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.
2 prof james bently differentiating high and low grade
1. COLPOSCOPY OF CIN;
DIFFERENTIATING HIGH GRADE
FROM LOW GRADE LESIONS
James Bentley , Professor Department of Obstetrics and Gynecology,
Dalhousie University, Halifax NS, Canada
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%
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
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
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
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
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