Cervical Intraepithelial Neoplasia

Cervical intraepithelial abnormalities are usually first detected by cytology screening. Treatment of cervical intraepithelial abnormalities is typically undertaken after a histologic abnormality has been proven by tissue biopsy.

I. Atypical squamous cells (ASC) is a cytological screening diagnosis that does not require treatment. ASC does require further evaluation to exclude the presence of higher- grade disease that might require treatment. Treatment may be initiated if there is biopsy proven dysplasia.

II. Low-grade lesions. Low-grade precursors of cervical cancer have been called low-grade squamous intraepithelial lesions (LSIL), low-grade cervical intraepithelial neoplasia (CIN I), and mild dysplasia. A. Management

1. Expectant management is preferred for the reliable patient with biopsy-confirmed CIN I in whom the entire lesion and limits of the transformation zone are completely visualized (ie, satisfactory colposcopic examination). If treatment is desired, ablative or excisional modalities are appropriate. An excisional procedure is the preferred diagnostic/therapeutic approach in all women if colposcopic examination is unsatisfactory.

2. Expectant management of women with biopsy confirmed CIN I and satisfactory colposcopy requires follow-up HPV testing at 12 months. In addition:

a. Colposcopy should be repeated if repeat cytology shows ASC or greater or HPV DNA testing is positive for a high-risk type.

b. After a negative HPV DNA test, annual screening may be resumed.

3. A lesion that persists after 1 to 2 years or any progression during the follow-up period suggests the need for treatment. Close follow-up should be continued for persistent CIN I; treatment should be provided if there is evidence of disease progression. Ablation and excision are both acceptable treatment modalities for women with satisfactory colposcopic examinations. Endocervical sampling is recommended before ablation and excision for recurrent disease after ablation.

III. High-grade lesions. High-grade squamous intraepithelial lesions (HSIL) include CIN II or III, moderate and severe dysplasia, and carcinoma in situ. Forty-three percent of CIN II lesions regress if left untreated, while 22 percent progress to carcinoma in situ or invasive cancer. For CIN III, the spontaneous regression rate is 32 percent, and 14 percent progress to invasive cancer if untreated.

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