GYNECOLOGY

2.2 Cervical Intraepithelial Neoplasia (Rey H. delos Reyes, MD, FPOGS)

Date: January 25, 2016
FEU-NRMF MEDICINE BATCH 2017
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INCIDENCE OF CERVICAL CANCER IN THE PHILIPPINES RISK FACTORS
(SOURCE) 2010 Philippine Cancer Society Cancer Facts and RISK FACTOR RELATIVE RISK
Estimates) HIV Very High
→ Second most common among women (11% or 11/100 women or
Moderate Dysplasia on Pap Smear Very High
11.7 / 100,000
within past 5 years
→ 4,812 estimated new cases will occur
Intercourse within 1 year of menarche 16
→ Estimated national standardized mortality rate = 5.3/100,000
No prior screening 10
→ 1,984 deaths in 2010
HPV (depending on subtype) 2.5-3.0
o 56% of Filipino women with cervical cancer will die within 5
Six or more lifetime sexual partners 5
years
Low socioeconomic class 5
o About 2/3 of cervical cancer is diagnosed in the advanced
Race (black vs. white) 2.5
stage (Stage IIIB), where mortality is high
Smoking 2
o <20% are diagnosed with stage 1 Current smoker 3.42
o Median survival 76 months Previous smoker of ≥5 pack 2.81
o Five year survival rate is 51.7% years
→ Incidence starts rising steeply at age 30 OPC use 1.2-1.5
→ Fifth leading site for both sexes (6%) Barrier contraception 0.6
nd
→ Developed countries – MC is breast, 2 is lung/endometrial CA → Most common culprit is HPV infection (99.7%), that will progress to
(Cervical CA is not even in the top 10)
low grade CIN, then high grade CIN, then becomes your invasive
→ According to DOH, 10% chance of having cervical CA in 30 years
old, and 56% at age 65 years Cervical CA
→ Progression from HPV infection to low grade may take several years
UTERINE CERVIX and to high grade squamous epithelial lesion may take 5-10 years
→ Estimated new cases → Progression to invasive cervical CA may take 15-20 years
o 12,340 cases of invasive cervical cancer are expected to be → Peak age incidence is 45 – 50 years old
diagnosed in 2013 → Early age at first intercourse and multiple sexual partners were the
o An estimated 11,070 cases of invasive cervical cancer are most consistent risk factors. (“EARLY” - a year after menarche)
expected to be diagnosed in 2008. Incidence rates have → It is clear that women who have a compromised immune system
decreased steadily over the past several decades in both
from any cause have a greater risk of developing persistent HPV
white and African American women. As Pap screening has
become more common, pre-invasive lesions of the cervix are infection
detected far more frequently than invasive cancer. → In the Philippines, it is prevalent due to poor screening knowledge of
→ Estimated deaths individuals. “Opportunistic screening” is where we just screen when
o 4030 deaths from cervical cancer are expected in 2013 they come in to our clinic, we don’t encourage them to have their
o An estimated 3,870 deaths from cervical cancer are screening. If there is a proper program for screening, then we can
expected in 2008. Mortality rates have declined steadily over detect the early lesion, treat properly and prevent Cervical CA.
the past several decades due to prevention and early → SMOKING is the only other independent risk factor which increases
detection as a result of screening. the risk for CIN 3 as much as a factor of 3.
→ Majority of cases are associated with infection of one or more types
LOCAL REGISTRY OF THE DOH of HPV which is sexually transmitted. (source) Walboomers et al
→ Increasing rate of Cervical CA from 10.1% at age 30 years old to 1999
56.3% at age 65 years old. o Human papillomavirus (HPV) showed a very strong
association. After adjusting for the strong effect of HPV, the
following significant risk associations remained: early age at
first sexual intercourse, increased number of sexual partners
and parity and decreased risk with a history of Pap smear
o The prevalence of all HPV types in the cases was 93.5% in
squamous cell carcinoma, 90.7% in adenocarcinomas and
9.2% in controls
o The most common HPV types in decreasing frequency
among cases were HPVs 16, 18, 45, 52, 58 (95% CI OR =
31–392). In squamous cell carcinoma, common types were
HPVs 16, 18, 45, 52 and 58; whereas it was HPVs 16, 18
and 45 in adenocarcinomas; in contrast to normal cervices,
HPVs 16, X, 18, 45, 6, MM4, 31, 52, 11, 54 and IS39
o A single novel HPV designated IS39 was identified which is
closely related to another novel virus, W13B (MM4), and its
variants and HPV 51
o The prevalence of antibodies to HPV 16 virus-like particles
(VLP) is higher in squamous cancers (47%) than in controls
(25%) and it is higher in cases where HPV 16 DNA is
detectable in cervical cells (62%). However, the sensitivity
and specificity of the serological assay are lower than that of
HPV DNA

