This document discusses screening and treatment strategies for cervical intraepithelial neoplasia (CIN). It recommends a see-and-treat single visit approach using cryotherapy, cold coagulation, or LEEP for lesions suggestive of significant CIN. Ablative treatments like cryotherapy are preferred for lesions entirely in the ectocervix while excisional treatments like LEEP are used for endocervical lesions or when histology is needed. Cold coagulation and LEEP have high success rates of over 95% for treating CIN while maintaining low risks. The document provides details on techniques, eligibility criteria, advantages, and disadvantages of different screening, diagnostic and treatment approaches for CIN.

1. Prof. Aboubakr Elnashar
Benha University Hospital, EGYPT
Aboubakr Elnashar

2. Aboubakr Elnashar

3. CIN: WHO Recommendation 2014.
CIN 1:
(i)immediate tt
(ii)follow the woman and then tt if the lesion is
persistent or progressive after 18 to 24 months.
CIN 2 and CIN 3:
Cryotherapy or LEEP.
AIS (adenocarcinoma in situ)
CKC
Aboubakr Elnashar

4. Strategy
Three visits strategy
one for screening
one for colposcopy,
one for treatment: poor compliance, especially
among rural women.
Single visit: see-and-treat strategy
satisfactory results
no significant extra morbidity
[Emam et al, 2009].
Aboubakr Elnashar

5. See & treat (Single visit diagnosis & tt)
•It means
(Cryo therapy, cold coagulator or LEEP) at first visit to
women with (VIA or colposcopic) findings suggestive of
SIL.
•Advantages:
False negative histology is low (4.7% )
Reduce waiting lists & anxiety
•Disadvantages:
Over tt of insignificant lesions
•It should be limited to HGSIL (Pastner,1994)
Aboubakr Elnashar

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7. Swede score
Aboubakr Elnashar

8. Swede score of 4 and above: Punch biopsies of
the cervix
Swede score 6 and above:
immediate treatment
with cold coagulation under visualisation with the
Gynocular and local anaesthesia.
patients not suitable for cold coagulation or with
biopsies revealing microinvasive cervical disease or
worse: appropriate diagnostic workup and
management protocol.
Aboubakr Elnashar

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10. Methods
Indications of ablative therapy
1. Satisfactory colposcopy
2. No suggestion of invasive disease
3. No suspicion of glandular disease
4. Cytology & histology correspond
suspicion of invasion or unsatisfactory
colposcopic assessment excludes any ablative
method of treatment.
Aboubakr Elnashar

11. Indication of Excisional therapy
1. Unsatisfactory colposcopy.
2. Suspicion of invasion
3. Suspicion of glandular disease
4. Discrepancy between cytology &
histopathology
Aboubakr Elnashar

12. I. Ablative
1. Cryotherapy
Relies on :
steady supply of compressed refrigerant gases (N2O
or CO2) in transportable cylinders.
Mechanism:
Excellent contact between the cryoprobe tip and the
ectocervix:
N2O-based cryotherapy: –89°C
CO2-based system: –68°C at the core of the ice ball and –
20°C at the edges.
Cells reduced to –20°C for one or more minutes will undergo
cryonecrosis.
Aboubakr Elnashar

13. Eligibility criteria
•The entire lesion is located in the ectocervix
without extension to the vagina and/or endocervix
• The lesion is visible in its entire extent and does
not extend more than 2 to 3 mm into the canal
• The lesion can be adequately covered by the
largest available cryotherapy probe (2.5 cm); the
lesion extends ≤2 mm beyond the cryotherapy
probe
Aboubakr Elnashar

14. • There is no evidence of invasive cancer
• The endocervical canal is normal and there is no
suggestion of glandular dysplasia
• The woman is not pregnant
• If the woman has recently delivered, she is at
least three months post-partum
• There is no evidence of PID
• The woman has given informed written consent to have the treatment
• CIN is confirmed by cervical biopsy/colposcopy
Aboubakr Elnashar

15. • Healing:
six weeks
Side effects:
watery vaginal discharge for 3-4 w after tt
• Advise
not to use a vaginal douche, tampons or have sexual
intercourse for one month after tt..
• Treatment failure:
5-10%
Aboubakr Elnashar

