1. Dr N Shailaja Dr Pradeep
Treatment of CIN
Dr N Shailaja
Dr Pradeep

3. Life Cycle Of Unstable Epithelium
IARC (international agency for research of cancer): WHO

5. The aim of treatment To remove the entire transformation zone (tz)
Should be efficient in eradicating the intra-epithelial lesions with minimum morbidity
Less adverse effects on future fertility, potential of childbearing and pregnancy outcomes.
Most of the women with CIN are of reproductive age with a mean age around 30s

6. Are we treating based on cytology/histology?
Treatment is based on histology not cytology
ASCUS, ASCH, LSIL and HSIL have to be confirmed on biopsy and treatment is done for CIN 1,2 ,3 and invasive disease.

7. What do you do for LSIL and ASCUS when HPV testing is available?
If HPV testing is available HPV triage
Positive cases are for colposcopy
Negative cases are for cytology 12m and 24m along with HPV testing

8. Then how to follow untreated CIN ?

9. What do you do for LSIL and ASCUS when HPV testing is not available?
High risk cases for colposcopy
Low risk cases for observation – repeat cytology 6m, 12m and 24m.

10. When do we treat CIN1? The disease persists for >2yr
noncompliant patient for follow up

11. What do you do with HSIL?
No HPV testing even if facility is available, will subject them for colposcopy directly.

12. Should we treat CIN 2 & 3 ? CIN 2 - Treat
CIN 2 can regress – up to 49%.
Risk of progression is real but usually takes significant time.
Exceptions may apply in selected cases of young women with small CIN2 lesions.
CIN 3 - TREAT
Observation is unacceptable since it cannot be predicted which CIN 3’s will invade.
CIN 1 IS a transient or stable HPV infection with minimal cancer risk:
CIN2-is a collection of CIN 3 and CIN 1 50% regression rate, low risk of invasion
. CIN3 is a true precancer, 30-50% progress
to cancer over 30 years

13. Select And Treat strategy
‘see and treat’ strategy under local anaesthesia can lead to over-treatment of insignificant lesions
therefore, a ‘select and treat’ strategy is recommended

14. Which method is appropriate?
Now you have decided to select and treat
Which method is appropriate?

15. The choice of the appropriate technique relies on
The individual case
The colposcopic appearance
Depth, severity and size of the lesion
The type of the TZ
The age and the fertility wishes of the woman
Clinician’s experience and preference and equipment availability.

16. Do you think everyone can receive conservative line of management?

17. Criteria to be fulfilled for conservative treatment
Entire lesion located on ectocervix and visualised within TZ entirely.
No features of microinvasion/invasion on cytology, colposcopy or biopsy.
No endocervical glandular involvement.
Cytology and histology should correspond.
Adequate follow up should be possible

18. What are the conservative methods available?

20. When do you do ablative technique?

21. Ablative technique is only for proven CIN 1 cases better to avoid for CIN 2 and 3 cases

22. Prerequisites for ablative therapy
Satisfactory colposcopy with fully visible TZ and the lesion
Always diagnosis should be confirmed with colposcopy and invasion should be ruled out
There should be concordance between cytological, colposcopic and histological findings.
Contraindicated in women with glandular lesions, suspicion of invasion and history of previous treatment.

23. Why do you prefer excisional method?

24. Excisional VS ablational
Excisional methods provide the specimen with the entire transformation zone with precise margins for HPE so it helps to recognize the presence of microinvasive or glandular disease that could be missed otherwise.
therefore allow a comprehensive histological investigation of with precise assessment of excision margins

25. When do you chose excisional method?

26. Indications for excisional treatment
suspicion of invasion, glandular lesions
unsatisfactory colposcopy with a not fully visible lesion
discrepancy between cytology, colposcopy and biopsy
in cases of treatment failure the specimen should ideally be removed as a single sample.

27. Suppose your biopsy shows positive margin
Suppose your biopsy shows positive margin. Would you like to do repeat excision?

28. Margin status
Women with involved margins are in significantly higher risk in comparison to women with clear margins (18% vs. 3%).
But does not justify routine repeat excision provided: - there is no evidence of glandular abnormality - there is no evidence of invasive disease - the woman is under 50 years of age
This is because, commonly, complementary diathermy destroys residual lesions.