JOSE TORRES III, RN, EMT 1

 o A 9.2% HPV (+) among normal cervices of Filipino women is → lA cancer associated HPV type causes neoplastic cellular changes
similar to other studies. HPV infection in women with normal when its DNA becomes integrated into the host cell genome à
cervices varies from 16.8% in Brazil to 4.6% in Spain, with certain repressor areas of the viral genome are lost.
predominant HPV DNA 16. Despite the compelling evidence
for an etiological role of HPV in cervical carcinogenesis,
when the prevalence rates of HPV in the normal population
are compared with the incidence of cervical cancer,
additional factors must be active in its carcinogenesis and it
may be premature to utilize HPV testing in the clinical setting.
o Prevalence of HPV in cervical cancer in 22 countries
including the Philippines indicated that HPV DNA was
detected in 93% of tumors, with no significant variation in
HPV positivity, with common HPVs 16, 18, 45 and 31. HPV
16 predominated in squamous cell tumors and HPV 18 in
adenocarcinoma and adenosquamous tumors. HPV 16 was
the predominant type in all countries except for Indonesia,
where HPV 18 predominated. A clustering of HPV 45 was
apparent in western Africa, while HPVs 39 and 59 were → A cancer associated HPV causes neoplastic cellular changes when
almost entirely confined to Central and South America. its DNA is integrated into the host cell genome. This causes certain
HUMAN PAPILLOMA VIRUS repressor areas of the viral genome to be LOST. As a consequence,
Low risk HPV 6, 11, seen in CIN I or Condyloma the loss of this control mechanisms allows the expression of the viral
40, 41, 42 acuminata (most common causing E6 and E7 genes. This codes for production of oncoproteins that
genital warts - 6 and 11 ) inactivate p53 and retinoblastoma repressors which leads to cell
Intermediate HPV 31, 33, seen in HSIL (CIN II/III) immortalization and rapid cell proliferation.
risk 35, 51, 52 → In certain individuals, however, the transformed cells are managed
High risk HPV 16, 18, seen in invasive CA (70% comes by the individual’s immune system and the infection or the
45, 56 from types 16 and 18, 85% others) intraepithelial neoplasia is defeated. FOR SOME WOMEN, FOR
→ 40 types of HPV are known to infect the genital tract of men and POORLY UNDERSTOOD REASONS, THE TRANSFORMED
women. Of these at least 13 are associated with Cancer. CELLS BEGIN TO REPLICATE AND IF UNTREATED, DEVELOPS
TRANSFORMATION ZONE INTO CANCER AFTER SEVERAL YEARS.
HPV Vaccines
→ Bivalent (16,18)
→ Quadrivalent (6, 11, 16, 18)
→ Three doses (0, 1, 6 months)
CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN)
→ A premalignant lesion; Grading is dependent on the percentage of
thickness of epithelium that shows cells with nuclear atypia.
CIN 1: Histopathology (Grade 1)
→ The location wherein Cervical CA start
→ It is developed when columnar is converted to squamous epithelium
→ During puberty, there is a physiologic eversion of the cervix, the “new
SCJ” that was formerly located inside, is now exposed to the vaginal
wall and it’s pH, and the “original SCJ” is shifted laterally, thus, with
the new environment, from columnar epithelium transforming into
squamous (transformation zone, as a form of metaplasia)
→ With HPV infection, the transformation zone is altered, and thus
resulting into malignant transformation then into cervical CA
→ Markers of transformation zone: Cervical Opening → Histologic changes known as CIN 1 or mild dysplasia is a result of
→ Eversion of cervix occurs not only in puberty but also in pregnancy HPV infection. Usually, these disappear SPONTANEOUSLY within
(most especially after delivery); multiparous women have bigger weeks to months. In a few, for unexplained reasons, these are
transformation zone compared to nulliparous persistent and the virus becomes integrated into the host genome
How does HPV causes carcinoma? allowing for development of malignant transformation. This process
→ Integration/Incorporation of DNA of cancer associated HPV into the is SLOW and takes several years.Involves 1/3 or less of epithelium.
host cell genome Cytology: Koilocytes
→ Initial indications of HPV infection

