Cervical Intraepithelial Neoplasia Procedures

Aka: Cervical Intraepithelial Neoplasia Procedures, CIN Management, Excisional Procedures for CIN Treatment, Ablative Procedures for CIN Teatment, Loop electrosurgical excision procedure, LEEP, Cervical Conization, Cervical Cone Biopsy, Cold Knife Conization

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II. Procedures: Diagnostic Excision

  1. Indications
    1. Colposcopy with CIN 2 or 3 on biopsy
    2. Persistent CIN 1 (for at least 2 years)
    3. Unsatisfactory Colposcopy with CIN Pap Smear
  2. Techniques: LEEP
    1. Office based procedure under Local Anesthesia
    2. Increased risk of Preterm Labor and low birth weight (but not extreme prematurity as with Cold Knife Conization)
    3. Post-LEEP cervical stenosis risk (if excessive cautery of crater rim)
    4. Cautery artifact occurs at excision margins (does not occur with Cold Knife Conization)
      1. LEEP histology has a high False Negative Rate
      2. Follow all dysplasia closely regardless of histology
      3. Livasy (2004) Obstet Gynecol 104:250-4 [PubMed]
    5. Post-procedure bleeding
      1. Perform LEEP procedure during Follicular Phase
      2. Luteal Phase associated with heavy bleeding
      3. Paraskevaidis (2002) Obstet Gynecol 99:997-1000 [PubMed]
  3. Techniques: Cold-knife conization
    1. Preferred if margin status is critical to determining residual disease (e.g. adenocarcinoma in situ)
    2. Increased adverse effects over LEEP
      1. Increased risk of extreme Preterm Labor and delivery (<28 weeks) at low birth weights (<2 kg)
      2. Higher risk of bleeding than LEEP
      3. Removes more tissue than LEEP

III. Procedures: Ablation

  1. Indications
    1. Colposcopy with CIN 2 or 3 on biopsy (HGSIL)
      1. Not recommended for recurrent lesions (excision is recommended)
    2. Persistent CIN 1 (LGSIL) for more than 2 years
      1. Not recommended for initial finding of CIN 1 (initial observation is preferred)
  2. Contraindications
    1. Unsatisfactory Colposcopy (Invasive cancer not ruled out)
    2. Entire lesion not visualized
    3. Abnormal endocervical curettage
    4. Lesion larger than 2 quadrants
  3. Acceptable Techniques of ablation
    1. Cryotherapy
    2. Electrofulguration
    3. Laser ablation
    4. Cold Coagulation
  4. Unacceptable Techniques
    1. Podophyllin or similar products
  5. Advantages
    1. Similar outcomes when compared with LEEP and conization as long as adequate Colposcopy and no contraindications
    2. Removes less tissue than excisional techniques
      1. Cryotherapy and laser ablation have no increased risk of Preterm Labor
      2. Laser conization associated with Preterm Labor risk if conization depth >10 mm
  6. Disadvantages
    1. No tissue available for histology

IV. Management: Post-procedure surveillance

  1. Excisional techniques with positive margins for CIN 2-3
    1. Repeat Colposcopy with biopsy and ECC at 4-6 months
    2. If positive at that time, re-treat, re-excise or offer Hysterectomy
  2. Excisional technique with negative margins (or post-ablation)
    1. See specific protocols for (CIN 1, CIN 2 and CIN 3, as well as ASC-US, ASC-H, ASGUS)

V. References

  1. Apgar (2013) Am Fam Physician 87(12): 836-43 [PubMed]
  2. Burness (2020) Am Fam Physician 102(1): 39-48 [PubMed]
  3. Massad (2013) J Low Genit Tract Dis 17(5 suppl 1):S1-S27 [PubMed]
  4. Wright (2003) Am J Obstet Gynecol 189:295-304 [PubMed]

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