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.

1. MANAGEMENT OF CERVICAL
INTRA-EPITHELIAL NEOPLASIA
(CIN)
Dr. Parul Sinha
Dept. of Obstetrics &
Gynaecology

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)

5. Cont..

6. Comparison of the WHO and
Bethesda System Terminology
WHO/ histopathologic terms Bethesda Cytology terms
CIN 1/ Mild dysplasia LSIL
CIN 2/ Moderate dysplasia HSIL
CIN 3/ Severe dysplasia HSIL
CIN 3/ Carcinoma in Situ HSIL
*LSIL : Low grade Sqamous Intra-epithelial Lesion
*HSIL : High grade Sqamous Intra-epithelial Lesion

7. Why We Want To Treat CIN?

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.

14. Treatment Modalities For CIN
* Ablative methods:
– Cryotherapy
– Electro coagulation diathermy
– LASER vaporization
* Excisional methods
– Loop Electrosurgical Excision Procedure (LEEP/LLETZ)
– Conisation : Laser, Cold Knife, LOOP
*Hysterectomy

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

22. Cervical Appearance after Cryotherapy
Immediately after After 2 weeks After 1 year

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

27. Disadvantage- Laser
 Expensive
 Lack of availability of Equipment
 Skill required – Necessity for special training

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

33. Excision of large Lesions : Multiple passes

34. LEEP :Complications
 Severe bleeding : <2%
 Secondary Hemorrhage
 Infection
 Cervical stenosis : 1-4%
 Squamocolumnar Junction in EC canal
 Recurrence Rate : 2-4%

35. Cervix : One year after LEEP

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

37. Technique for Conization
 Techniques:
– Laser
– Cold Knife
– Loop / Hot Knife,
 Success Rate – 90-94%
 Clear Margins : Risk Of Recurrence < 1%
 Complications & Sequlae
– Hemorrhage : Significant 2%
– Cervical Stenosis
– Cervical Incompetence

38. Excisional Procedures- Results
Cochrane Database Review
( Martin Hirst . 2002 )
 With satisfactory colpo.& proper case selection
 Results with LEEP,Laser & Cold knife conisation
are comparable
 Choice depends on equipment available, skill
and cost factor

39. Post treatment Follow -up
Follow-up
Cytology
+/Colposcopy
4 -6 months
HPV testing
6-12 months
Negative
Annual Screening
Positive
Colposcopy &
ECC
3 cytology : Negative
Annual Follow-up
ASC or greater
Colposcopy
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.