JOSE TORRES III, RN, EMT 2

CIN 2 (Grade 2) DIAGNOSIS OF PREMALIGNANT LESION OF THE CERVIX
Screening tools
→ Cytology (most popular)
o Conventional (Pap Smear)
o Liquid based
→ HPV DNA testing (to determine if high risk or low risk
→ VIA (Visual inspection with Acetic Acid)
→ VILI (V.I. with Lugol’s Iodine)
→ CIN 2-involves ½ to 2/3 of epithelial thickness.
→ The process is still reversible at this stage with 40% disappearing
CONVENTIONAL CYTOLOGY (PAP SMEAR)
spontaneously without treatment
CIN 3 (Grade 3) → 3 sites to get smears: endocervical sample, transformation
zone, lateral vaginal wall (for maturation index; to determine what
hormone is predominant during sampling)
→ Because the vaccines currently
available do not provide protection
against all cancer-associated HPV
tyoes, screening Pap test will need
to be continued indefinitely.
→ ACOG 2009: Pap test beginning at
→ CIN 3/Ca in situ-involves full or almost full thickness; severe age 21.THIS CHANGE TO AN
dysplasia. OLDER AGE OF ONSET OF PAP
→ Believed to be the PRECURSOR to invasive Ca, TREATMENT IS TESTING IS BASED ON THE
RECOMMENDED. ABOUT 1/3 of these lesions may disappear FACT THAT THE RISK OF INVASIVE CERVICAL CANCER IN A
spontaneously WOMAN <21 IS ONLY 1 IN A MILLION.
CIN
→ Frequency remains controversial.. Annual testing used to be the
norm in the US but other developed countries have seen similar
incidence of cervical cancer with less frequent testing. In future bi-
or triennial testing maybe the norm and that testing for high risk
HPV-DNA will be accepted as an alternative to cytology for those
>30 years of age.
→ Combination maybe the most effective for women >30 y.o. If both
are negative, the risk of HSIL during the nest 3-5 years is very low
→ ANNUAL PAP TEST IS ACCEPTABLE BUT UNNECESSARY
→ It takes several to many years for CIN to progress to invasive cancer. FOR MOST WOMEN
→ Treatment at anytime during the intraepithelial stage will halt further → Sensitivity – 67-90%, Specificitiy 60-70%, False Positive 5-10%,
progression.
False negative 20-40%
→ There is even an early stage of microinvasive cancer as identified
by colposcopy.
COLLECTING DEVICE IN LOW RESOURCE SETTING
→ First photo (Ayer’s
spatula)
→ Spatula and cotton
swab in low
resource setting
→ Endocervical
sample (Use cotton
pledget applicator
FIG. Diagram of cervical epithelium showing various terminologies used or cytobrush/ cervix
to characterize progressive degrees of cervical neoplasia brush)
→ SIL grading pertains to cytologic specimen while CIN grading → When you use
pertains to tissue specimen Cervix brush
(rightmost photo), the tip is for endocervical sample and the side
CIN I Lower third layer takes the transformation zone samplex
Presence of Koilocytes with mild dysplasia → Dipping of the cotton applicator in saline will increase the yield of
CIN II Involves the lower and middle third endocervical cells
CIN III Involves the upper third / entire thickness → Advantage of Cervix brush is that when you use the liquid based
→ >12% of CIN 3 will progress to cervical CA whereas 1% of CIN 1 will cytology, you just remove tip and placed in a preservative and
brought to the lab then process it
progress
Natural History of CIN (From Ostor , 1993)
NORMAL CYTOLOGY
CIN Regression % Persistence Progression to Progression to
% CIS % Invasion % SUPERFICIAL CELLS Young women (due to estrogen)
1 57 32 11 1 PARABASAL CELLS Post Menopausal women
2 43 35 22 5 INTERMEDIATE CELLS Pregnant (more progesterone)
3 32 <56 >12 INTERMEDIATE AND Mid part of mens cycle
METALASTIC

