1) Differentiating between high grade (CIN 2/3) and low grade (CIN 1) cervical lesions is important for treatment decisions. 2) Colposcopic features that suggest high grade lesions include coarse mosaicism, irregular blood vessels, thick opaque white epithelium, well-demarcated ridges, and papillary configurations with sharp borders. 3) Low grade lesions typically have features like a transient whitening with acetic acid, fine punctation, ill-defined margins, and peripheral or small sizes.

1. COLPOSCOPY OF CIN;
DIFFERENTIATING HIGH GRADE
FROM LOW GRADE LESIONS
James Bentley , Professor Department of Obstetrics and Gynecology,
Dalhousie University, Halifax NS, Canada

2. Normal
CIN 1
CIN 2
CIN 3
Cancer

3. Progression/Regression of CIN
Regress Persist Progress
to CIS
Progress
to
invasion
Months to
CIS from
baseline
CIN 1 57% 32% 11% 1% 58
CIN 2 43% 35% 22% 5% 38
CIN 3 32% <56% - >12% 12
OsterAG. Int J Gynecol Pathol 1993;12:86
Richart RM, Barron BA. A follow-up studyof patientswith cervical dysplasia.Am J Obstet
1969;105:386–393
Resolution of CIN 1 in adolescent is 90%
CIN 3/ CIS progression to cancer in 31% of cases
treated by Bx;
McCredie et al Lancet Oncology 2008 9(5) 425-34

4. ASCUS
LSIL
Images downloaded from http://nih.techriver.net/bethesdaTable.php

5. Results: hc2 +ve
Pap smear history Number of cases HybridCapture 2
+ve 1
95%Confidence
intervals
ASCUS/ASCUS 87 58 (67%) 56% to 76%
ASCUS/LSIL 33 23 (74%) 52% to 82%
LSIL/ASCUS 19 18 (95%) 73% to 100%
LSIL/LSIL 21 15 (71%) 49% to 86%
All cases 160 114 (72%) 64% to 78%
1 note 10 specimens had insufficient sample
•No significant difference between groups for hc2
Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC
2008

6. Results: CIN2 + on Bx
Pap smear history Number of cases CIN 2 or greater 95%CI
ASCUS/ASCUS 87 23 (26%) 18% to 37%
ASCUS/LSIL 33 7 (21%) 10% to 38%
LSIL/ASCUS 19 2 (10.5%) 1.7% to 32%
LSIL/LSIL 21 3 (14%) 4% to 35%
All cases 160 35 (22%) 16% to 29%
•No significant difference between groups for histology
Triage using repeat ASCUS or LSIL pap smears; is there any difference between categories? Bentley et al IFCPC
2008

7. CIN2 and 3 after low grade
cytology
 ALTS trial:
 Progression to CIN2 or 3 in 13% of women referred
for the evaluation of LSIL or ASCUS HPV +ve smear
 NS Data:
 2ASCUS, 2 LSIL, or combination
 HR HPV +ve 72 %
 CIN2 or > 22%

8. ASC-H
Images downloaded from http://nih.techriver.net/bethesdaTable.php

9. CIN2 or > after ASC-H
 Significant pathology seen in the majority of
cases
 Barreth et al.:
 CIN2 or > in 70% of cases
 2.9% invasive disease
 1.7%AIS

10. HSIL

11. CIN2 or > after HSIL
 WrightASCCP:
 CIN2 or > 53%-66% with Biopsy
 90% if policy of immediate colposcopy

12. AGC cytology
Pathology finding1
CIN 1 7%
CIN 2 or 3 36%
Adenocarcinoma in situ 20%
Cervical Cancer 9%
Endometrial Pathology 29%
1Daniel A Int.J.Gynaecol.Obstet 2005; 91(3)238-242
2 Wright T Emerging Issues on HPV infections 2006 p
140-146
Cytology2 Any high-grade
lesion
High grade
glandular
AGC-NOS 9-14% 0-15%
AGC-N 27-96% 10-93%

13. ASC-H
Colposcopy
NoCIN
Manage as per SCC
guidelines
CIN1 or >
Colposcopy, cytology,
at 6 months x 2 (HPV
testing at 6 or 12
months ideally)
Return to screening
protocol
CIN 1 or >
No CIN
HPV +ve follow in
colposcopy clinic

