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Cin managment
This document discusses the management of cervical intraepithelial neoplasia (CIN). It covers who and when to treat CIN, treatment options including cryotherapy, laser vaporization, loop electrosurgical excision procedure, and conization. It provides guidance on treatment based on CIN grade, patient characteristics like pregnancy, and risk factors. The main treatment goals are prompt treatment of CIN 2-3 while allowing regression of many CIN 1 cases. Complications, reproductive outcomes, and prognosis after treatment are also reviewed.
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Cin managment
- 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 totreat? — When to treat? — Treatment options — Treatment principles — Complications
- 3. CIN I — CINI preceded by LGSIL — CIN I preceded by HGSIL
- 4. CIN I precededby 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
- 6. CIN I precededby 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
- 8. Adolescent women with CINI — Undetected high grade disease is uncommon, invasive cancer is rare, regression to normal is common — Expectant management is preferred
- 10. Pregnant women — highrate of postpartum regression of CIN I to normal — Follow up is deferred until 6 weeks postpartum
- 11. CIN 2,3 — Prompttreatment is recommended with some exceptions of pregnant women and adolescents
- 15. Treatment options — Cryosurgery — CO2 Laser Vaporization — Electrocoagulation — Sharp Conization — Laser Excisional Conization — Electrical Loop Excision — Hysterectomy
- 16. 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
- 17. Ablative techniques — Theprincipal 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
- 18. Cryotherapy — Office procedureusing 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
- 19. Cryosurgery — A thinlayer 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
- 20. Cryosurgery — There isusually 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
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- 22. CO2 laser — Laseris 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
- 23. Excisional therapy — Coldknife conization — Laser conization — LEEP (LLETZ)
- 24. Treatment specifications — Performcolposcopy 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
- 25. 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
- 26. Sharp Conization — Oneof 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
- 33. Laser Excisional Conization — More precise than the cold knife cone — Less blood loss but more thermal artifact — Requires advanced training and skill
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- 42. 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
- 43. 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)
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- 54. Conizacion cervical vfinal - YouTube.flv
- 55. Complications — Intraoperative bleeding — Postoperative bleeding: early or delayed — Infection — Cervical stenosis
- 56. Hysterectomy — If thereis coexistent gynecologic conditions requiring hysterectomy — Patient request and persistent or recurrent CIN 2,3
- 57. Reproductive outcome — Coldknife 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
- 58. Prognosis — The rateof 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
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