JOSE TORRES III, RN, EMT 3

→ Can be reported as “Negative for Intraepithelial lesion” or → The second abnormality is ASCH which means that there are cells
“malignancy – no cytologic evidence of neoplasia” that are worrisome for a significant lesion but are too few in number
→ LSIL - ALMOST ALL of these women were HPV-DNA positive. LSIL
THE BETHESDA SYSTEM REPORTING CERVICAL CYTOLOGY is usually consistent with histology reports of CIN 1 + HPV and/or
ADEQUACY OF SAMPLE mild dysplasia. But it is not possible at present to pick out which
SATISFACTORY UNSATISFACTORY women will have the potential to progress to a higher lesion.
→ The presence or absence of an → If a slide is categorized as → HSIL- women with this often have CIN 2 or 3 and very occasionally,
endocervical or transformation such, the reason should be cancer.
zone component (which specified. → If solid evidence of carcinoma is present in the smear then this will
consists of intermediate and → Obscuring elements be reported. This is rare for countries with good screening programs.
metaplastic cells) (inflammation, blood, drying
→ Other quality indicators partly artifact others) cover more → Cells resemble superficial or intermediate squamous
obscuring inflammation or than 75% of epithelial cells ASCUS cells in size & configuration
blood → Nuclei: 2-3x the size of the normal intermediate cells
→ Round to oval with minimal irregularities
→ THE FIRST PART of the TBS states whether the sample is → Normochromatic to slightly hyperchromatic
satisfactory or unsatisfactory. Unsatisfactory results include: lack of ACSH → Parabasal or basal cells in size & configuration
label, loss of transport medium, scant cellularity, or contamination by → Often have uneven chromatin distribution & are
foreign material. Liquid based cytology will have less unsatisfactory hyperchromatic
results than the traditional Pap → Contour is often irregular
→ If abnormalities are found on an otherwise unsatisfactory slide, it will, → Requires further investigation
by definition, be considered satisfactory for interpretation LSIL → Parabasal cells with nuclear enlargement, irregular
nuclear outlines and coarse chromatin (hyperchromatic
CONVENTIONAL VS. LIQUID BASED CYTOLOGY (LBC) nucleus and binucleation)
HSIL → Intermediate and parabasal cells with nuclear
CONVENTIONAL enlargement, irregular nuclear outlines
→ Require special care to avoid drying of cells
→ Fixation is carried out immediately by spray or immersion GLANDULAR CELL ABNORMALITIES
→ Can be obscured by blood, mucus, and inflammation → Atypical glandular cells, specify site of origin, if possible
→ The conventional Pap smear is made by hand; the physician → Atypical glandular cells, favor neoplastic
"smears" the sampling device across a microscope slide to → Adenocarcinoma in situ
spread a layer of cells. Each physician may do it differently,
→ Adenocarcinoma
leading to some slides with thick lumps and clumps, and some
slides with clear areas of no cells → OTHER CANCERS (e.g. lymphoma, metastatic, sarcoma)
→ Up to 90% of those False Negatives are due to limitations of * This is seen in about 3 for every 1000 samples. The classification is long
