1. Case Presentations: Pre-Invasive Cervical Neoplasia
Kathleen M. Schmeler, M.D.
Assistant Professor
Department of Gynecologic Oncology

2. Case #1 25 yo Smokes 1 pack of cigarettes per day
Routine Pap test: high-grade squamous intraepithelial lesion (HSIL)
Next step? 2

4. Case #1
Cervical biopsy: CIN 3
Endocervical curettage: CIN 3 4

6. CIN 2/3 5% of women undergoing Pap tests in the USA
Typically diagnosed between age 25 and 35 years
Progresses to cancer 8 to 13 years after a diagnosis of CIN 2/3
Caused by persistent infection with high-risk HPV subtypes
HPV infection is necessary but not sufficient to develop CIN 2/3 6

7. CIN 2/3 Co-Factors HIV infection
Immunosuppressive therapy (renal transplant, chemotherapy)
Cigarette smoking 7

8. Case #1
Treatment for CIN 2/3? 8

10. Cervical Conization Cold knife conization (CKC)
Loop electrosurgical procedure (LEEP), also known as large loop excision of the transformation zone (LLETZ)
Laser conization
** Hysterectomy should not be performed as the initial treatment for CIN 2/3 10

11. Complications of LEEP/CKC
Intraoperative or postoperative bleeding
Infection
Cervical stenosis
Infertility
Pregnancy loss/Preterm birth:
- CKC = 14% preterm birth rate
- LEEP = 11% preterm delivery rate 11

12. Prognosis Untreated CIN 3:
Risk of cancer is 20% at 10 years and 31% at 30 years
Treated CIN 3:
Risk of cancer is 0.3% at 10 years and 0.7% at 30 years
McCredie et al., Lancet Onc, 2008 12

13. Hysterectomy
Hysterectomy should NOT be performed as initial treatment for CIN 2/3
Hysterectomy indicated if:
- Positive margins for CIN 2/3 and repeat excision not technically possible
- Cervix/vagina scarring limiting follow-up exam
- Persistent/recurrent CIN 2/3
* Consider frozen cone before hysterectomy if positive margins 13

14. Case #1
What if patient were pregnant with CIN3? 14

15. Pregnancy Do NOT treat CIN 2/3 during pregnancy
Perform excision only if cancer suspected
Up to 70% regress in postpartum period
Significant bleeding and risk of preterm labor if treated during pregnancy
ECC should never be performed during pregnancy
Repeat cytology and colposcopy 6 to 12 weeks postpartum 15

16. Case #2 45 yo Routine Pap test shows atypical glandular cells?
Work-up? 16

17. Case #2 Colposcopy: negative
Endocervical curettage: adenocarcinoma-in-situ
Endometrial biopsy: negative
Next steps? 17

18. Case #2 Cone biopsy: adenocarcinoma-in-situ with positive margins
Next steps? 18

19. Case #2
Repeat cone biopsy: no residual disease
Next step? 19

20. Case #2
Hysterectomy: no residual disease 20

21. Adenocarcinoma-in-Situ (AIS)
Atypical glandular cells without invasion
Precursor to adenocarcinoma of the cervix (25% of cervical cancers)
HPV infection is required (similar to squamous lesions)
% of patients have multi-focal disease (“skip lesions”)
50% of patients have concomitant squamous dysplasia or cancer 21

22. Adenocarcinoma-in-Situ (AIS)
Recommend CKC over LEEP due to higher probability of negative margins and no thermal artifact
Standard treatment for AIS is hysterectomy once child-bearing is complete
If positive cone margins, recommend repeat cone prior to hysterectomy to reduce the possibility of missing an occult cancer and performing incorrect procedure 22

23. Thank You 23