & willingness , to come for follow up.
Options : Any one of the following
-Cytology at 6 month & 1year : If 2 smear –Ve annual FU.
-HPV DNA at 1year : If –Ve annual FU
-Colposcopy + Cytology at 1year :If – Ve annual FU
If the lesion progress during follow up or persist at 2years
-Treatment should be performed
(Regression after 2years decreases)
11. Immediate Treatment For CIN 1
Recommended :
-Extensive lesion
-Unsatisfactory Colposcopy
-Persistent lesion
-Not reliable for follow up
12. Management Protocol
CIN I
Satisfactory Colposcopy Unsatisfactory Colposcopy
observation
Excision/ablative
Treatment Diagnostic
Excisional
Procedures
Pregnancy
Adolescent
Cytology
6/12 months
HPV DNA
Negative :
Annual FU
ASC-US or
more
Colposcopy
Negative: FU
+ve :
Colposcopy
Cryo
LEEP
Electofulgration
ECC : Prior
Colposcopy + Cytology : accepted Follow-up
Ablative procedure: Unacceptable with unsatisfactory colposcopy
13. Management of CIN 2 or 3 /
Moderate or severe dysplasia
All cases with CIN II/III should be treated
Spontaneous regression only 30-40%, progression
22%,progress to cancer 12-15% in 5-15yrs
Preferred treatment for CIN 2& 3 is excisional
Persistent & recurrent disease rates are 4%to 10%
Strict follow-up
Observation in pregnancy or occasionally in very young
patients.
15. Selection of Treatment Modality
Depends on :
Lesion size, grade, placement
Size & contour of cervix
Pt’s age & Reproductive history
Compliance for follow up
Associated gynecological condition
Clinician skill & Experience
Equipment available
16. Ablative Treatment
Ablation Suitable for
CIN grade 1-2
Small lesions<_2 adjacent quadrants
Lesion located on the ectocervix & can be seen
entirely
Negative ECC
No evidence of micro invasive / invasive on
cytology,colposcopy& ECC
17. Cryotherapy :Principle
Destruction of tissue is by freezing
Consist of a probe Tip of probe is cooled below
freezing point (- 60*C) by rapid expansion of gas which
pass through it
Freezing Cellular dehydration by crystallization of
Intracellular water Cell death
18. Cryotherapy : Eligibility Criteria
Entire lesion visible on ectocervix
No extension on to vagina/canal
Lesion should be covered by largest available
Cryotherapy probe.
CIN confirmed by biopsy/Colposcopy
No invasive carcinoma.
Endocervical canal normal.
No evidence of glandular dysplasia.
19. Cryotherapy Equipment
• CO2 /N2O : refrigerants
of choice.
• The probe must cover
the lesion and the entire
TZ.
20. Cryotherapy : Procedure
OPD procedure done without anaesthesia
Postmenstrual phase
Informed Consent
Clear mucus & debris of cervix with cotton swab
Choose correct size Probe
Apply appropriate Probe to the cervix
21. Cont.
Freezing activated
3 mts Freeze-5mts Thaw-3mts Freeze
When Ice ball 4-5 mm is obtained beyond the edge
of the probe stop Freezing
The probe thawed and remove
Probe should not pulled out until it separate
Depth of cryo-destruction is 5mm
23. Follow-up Instructions
Watery discharge for 4-6 weeks.
Avoid intercourse for 1 month
Should report immediately if bleeding, fever, foul
smelling discharge, severe pain
Granulation – 2-3 weeks
Total wound healing : 8-12 weeks
Follow-up at 4,8,12,18 &24 months
Cytology/VIA/Colposcopy
24. Disadvantages
Ablative method.
No tissue for confirmation
Not adequate for larger lesions, lesions involving
Endocervical canal, vagina
5-10% failure rate.
Complications : Infection, Bleeding &
Cervical stenosis(1%),
25. Ablative Procedure- Laser
Laser Vaporization by CO2 Laser
Useful When:
Large lesion involving >2 quadrants
Irregular Cervix with deep depth
When disease extends into vagina
Satellite lesions in vagina / valva
26. Advantages - Laser vaporization
Even in high grade lesion success is upto 90-95%
( recurrence 2-10%)
Ability to control depth and width of destruction
Ablate till 7mm depth
Can combine Laser & Laser Cone
Rapid healing
28. Excisional Procedure
Should be considered
Lesions are large involve >2 quadrants
High grade
>5mm in cervical os
Recurrent CIN- Prior ablation performed
Advantages
Tissue available for H/P
Diagnosis of unsuspected invasive disease
29. Loop Electrosurgical Excision Procedure
(LEEP / LLETZ)
A loop (2-3cm) of very thin (0.5mm) stainless steel,
tungsten wire is used for excision of TZ
Blended current (cutting & coagulation), low voltage
output is used
The crater produced by LEEP is fulgurated with a ball
electrode for adequate haemostasis
30. Cont.
Simple / Effective procedure
Can be done under LA/ GA
Both diagnostic and therapeutic
Tissue up to a depth of 10mm or more can removed
31. Eligibility : LEEP
Biopsy confirmed CIN whenever possible
Entire TZ must be seen. If the lesion extends in
cervical canal, the upper end of lesion must be seen.
The depth inside cervical canal must not be more than
1 cm.
No glandular dysplasia/ Invasive carcinoma.
32. • Use the loop wider than the lesion
• Depth of the loop should be minimum 5 mm.
• Excision : Single pass
36. Excisional Procedure
Conization
Indications
1.Unsatisfactory Colposcopy with HGCIN
2.Endocervical cytology / ECC +ve for CIN 2or3
3.Lack of correlation between cytology, biopsy and
colposcopy
4.Microinvasion suspected on cytology, biopsy or
colposcopy
5.Adenocarcinoma in situ on biopsy or ECC
40. Risk Factors for Recurrence after Treatment
Increasing age
Large Lesion
Endocervical Extension
Positive margins of specimen
Positive HPV after 6months ,12months
41. Cone Margin or ECC +VE
Counsel her – She needs very vigilant follow up
According to ASCCP guide line there is role of follow up
with Colpo + ECC +HPV at 6 months interval- Preffered
If Pt. insist-Repeat diagnostic procedure- Acceptable
If above not possible – Hysterectomy –Acceptable
On Follow up ,Recurrent / Persistent CIN 2,3
Hysterectomy - Acceptable
42. Role of Hysterectomy-CIN
To be considered if :
Microinvasion
Coexistent Gynecological aliment e.g. Fibroid Uterus
Poor compliance with follow-up.
HGCIN in postmenopausal woman
Adenocarcinoma in situ/ Microinvasion
Histologically confirmed recurrent high grade CIN
43. Conclusion
Sqamous metaplasia - a physiological change needs
no Tt.
All HGSIL should have colpo.+ ECC
Individualize patient care
Spontaneous regression observed in most of CIN1
so expectant management is ‘preferred’ in reliable pt.
with satisfactory colposcopy.
44. Cont.
All HGCIN must be treated except in adolescent &
pregnancy
Satisfactory colpo – Ablation/ Excision -Acceptable
Unsatisfactory colpo – Diagnostic Excisional procedure
Recurrent CIN 2,3 – Diagnostic Excisional procedure /
Hysterectomy
All treated case should follow up – Cyto + colpo or by HPV
6 monthly. If any +ve – Biopsy +ECC.