sampling or slide preparation and complicated
→ Discarded after a single conventional smear is done
LBC Atypical Glandular Cells
→ Sampling and cell transfer to a liquid medium → Lacks the diagnostic features of AdenoCA, irrespective of whether
they are endometrial or endocervical origin
→ Preserves the cells and minimizes cell overlap, blood, mucus, → Sheets of atypical glandular cells with enlarged nuclei with similar
and inflam-mation. It creates a mono-layer, a layer one cell thick, chromatin pattern in all cells
with no overlapping cells → There is not enough evidence to recommend or to discourage the
→ The ThinPrep® Pap Test® makes Pap smear slides by an use of liquid-based cytology as an alternative screening for CIN2+,
automated slide preparation unit, the ThinPrep® 2000 Processor, as compared to conventional cytology provided that the conventional
that produces uniform thin-layer slides, a one-cell thick cytology is satisfactory. (PSCPC)
→ If you are in an area with limited facilities, one may use conventional
monolayer, virtually free of obscuring artifacts such as blood,
cytology provided there is proper collection of Pap smear and the
mucous, and inflammation handling of the specimen during processing followed the standard
→ Return of visits and repeat Pap smears is diminished. procedures.
→ Residual LBC can undergo testing for HPV, herpes simplex virus, CERVICAL CYTOLOGY SCREENING GUIDELINE
N. gonorrhea, C. trachomatis Primary HPV DNA Testing
USPSTF Recommend against screening for cervical cancer
SQUAMOUS CELL ABNORMALITIES 2012 with HPV testing (alone or in combination with
o Atypical squamous cells (ASC) cytology) in women aged <30 years.
§ ASC of undetermined significance (ASCUS) (D recommendation)
§ ASC cannot exclude high grade lesion (ASCH) ACS- For women aged 30-65 years, screening by HPV
o Low grade squamous intraepithelial lesion (LSIL) ASCCP testing alone is not recommended in most clinical
o High grade squamous intraepithelial lesion ( HSIL) 2012 settings.
o Squamous cell carcinoma (Weak recommendation)
→ These indicate whether the cellular material is normal. If not normal, ACOG 2012 Not Addressed
the abnormalities are further divided into SQUAMOUS AND
PSCPC There is limited evidence to recommend the use
GLANDULAR. If there is an infection, comment on “presence of
Sept. 2012 of primary HPVDNA Testing in asymptomatic
infection” may also be included. women aged 30 years old and above as an
→ SQUAMOUS ABNORMALITIES are seen in 5%-6% of samples. The
alternative screening method for cervical cancer
MOST common is ASCUS. This means that the cells show features USPSTF - US Preventive Services Task Force
of squamous lesions but there are few of these cells or the changes ACS, ASCCP - American Cancer Society, American Society for Colposcopy and
are not consistent. ASC-US occurs in 3-5% of samples. Cervical Pathology
→ MOST ASCUS ARE NOT ASSOCIATED WITH HSIL. Some ACOG - American College of Obstetricians and Gynecologists
ASCUS maybe due to infections, premalignant, or cervical CA itself. PSCPC – Philippine Society of Cervical Pathology and Colposcopy

