This lecture forms part of the BSCCP on line course for colposcopists

1. THE MANAGEMENT OF WOMEN
WITH CIN2 AND PERSISTENT
CIN1
Dr Grainne Flannelly
BSCCP colposcopy course on line 2013

2. Objectives
Principles of Unanswered
When to treat
management questions

3. Aims of cervical screening programmes
Detection and
treatment of high
grade
precancerous
lesions
Reduce the
incidence and
mortality of
cervical cancer

4. Treatment of CIN - in search of balance
Risk of Risk of
Cancer Harm

5. Prompt
diagnosis of
Compliance
high grade
CIN
Avoid Effective use
overtreatment of Resources
Core Issues

6. Therapeutic
Goals
What we are trying to Recognition of covert CIN-III
achieve
Treatment/Eradication of abnormal
cells
Return to normal cytology
Reassurance for woman

7. Natural History of HPV infection
Malignant
Infection
•Transmission by •Less than 20% Transformation •Loss of tumour
sex persist supressor gene
•Transient •Virus integrates
•Lifetime risk 80% - •No antibodies E2
most within 18 •Most resolve detectable
into host DNA
•Uncontrolled cells
months within 18 months division
Exposure Persistence CIN

8. Summary- management of Cin
Cin 3
• Cancer precurser
• Diagnosis reproducible
Cin 2
• Standard of care –
treat as Cin 3
Cin 1 • But heterogenous
• Evidence of transient group
HPV infection • Future more tailored
• Most will regress within management possible
18 months
• Evidence in favour of
expectant
management

9. Natural history of Cin – risk
assessment
Cin 1 Cin 2
• 60-80% regression 2-5 years • 40% regression
• 20% Cin 3
• <5% invasive cancer
Cin 3
• 31% invasive cancer
• 50% in subgroup presistent at 24
months

10. Natural history studies – warning unwrap
carefully
• Different populations
• Surveillance tools
• Initial histology
• Exit histology
• Definition of
progression/regression

11. Caveats – Biopsy process
• Type of TZ
• Size of lesion
• Consider more than one
(Massad, 2007)
Cervical lesions are
not uniform
Not like More like
this this

12. Caveats histology -Inter and intra-
observer differences
(Carrera JD, 2007)

13. Management of biopsy proven CIN 1
What was the presenting smear?
HSIL LSIL/ASCUS
Discuss at MDT
Consider repeat
and manage Surveillance
Biopsy
accordingly

14. Women with low grade abnormalities;
management at colposcopy- Tombola
Targeted punch
Comparison of immediate biopsies with
LLETZ versus biopsy and • Subsequent
deferred treatment treatment for
CIN2/3
• Cytological
• 60% of LLETZ showed surveillance for
no CIN grade I or less
• No difference in Immediate
cumulative detection of treatment with
CIN 2/3 LLETZ should be
avoided
BMJ 2009;339:b2548

15. Surveillance – for how long?
• Eighteen months – two years
• Risk of default is high particularly in
young women
• Tombola – UK – compliance 61%
• Eliat, Discacciati – Canada and Brazil –
Compliance 62%

16. CIN 2 - Time for a change in direction?

17. CIN 2 – Mixed bag
• HPV screening studies demonstrated an increased
yield of Cin 2 in young women
• Many of these lesions were transient – particularly if
they did not contain HPV 16
• Cin 2 in women under 25 may have a different course to
that in older women
• Expectant management of some is safe but should be part
of trials
Expectant management
For now - Cin 2 should should only be at age
be treated the same way less than 25, low risk of
as Cin 3 default and experienced
colposcopy (Petry, 2011)

18. Unanswered questions
Effectiveness of biomarkers in developing better
individualised treatment strategies for women with
Cin 1 and Cin 2
What will be the best management strategy in
vaccinated women with Cin?

19. Conclusion – we need to keep a close eye on
emerging evidence and make adjustments
accordingly