16. Aboubakr Elnashar

17. Technique:
Two sequential freeze-thaw
cycles,
Each cycle consisting of :
3 min of freezing followed by 5
min of thawing (3min freeze-5
min thaw-3 min freezethaw).
Adequate freezing:
when the margin of the ice ball
extends 4-5 mm past the outer
edge of the cryotip:
cryonecrosis down to at least 5
mm depth.
Aboubakr Elnashar

18. Advantages
1. Favorable safety profile
2. Outpatient procedure
3. No anesthetic requirements
4. Ease of procedure
5. Low-cost equipment with minimal maintenance
6. Bleeding complications rare
7. No proven adverse reproductive effects
8. Acceptable primary cure rate
Aboubakr Elnashar

19. Disadvantages
1. No tissue specimen for histopathology
2. Cannot treat lesions with unfavorable sizes or
shapes
3. Uterine cramping
4. Potential for vasovagal reaction
5. Profuse vaginal discharge postprocedure
6. Cephalad migration of SCJ
Video
Aboubakr Elnashar

20. 2. Cold coagulation
Method:
lesion is treated with tefloncoated probe to 100°C-
120°C
The probe is applied to each part of the cervix for
30-40 sec. ensuring that the whole TZ is destroyed
beyond the limit of acetowhite epithelium.
Sultrin cream vaginally, nightly for one week
avoid intercourse and use of tampons for 3w.
Aboubakr Elnashar

21. Advantages:
1.All grades of CIN can be treated
2.outpatient clinic.
3.Relatively painless procedure requiring minimal or
no analgesia.
4.Safe, efficient, with a very low morbidity rate.
5.Short tt time
6.Well accepted by both patients and colposcopists
Aboubakr Elnashar

22. Success Rate
CINIII: 95%
CIN I and III: 96.5% -99% following one or more tt
Persistent disease:
very low rate (7. 1%)
(Semple. Et al; 2008)
Recurrence rate
very low, 5.6%,
Aboubakr Elnashar

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24. II. Excesional
1. LEEP
Loops:
0.2 mm hard stainless steel or titanium
Diameters : 1-3 cm.
Aboubakr Elnashar

25. Aboubakr Elnashar

26. The eligibiligy criteria that must be met before
LEEP is performed
• If the lesion involves or extends into the
endocervical canal, the distal or cranial limit of the
lesion should be seen; the furthest (distal) extent is
no more than 1 cm in depth
• No evidence of invasive cancer or glandular
dysplasia
• No evidence of PID, cervicitis, vaginal
trichomoniasis, bacterial vaginosis, anogenital ulcer
or bleeding disorder
Aboubakr Elnashar

27. • If the woman has recently delivered, she
should be at least three months postpartum
• Women with hypertension should have their
blood pressure well controlled
•CIN is confirmed by cervical biopsy, when possible
Failure rate:
10%.
Aboubakr Elnashar

28. Technique
1.Lithotomy position, speculum inserted, colposcopy ,
cervix is painted with Lugol’s iodine.
2.Patient grounded with pad return electrode
3.Circumferential cervical block using 1% lidocaine.
Inject just beneath & lateral to the lesion
4.Short lasting IV sedation is given to women who so
demanded.
5.A loop wider than the lesion(s) and the TZ to be
removed should be used; otherwise, the lesion should
be removed with multiple passes
6.Depending on the loop size, a power setting 25-55
watts of blend (cutting plus coagulation) current
Aboubakr Elnashar

29. 7. An attempt to remove entire involved lesion in a
single pass moving from right to left.
8. If endocervical excision is needed, a smaller loop
(usually 0.8 cm in width) is used for second pass,
removing the region around the endocervical
canal in a “top hat” fashion. The power setting is
lowered when using the smaller loop.
9. Coagulate the base of the cone by the ball
electrode (60 W) even if no apparent bleeding
Aboubakr Elnashar

30. Haemostasis
1. Roller ball coagulation
2. Monsel’s paste
3. Silver nitrate
3. Packing with roller gauz soaked in povidone
iodin
4. In case of a spurting vessel not controlled by
cautery: 2-0 chromic catgut suture .
Aboubakr Elnashar

