1. Trreatment of Preinvasive Lesions
Nejat Özgül Assoc. Prof.
Hacettepe University Faculty of Medicine
Department of Obstetrics and Gynecology

2. The Primary Goal in the Management of Preinvasive Lesions
The Primary goal in the management of Preinvasive Lesions is to prevent the development of invasive cervical cancer progression to cancer.

3. Management of Preinvasive Lesions
to select the women who are in danger of developing cervical cancer and to protect those who are not risk of cancer from over-treatment
Colposcopy plays a central role in selection of patients at the risk of developing Cervical Cancer and treatment modalities.
Should provide as little harm to the women as possible
Should be cost-effective

4. How can we decide about the choice of therapy for Preinvasive Lesions ?
Cytologic and colposcopic findings
The patient’s age and further desire for fertility
The type of TZ
The experience of the physician
Guidelines

5. Massad LS, J Low Gen Tract Dis 2013
ASCCP Guidelines
Massad LS, J Low Gen Tract Dis 2013

6. Follow-up without treatment
Management of women with a histological diagnosis of CIN 1 preceded by ASCUS, LSIL, HPV 16/18(+) or Persistent HPV infection
Follow-up without treatment
*Cytology if age <30 years, cotesting if age ≥30 years
£Either ablative or excisional methods 1Y
≥ASC or HPV (+)
Colposcopy
HPV (-) and Cytology negative
Age appropriate‡ retesting*
@ 3 Y
No CIN 2,3
CIN 2,3
CIN 1
Cytology Negative+/- HPV (-)
Manage per ASCCP Guideline
Follow-up or £ Treatment
If persists for at
least 2 years
Routine Screening

7. CIN1 (Preceded by ASC-H or HSIL Cytology)
Review of cytological,histological,and colposcopic findings
€ Cotesting
1. and 2. Year
£ Diagnostic excision procedure or or
Manage per ASCCP
Guideline
HPV (-) and cytology(-)
at both visits
≥ASC <HGSIL
or HPV (+)
HGSIL
(at either visit)
Age-specific retesting*
@ 3 Y
Colposcopy
€Colposcopy ‘s adequate and ECC (-)
£Except in pregnant women and those ages 21-24
*<30 Y cytology, ≥30 Y cotesting

8. CIN 1 (Women Ages 21-24 ) Colposcopy Repeat cytology @ 12 months
After ASC-US or LGSIL
After ASC-H or HGSIL
Repeat cytology
@ 12 months
inadequate colposcopy
adequate colposcopy
£ Diagnostic
Excisional procedure
Colposcopy and cytology
@ 6 and 12 month
Review of cytological,histological,and colposcopic findings
<ASC-H or HGSIL
≥ASC-H or
HGSIL
Repeat cytology
@ 12 months
HGSIL
(at either visit)
Cytology negative
(at both visits)
Other results
Changing results
Colposcopy
Routine Screening
Manage per ASCCP
Guideline
Negative
≥ASC
Routine Screening
€No pregnancy

9. Treatment of CIN 1 If lesion persists for ≥ 2 years
Progression of cervical lesion
ASC-US ASC-H LGSIL HGSIL
Cytology ASC-US or LGSIL
Inadequate colposcopy ECC >CIN1
Cytology ASC-H or HGSIL
No lesions in colposcopy, however biopsy CIN1, ECC (+)
Ferlay J, GLOBOCAN 2002; IARC Cancer Base 5, IARC Press, 2004; NCCN, Practice Guidelines in Oncology-v

10. Management of Women with CIN 2, 3 (except pregnant and age 21-24 women)
Adequate Colposcopy
Inadequate colposcopy or
recurrent CIN 2,3 or ECC is CIN2,3
Either excision or ablation of T-zone
Diagnostic excisional procedure
12 and 24 months
2x Negative results
Any test abnormal
Repeat Cotesting
@ 3 Years
Colposcopy with ECC
Routine Screening

11. Management of Women with CIN 2,3(Age 21-24)
If adequate colposcopy; treatment or observation is acceptable.
When CIN 2 is specified, observation is preferred.
When CIN 3 is spesified, or colposcopy is inadequate, treatment is preferred.
Observation – Colposcopy and cytology
(6 months interval for 12 months)
Treatment using excision or ablation
2x Cytology (-) and
Normal colposcopy
Colposcopy worsens or
High grade cytology or
colposcopy persists for 12 Moths
Colposcopy/
Biopsy
Recommended
Either test abnormal
CIN3 or
CIN 2,3 persists for 24 moths 1Y
Both tets negative
Treatment recommended
3 Years