14. HSIL
Colposcopy
(Bx, +/- ECC)
NoCIN 2, 3
Manage as per SCC
guidelines
CIN 2 or greater
Satisfactory
Colposcopy
Unsatisfactory
Colposcopy
Observe
with
Colposcopy
and cytology
Q 6/12 x2*
Return to screening
protocol
Diagnostic
Excision procedure
* Consider HPV testing
Cytology/histolo
gy review
disagreeagree

15. Colposcopic Approach
 Examine whole lower genital tract
 Use acetic acid liberally
 Beware the small lesion
 Take >1 biopsy
 Liberal use of ECC
 Always do ECC with unsatisfactory colposcopy

16. High grade features: Snow white
epithelium

17. Low grade colposcopic
features: colour
 The acetowhite reaction is
slower in onset and more
transient than high grade lesions
 Semi-transparent
 Snow-white colour
 Gray-white colour higher grade

18. Low grade: colour

19. Low grade Colposcopic features: size /
position
 Peripheral lesions
 Often smaller

20. Low grade Colposcopic features: size /
position

21. Low grade Colposcopic features:
margins
 Feathered
 Geographic
 Flat with indistinct margins
 Satellite lesions

22. Colposcopic features:
margins

23. Low grade Colposcopic features:
margins

24. Low grade Colposcopic features:
margins

25. Colposcopic features: iodine
staining

26. Colposcopic features: iodine
staining

27. Colposcopic features: iodine
staining

28. Colposcopic features: iodine
staining

29. High grade features: Coarse Mosaicism

30. Low grade Colposcopic features:
vessels
 Ill defined areas of fine
punctation or
mosaicism

31. Colposcopic features: vessels

32. High grade features: Irregular vessels
vascularity
Hair pin vessels from
cancer
Punctation from CIN2

33. High grade features: Thick keratosis

34. High grade features: inner border sign

35. High grade features: ridge sign

36. High grade features: papillary lesion;
sharp border

37. CIN3

38. CIN 3 in pregnancy

39. Colposcopic mimics of CIN 1

40. CIN 2 Photo courtesy of Dr LGeldenhuys
Histology of CIN 2

41. CIN 3 Photo courtesy of Dr LGeldenhuys
Histology of CIN 3

42. CIN 1 on Biopsy
or ECC
SatisfactoryColposcopy
Observe
with
Colposcopy
and cytology
Q 6/12 x2
Return to screening
protocol
Unsatisfactory
Colposcopy
Observe with
Colposcopy
and cytology
at 24 months2
Treatment1
1 consider ablative therapy for persistent CIN1
2 if cytology persists continue FU in colposcopy
Colposcopy and
cytology -ve
CIN persists or
progresses
Observe with
Colposcopy
and cytology
12 months
persisten
t

43. CIN 2,3 on
Biopsy
Return to screening
protocol
Diagnostic Excision
procedure
CIN 2,3
Treatment1
SatisfactoryColposcopy Unsatisfactory
Colposcopy
Follow-upat 6 and 12
months with colposcopy
and cytology
Follow-upat 6 months
with colposcopyand
cytologyand HPV2
OR
Treat per guidelines
CINNegative
1 LEEP or excision preferred for CIN 3
2 HPV testing for high risk HPV

44. CIN 2,3 on Biopsy in
women < 25 yrs old
CIN 2
Return to screening
protocol
Diagnostic
Excision procedure
CIN 3
Observe with
Colposcopy
and cytology
Q 6/12 x2 yrs
Treatment
SatisfactoryColposcopy
Unsatisfactory
Colposcopy
CIN persists
or progresses
CIN Resolves

45. CIN 3 with AIS (on final LEEP)

46. HSIL pap: colposcopic view after acetic
acid

47. 21 yr old G0 P0 with LSIL pap,
CIN 1 on Bx
20 yr old with ASC-H on pap
andCIN 2 on Biopsy
Adolescent

48. Conclusion
 CIN 1 does not warrant therapy as most will
resolve spontaneously
 CIN 3 and CIN 2 are recognised cervical
cancer precursors
 They can be identified following both high
grade and low grade cytology
 The colposcopic features should allow
differentiation between CIN 1 and CIN 2/3