CIN - managment

1. Management of CIN
A. Alobaid, MBBS, FRCS(C), FACOG
Consultant, Gynecologic Oncology
Assistant professor, KSU
Medical Director, Women s Specialized Hospital
King Fahad Medical City

2. — Who to treat?
— When to treat?
— Treatment options
— Treatment principles
— Complications

3. CIN I
— CIN I preceded by LGSIL
— CIN I preceded by HGSIL

4. CIN I preceded by LGSIL
— Spontaneous regression is observed in most
women (80%)
— Expectant follow up is warranted
— Treatment acceptable if:
1. CIN I persists for more than 24 months
2. Relieve patient s anxiety
3. Patient at very high risk to follow-up

6. CIN I preceded by HGSIL
— There is 70% chance of having underlying CIN II, III
or worse
— Excisional diagnostic procedure Is generally
recommended
— An alternative approach is expectant management
with intensive monitoring

8. Adolescent women with
CIN I
— Undetected high grade disease is uncommon,
invasive cancer is rare, regression to normal is
common
— Expectant management is preferred

10. Pregnant women
— high rate of postpartum regression of CIN I to
normal
— Follow up is deferred until 6 weeks postpartum

11. CIN 2,3
— Prompt treatment is recommended with some
exceptions of pregnant women and adolescents

15. Treatment options
— Cryosurgery
— CO2 Laser Vaporization
— Electrocoagulation
— Sharp Conization
— Laser Excisional Conization
— Electrical Loop Excision
— Hysterectomy

16. Candidates for ablative
therapy
— Satisfactory colposcopy
— Negative ECC
— Cytology and histology that correspond to each
other
— Should be avoided in pregnant women and those
with previous treatment

17. Ablative techniques
— The principal disadvantage of these techniques is
that they do not provide a specimen for pathologic
evaluation
— The endocervical canal cannot be studied
effectively
— Ill-defined and ill-controlled tissue destruction
— Simpler, faster, and more hemostatic than
excisional techniques
— Greater late complications like reduced cervical
volume and cervical stenosis

18. Cryotherapy
— Office procedure using local anesthesia and
NSAID s
— Using refrigerant gas (CO2 or N2O)
— The ectocervix must be cooled to -20 C to cause
crystallization of intracellular water and destroy the
lesion
— It is achieved by forming an ice ball in the cervical
tissue that is at least 5 mm from the tip of the
probe

19. Cryosurgery
— A thin layer of water-soluble lubricant is applied
over the tip of the probe to allow more uniform and
rapid freeze of the cervix
— The probe should cover the entire lesion, and a 4-5
mm ice ball around the probe is required for an
adequate freeze
— Repeat freeze thaw cycles will produce greater
tissue volume destruction than single freeze cycles
for the same amount of time provided

20. Cryosurgery
— There is usually a watery discharge for 10-14 days
— The patient is re-evaluated after 4 months of the
treatment
— If the pap smear remains positive 6 months after
therapy, then cryosurgery is considered a failure
and the patient should be reevaluated and retreated

21. Criocirugia-YouTube.flv

22. CO2 laser
— Laser is directed at the lesion under colposcopic
guidance
— Water in the tissue absorbs the laser energy which
destroys the tissue by vaporization
— The lesion is ablated to a depth of 5 mm on the
ectocervix and 8-9 mm around the endocervix

23. Excisional therapy
— Cold knife conization
— Laser conization
— LEEP (LLETZ)

24. Treatment specifications
— Perform colposcopy during treatment phase to
obtain accurate view of the entire TFZ
— 3 mm margin is obtained around the abnormal TFZ
to allow for glandular involvement
— Obtain 1 cm endocervical margin for LGSIL
— Obtain 1.5 cm endocervical margin for HGSIL

25. Indications for excisional
therapy
— Unsatisfactory colposcopy
— Lesions extending into the endocervical canal
— +ve ECC
— Discrepancy between the cytology and biopsy results
— Suspected microinvasion
— Suspected AIS
— Invasive disease suspected
— Recurrence after previous treatment

26. Sharp Conization
— One of the oldest techniques
— Recommended for women with suspected
microinvasion and AIS
— The margins of the cone are plotted colposcopically
using acetic acid or Lugol s solution
— The configuration of the specimen is based on the
extent of disease
— Complications include: bleeding (immediate or
delayed), cervical stenosis, cervical incompetence

33. Laser Excisional Conization
— More precise than the cold knife cone
— Less blood loss but more thermal artifact
— Requires advanced training and skill

41. Colposcop?aCono-l?ser-YouTube.flv

42. Electrical Loop Excision
— Appears to be the current treatment of choice
— Done on an outpatient basis
— Advantages include: simplicity, low expense, short
learning curve
— Does not increase the risk of preterm deliveries
— Complications may include bleeding and large
excisions

43. Electrical Loop Excision
— Should be performed under colposcopic guidance to the
peripheral extent of the abnormal TFZ
— The patient is grounded
— Local anesthetic is injected just beneath and lateral to the lesion
— The cutting current is set at 35-60W
— The diameter of the loop must be large enough to encompass
the entire lesion
— A second excision of the endocervical canal using a smaller loop
may be used for high grade lesions
— Ball coagulation is set at 60W
— The base is coagulated even if there is no bleeding (non-touch
coagulation)

53. Colposcop?a-ConodeCÈrvix-YouTube.flv

54. Conizacion cervical v final - YouTube.flv

55. Complications
— Intraoperative bleeding
— Postoperative bleeding: early or delayed
— Infection
— Cervical stenosis

56. Hysterectomy
— If there is coexistent gynecologic conditions
requiring hysterectomy
— Patient request and persistent or recurrent CIN 2,3

57. Reproductive outcome
— Cold knife conization is the only treatment modality
that increases the risk of perinatal mortality and
preterm delivery
— During pregnancy, surveillance with serial TV
ultrasound for cervical length measurement is
recommended for patients who had CKC

58. Prognosis
— The rate of recurrent or persistent CIN is 5-17%
following any treatment modality
— Higher rates of persistent disease are associated
with:
1. Large lesion size
2. Endocervical gland involvement
3. Positive margin status
4. Positive HPV DNA positivity after treatment

59. Thank you