12. Management of Margin (+) patients
Reflex hysterectomy
no desire for future fertility
Possibility of invasive disease: stage ≤1A
Re-excision (in 1-3 months)
CIN2+; ectocervical or endocervical margin(especially age >50)
Complication rates are similar with primary approach
Uncertain effect on pregnancy and fertility
Ablation of excision crater is not recommended
Invasive cancer may be omitted
Benefit ?
Uncertain superiority on fertility or preterm birth
Ghaem-Maghami S, Lancet, 2007; Siriaree S, Asian Pac J Cancer Prev, 2006; Kietpeerakool C, J Obstet Gynaecol Res, 2007

13. Hysterectomy in patients with CIN 2-3
Operation for other gynecological reasons
If there is no possibility for conization, because of cervical structure
CIN (+) : LEEP or conization margins
[ no desire for future fertility]
Cancer phobia
Das N, Gynecol Oncol, 2005

14. Management of Women Diagnosed with AIS during a Diagnostic Excisional Procedure
Conservative Management
Acceptable if future fertility desired
Hysterectomy Preferred Treatment
Margin (+) or ECC (+)
Margin (-)
Re excision is recommended
Re-evaluation*
@ 6 months Acceptable
Long term Follow up
*Cytology, HPV Testing, Colposcopy and ECC

15. EFC Guidelines-2007
Whereas there is no obviously superior conservative surgical technique for treating and eradicating cervical intra-epithelial neoplasia (CIN),
Excision is preferred because of better histopathological assessment

16. Ablative techniques are only suitable when:
EFC Guidelines-2007
Ablative techniques are only suitable when:
The entire transformation zone is visualised
There is no evidence of glandular abnormality
There is no evidence of invasive disease
There is no discrepancy between cytology and histology
Cryocautery should be used only for low grade CIN and a double freeze technique should be used.

17. EFC Guidelines-2007
When excisional techniques are used for treatment, every effort should be made to remove the lesion in one specimen.
The histology report should record the dimensions of the specimen and the status of the resection margins with regard to intraepithelial or invasive disease.
For ectocervical lesions, treatment techniques should remove tissue to a depth of 6 mm.

18. EFC Guidelines-2007
A see and treat policy at first visit can be used where audit has identified that CIN is present in the majority of the excised specimens.
A target of CIN in ≥90% of the excised specimens should be achieved.
Treatment at first visit for a referral of borderline or mild dyskaryosis should be used only in exceptional cases to minimise the possibility of over-treatment.

19. EFC Guidelines-2007
CIN extending to the resection margins at LEEP excision results in a higher incidence of recurrence but does not justify routine repeat excision as long as:
The entire transformation zone is visualised
There is no evidence of glandular abnormality
There is no evidence of invasive disease
The women are under 50 years of age

20. EFC Guidelines-2007
Women over the age of 50 years with incomplete excision of CIN at the endocervical margin are at high risk for residual disease.
Careful and adequate follow-up endocervical cytology is a minimum requirement.
Re-excision is an alternative.

21. EFC Guidelines-2007
Women with adenocarcinoma in situ / CGIN can be managed by local excision for women wishing to retain fertility.
Incomplete excision at the endocervical margin requires a further excisional procedure to obtain clear margins and exclude occult invasive disease.

22. EFC Guidelines-2007
Microinvasive squamous cancer FIGO stage Ia1 can be managed by excisional techniques if:
The excision margins are free of CIN and invasive disease.
If the invasive lesion is excised but CIN extends to the excision margin then a repeat excision should be performed to confirm excision of the CIN and to exclude further invasive disease.
This should be performed even in those cases planned for hysterectomy to exclude an occult invasive lesion requiring radical surgery
The histology has been reviewed by a specialist gynaecological pathologist

23. Preinvasive lesion in pregnancy
Treatment should be postponed until 2 months after delivery
Invasive disease must be excluded by colposcopy. Loop or wedge biopsy is more appropriate than punch biopsy to obtain a histological specimen with sufficient stroma
Cone biopsy during pregnancy should be performed only when there is a strong suspicion of invasive cancer.

24. Conclusions
Excisional treatments are diagnostic and therapeutic procedure for women with HGSIL
Treatment should be performed under colposcopic vision
The technique and the configuration of the cone should be individualized, depending on the specific lesion
TZ should be excised entirely
The most significant perioperative complication of cone biopsy is bleeding, which is generally managed with local measures

25. Conclusions
The excisional treatment of CIN do not compromise future fertility, but is associted with an increased risk of preterm labour according to type of excision
The excisional treatment of AIS is regarded to be appropriate ıf fertility is desired.But close follow-up is important

26. Conclusions Hysterectomy is not a treatment option for CIN1
Hysterectomy should not performed with a cytological diagnosis.
Hysterectomy is not primary treatment in patients with HGSIL: possibility of recurrence is similar with hysterectomy and local treatment
Long-term follow-up is essential
Colposcopy is a very important diagnostic tool in the management of cytological abnormalities
The follow-up is easier at centers with HPV testing capability