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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
- 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
- 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)
- 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