31. Advise
Avoid: for one month after LEEP.
vaginal douche
Tampon
sexual intercourse
any vaginal medication
To report immediately on having
severe pain
foul smelling discharge or
severe bleeding.
Aboubakr Elnashar

32. Follow up
At one week: review of Histopathology report
At one month: to examine cervix
ask about problems
At 6 &12 months: VIA, VILLI and Colposcopy.
Aboubakr Elnashar

33. Complications
1.Bleeding: primary secondary
Moderate to severe: ≤2%
2. Infection
3. Discharge: brown or black for up to two weeks
4. Incomplete removal of lesion
5. Inadvertent burns
6. Cervical stenosis
Aboubakr Elnashar

34. Advantages
 Over ablative methods
 Tissue specimen for histopathology evaluation
Over laser
 tt time is shorter
Easier to learn
No hazard to the eyesight
Equipment breakdowns occur less often
Cone sampling is better than laser
less handling of tissue
Discomfort is reduced
Low costs of equipment
Aboubakr Elnashar

35. Disadvantages
1. Thermal damage may obscure specimen
margin status
2. Special training required
3. Risk of post procedure bleeding
4. Theoretical risk of vapor plume inhalation
Aboubakr Elnashar

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42. Video
Aboubakr Elnashar

43. 2. Cold-knife conization
Indications
•The lesion extends into the endocervical canal and
it is not possible to confirm the exact extent.
• The lesion extends into the canal and the farthest
extent exceeds the excisional capability of the LEEP
cone technique (maximum excisional depth of 1.5
cm).
• The lesion extends into the canal and the farthest
extent exceeds the excisional capability of the
colposcopist.
• The cytology is repeatedly abnormal, suggesting
neoplasia, but there is no corresponding colposcopic
abnormality of the cervix or vagina on which to
perform biopsy. Aboubakr Elnashar

44. • Cytology suggests a much more serious lesion
than that which is seen and biopsy-confirmed.
• Cytology shows atypical glandular cells that
suggest the possibility of glandular dysplasia or
adenocarcinoma.
• Colposcopy suggests the possibility of glandular
dysplasia or adenocarcinoma.
• Endocervical curettage reveals abnormal histology.
Aboubakr Elnashar

45. Begin the cone biopsy by
placing lateral sutures at
the cervicovaginal junction
to decrease bleeding.
Use a #11 surgical blade to
make the circular incision,
angling the tip of the blade
toward the endocervical canal.
Aboubakr Elnashar

46. Grasp the specimen, including
the entire transformation zone
and distal endocervical canal,
with an Allis clamp.
Complete the cone excision by
cutting across endocervix. Apply
light cautery to the edges of the
cervical bed.
Aboubakr Elnashar

47. Advantages
 Tissue specimen for histopathology without margin
compromise
Disadvantages
 Potential for hge
 Lengthier procedure
 Postoperative discomfort
 General or regional anesthesia required
 Operating room setting
 High cost
 Larger volume of cervical stroma removed
 Increased risk of adverse reproductive outcomes
Aboubakr Elnashar

48. III. Hysterectomy
Indications
1. Other gynecological conditions:
.fibroid, prolapse, endometriosis, PID .
2. Refuse all other forms of therapy
3.SIL at limits of conization specimen
4. Poor compliance with follow-up
Sterilization is not an indication
Aboubakr Elnashar

49. Follow up after treatment of CIN
• Non of the methods for tt of CIN offers an absolute
cure rate.
• Recurrences most common: in the first 2 yr, in the os &
on the outside margins
Aim
Persistent or recurrent disease (after 12 mo)
Visits
6 mo intervals for 2 yr, then annually
Assessment
Combined cytology & colposcopy at first visits, then
cytology (endocx & ectocx), VIA
Aboubakr Elnashar

50. Treatment of CIN during pregnancy
•Abnormal cytology Colposcopy
•Colposcopically directed punch biopsy or
small loop biopsy
•Knife or LLE cone: rarely indicated
•Colposcopy/ 3 m to ensure that the lesion is not
progressing
•CIN 3: treatment after delivery
Aboubakr Elnashar

51. Prof. Aboubakr Elnashar
Benha University Hospital, EGYPT
E-mail: elnashar@hotmail.com
Aboubakr Elnashar