JOSE TORRES III, RN, EMT 4

→ Co testing with HPV DNA testing and cytology may be used as an → Beneficial for areas where pap testing is not
alternative screening tool to increase the detection of CIN2+ in readily available due to lack of cytopathologists
women aged 30 years and above. or cytotechnicians
HPV Co-test → LBC (or any other cytology) and HPV-DNA
VISUAL INSPECTION USING ACETIC ACID (VIA) (Co- testing) testing done SIMULTANEOUSLY regardless
of cytology result
→ May be used as an alternative screening tool in
increasing the detection of CIN 2+ (incudes
CIN II, CIN III, and invasive ca in-situ) in
women 30 years old and above
HPV Reflex → Performance of HPV testing only in response
to an abnormality to stratify risk and guide
further management.
→ LBC done first, if with (+) findings, then do HPV
DNA testing
Endometrial → Includes obtaining a specimen for histologic
sampling evaluation using an endometrial biopsy,
dilation and curettage, or hysteroscopy.
Endocervical → Includes obtaining a specimen for either
sampling histologic evaluation using an endocervical
→ 3-5% Acetic acid curette or a cytobrush or for cytologic
→ (+) result if cervix whitens evaluation using a cytobrush.
→ Reporting: Endocervical → Process of evaluating the endocervical canal
o No Acetowhite (AW) lesion (negative) - first upper two rows Assessment for the presence of neoplasia using either a
o Ill-defined faint transluscent AW lesions colposcope or endocervical sampling.
o AW of endocervical polyps, nabothian cysts Diagnostic → Process of obtaining a specimen from the
o Prominent AW of the SCJ Excisional transformation zone and endocervical canal for
o Dot like AW scattered all over the cervix Procedure histologic evaluation and includes laser
o Geographic satellite AW lesions not touching the SCJ conization, cold-knife conization, loop or
→ Reporting: (Accdg to delos Reyes) needle electrosurgical excision, and loop
o Negative for AW lesion (r/o leukoplakia or candida infection, electrosurgical conization
if it is white even before pouring the acid) Lesser → Those that carry lower risk of CIN 3+ than other
o Positive for AW lesion abnormalities results. These include negative cytology with
o Malginant/Cancer (gross lesion of CA) either HPV-16 or HPV-18 or persistent untyped
→ In areas where facilities for conventional cytology are not available, oncogenic HPV, ASC-US, and LSIL. (CIN 2
the use of visual inspection with acetic acid (VIA) is an acceptable and below)
alternative screening method for cervical cancer in asymptomatic
women. (*No cytoscreeners, cytopathologists, materials, laboratory for CERVICAL CYTOLOGY SCREENING GUIDELINES
processing etc) PSCPC SEPTEMBER 2012
→ “Right now, the government is embarking on having VIA as the When to start → 3 years after onset of vaginal intercourse, but
national cervical ca screening tool in less developed areas” no EARLIER than 21 years (The guideline is
talking about patients with low risk; with High
VISUAL INSPECTION WITH LUGOL’S IODINE risk patients, screening can be done <21 y/o)
Principles of “Schiller’s test”: → Why 21? Because Cervical CA is rare in less
→ Application of Lugol’s Iodine than 21 y/o
→ Uptake of Iodine by glycogen-rich epithelium (normal 21-29 years old → Not recommended
epithelium) 30-65 years old → Every 5 years (Co-testing)
o Color: Mahogany brown or black
o Mature Squamous Epithelium Both 21-29 and 30-65 (high risk)
→ Glycogen - deficient epithelium → Due to the disease burden in the local setting
o Color: Partial staining or thick mustard yellow either ANNUAL screening using
o Immature squamous epithelium, columnar, conventional cytology or BIENNIAL
leukoplakia, CIN, cervical cancer screening with LBC (GPP)
→ There is limited and poor quality evidence to recommend the >65 years old → After 65 years old, continue Annual
use of visual inspection with Lugol’s Iodine (VILI) as an screening. After three (3) negative tests,
alternative screening method. you do BIENNIAL screening (every other
year) using LBC, or Co-testing with DNA
TERMINOLOGIES test every 5 years
Post → If the lesion removed is benign, no further
HPV Typing → Determines if the patient is of HIGH or LOW hysterectomy screening are done
risk → If the indication for hysterectomy was
→ High Risk (oncogenic ) HPV types (mainly 16, malignant condition, screening should
continue, recurrence is still high
18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59)
HPV-DNA → Adjunct SCREENING with Pap testing for PAPANICOLOAU SMEAR ACCURACY
Testing women 30 years old and above → Sensitivity: 67% - 90.6%
→ Appears to be more sensitive than pap testing → Specificity: 60% - 70%
→ False Positive: 5% - 10%
→ False Negative: 20% - 40%