29. When do you do hysterectomy?
May be suitable if other gynaecological problems co-exist or if local excision has failed

30. How do you follow up the treated cases of CIN if you have facility for HPV testing?

31. Cytological follow-up of women treated for CIN and ‘test of cure’

32. Suppose you don’t have facility for HPV testing, then how do you follow up the cases of treated CIN?
Cervical smear every 6m, 12m and then annually for 9 years

33. How do you treat CGIN?

34. CGIN
If borderline glandular changes are present, colposcopic assessment with appropriate cervical biopsies and selective endometrial biopsy are indicated
Colposcopic findings are usually non-specific but always essential, as a high percentage of these women have concomitant CIN

35. Treatment of CGIN
Managed conservatively using excisional treatment methods provided adequate follow-up can be undertaken.
The margins of the excised specimen should be disease free. If the margins are involved, further excisional treatment may be undertaken.
The option of hysterectomy after completion of childbearing should also be considered.

36. How do you follow up the treated cases of CGIN if you have facility for HPV testing?

37. Management of women following treatment of CGIN

38. How do you follow up the treated cases of CGIN if you don’t have facility for HPV testing?
Cervical smear every 6m for 5yr and then annually for 5yrs

39. Why is follow up so important?

40. Risk of persistent disease is more in
endocervical margin involvement
glandular lesions
age over 40 years
high-grade and large size lesions
The majority (around 90%)of treatment failures (residual and recurrent disease) will be picked up within 24 months of treatment.

41. What are the limitations of cytology and colposcopy follow of treated cases of CIN/CGIN?

42. Limitations of cytological follow-up of women treated for CIN
Cytology after treatment is less accurate and sampling should ensure endocervical cells if appropriate.
Residual/recurrent disease may be more difficult to detect cytologically because of scarring and it often retracts deep in the endocervical canal.

43. Limitations of colposcopy follow-up of women treated for CIN
Colposcopic assessment is technically more difficult in women who have undergone treatment.
Foci of CIN and/or invasive disease may be buried under an apparently normal epithelium.
The transformation zone may be difficult to visualise in its entirety due to scarring and because it often retracts deep in the endocervical canal

44. Would you like to do smear following hysterectomy?

45. CIN following hysterectomy
On routine recall and with no CIN in their hysterectomy specimen → no further vaginal vault cytology is required
Not on routine recall, and with no CIN in their hysterectomy specimen → vaginal vault cytology at six months and then ceased if the cytology is negative
Completely excised CIN → vaginal vault cytology at six and 18 months
Incompletely excised CIN (or uncertain excision), follow up should be as if their cervix remained in situ
– CIN 1: vault cytology at six, 12 and 24 months
– CIN 2/3: vault cytology at six and 12 months, followed by nine annual vault cytology samples or 65 years of age whichever is later

46. What is the role of cervical smear during pregnancy?
Routinely do you want do one?

47. Cervical screening during pregnancy
Routine screening should be deferred
Repeat smear has to be done in second trimester

48. What about colposcopy during pregnancy?

49. Indications for colposcopy
Colposcopy should be done in late first or early second trimester
For low-grade changes triaged to colposcopy on the basis of a positive HPV test, the woman’s assessment may be delayed until after delivery
High grade change in cytology

50. continued…….
All cases of CGIN following treatment unless there is obstetric contraindication.
CIN2 or CIN3 only with involved or uncertain margin status following treatment

51. How to manage?
if CIN1 or less is suspected-- repeat the examination three months postpartum
if CIN2 or CIN3 is suspected, repeat colposcopy at the end of the second trimester. If the pregnancy has already advanced beyond that point, repeat three months following delivery

52. How to manage?
If invasive disease is suspected clinically or colposcopically → a biopsy adequate to make the diagnosis is essential
Cone, wedge, and diathermy loop biopsies are all associated with a risk of haemorrhage and such biopsies should be taken only where appropriate facilities to deal with haemorrhage are available.

53. What is your say on postpartum assessment of these women?

54. Colposcopy follow up after pregnancy
If colposcopy has been performed during pregnancy and found to have abnormal cytology or biopsy-proven CIN → post-partum assessment of women is essential
Excision biopsy in pregnancy cannot be considered therapeutic and these women should be seen for post- partum colposcopy.

55. Treatment of CIN and CGIN