JOSE TORRES III, RN, EMT 5

FIRST STEP IN EVALUATION OF WOMAN WITH ABNORMAL LSIL (CIN I)
CERVICAL CYTOLOGY REPORT → Small amount of nuclear protein, lower 1/3
SQUAMOUS LESIONS: epithelium
→ ASC-US → Appearance of whiteness is delayed and
o HPV DNA testing (as to Reflex HPV, since nag less intense
positive na) for high risk types HSIL (CIN II-III)
o Repeat PAP test in 6 months (low risk) → Greater amount of nuclear protein, 1/3 to
o Colposcopy (mandatory for high risks) full thickness of the epithelium
→ ASC-H: Colposcopy → Appearance of whiteness is densely
→ LSIL: Colposcopy or HPV DNA testing white, opaque and immediat
→ HSIL: Colposcopy
GLANDULAR LESIONS: Principles of Observed Vascular Features
→ All reports require colposcopy and further evaluation if → Vasculature patterns observed after application of saline solution.
negative Use green filter.
→ Mosaic and Punctations, vessels of abnormal caliber
From Bernabe Trans

COLPOSCOPE
→ A low-power binocular microscope with a powerful light source that
is focused 30 cm beyond the front objective. Its useful magnification
is from 3x to 15x (accdg to ppt, but 10-40x sabi ni doc)
→ The instrument is placed just outside the vagina after a speculum
has been inserted and the cervix is brought into view.
→ Mucus is removed with a swab and normal saline and the cervix is
then examined. Dilute acetic acid is then applied and after 30 secs,
cervix is reexamined.
→ A green filter is used to highlight the whiteness of the cervical
epithelium
→ Then, Lugol’s Iodine is applied for confirmation

Colposcopic Features TREATMENT METHODS IN CIN

→ COLOR tone & INTENSITY of acetowhitening (oyser white) Goal of Treatment
→ MARGINS and SURFACE CONTOUR → To remove the lesion and any technique that accomplishes this
→ VASCULAR features goal can be used. Tx is office-based
→ COLOR CHANGES after iodine application (Schiller’s test) → Hysterectomy is not recommended (in purely CIN, if she has
completed her reproductive career)
Results of Colposcopy → ABLATION METHODS
→ Satisfactory colposcopy o Cryotherapy (easily available)
o Margins of the lesion(s) and the entire SCJ are visible o Thermoablation
→ Acetowhite o CO2 laser ablation
→ Leukoplakia → EXCISION METHODS
→ Punctation o LEEP or LLETZ
→ Mosacism o LEEP (Loop electrosurgical excision procedure)
→ Atypical Blood vessels o LLETZ (Large loop excision of the transformation zone)
o Cold Knife Conization (surgical)
Principles of Acetic Acid Test in Colposcopy
→ 3-5% Acetic Acid (same principle with VIA, but this time there is
magnification and the use of green filter)
CIN 1 → Treatment is no longer recommended at any age.
→ Swelling of epithelial tissues
→ Reversible coagulation of nuclear proteins and cytokeratins → Exception is when the lesion persists for at least 1 year.
→ The exact mechanism of action has not been determined. The acetic → In those < 21, tx is not recommended unless persistent
acid causes several areas of increased nuclear density to be seen for >24 mos.
and distinguished from normal epithelium. → Almost all CIN 1 is a manifestation of transient HPV and
→ Acetowhitening (AW) is NOT UNIQUE to CIN. There are other is far removed from cancer thus is not considered a
conditions with AW: serious finding. Patients are followed up to ensure
o Immature squamous metaplasia
regression
o Inflammation
o Leukoplakia
o Condyloma CIN 2 → About 40% regresses spontaneously
→ Women <21 are not treated.
Normal Squamous Epithelim → Older than 21 are followed and treated IF condition
→ Lesser coagulation progresses to CIN 3
→ Superficial cells are sparsely nucleated CIN 3 → Most Cases persist or in some progress to CA so these
→ Coagulation insufficient to block color of lesions are treated and long term follow-up is needed.
underlying stroma
Cervical Intraepithelial Neoplasia (CIN)
→ Cells have high nuclear content Thank you pretty girl Doyenne Sadicon <3
→ Maximal coagulation
→ Sub-epithelial vessel pattern is obliterated

JOSE TORRES III, RN, EMT 6