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Cervical Intraepithelial Neoplasm

Cervical Intraepithelial Neoplasm. Speaker: Tseng Jen-Yu. Introduction. Cervical cancer was the most common malignancy in both incidence and mortality among women prior to the 20th century

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Cervical Intraepithelial Neoplasm

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  1. Cervical IntraepithelialNeoplasm Speaker: Tseng Jen-Yu

  2. Introduction • Cervical cancer was the most common malignancy in both incidence and mortality among women prior to the 20th century • Incidence fallen dramatically in developed nations due to implementation of population based screening, detection, and treatment programs for pre-invasive disease

  3. Epidemiology and Risk Factor • 500,000 cases of cervical cancer diagnosed • 2nd leading cause of cancer death • Risk factors • Sexually transmitted disease • Human papilloma virus • Multiple sexual partners • Intercourse at early age • Poor personal hygine • Immunocompromise • Cigarette smoking

  4. Pathophysiology • Transformation zone • Area where glandular epithelium undergoes squamous metaplasia • Metaplasia • Occurs during fetal development / adolescence / and first pregnancy • Columnar cells replaced by squamous cells • Cells undergoing metaplasia are vulnerable to carcinogens

  5. Bethesda System • LSIL • Low grade squamous epithelial lesion • HSIL • High grade squamous epithelial lesion • ASCUS • Atypical squamous cells of undetermined significance • AGUS • Atypical glandular cells of undetermined significance

  6. Terminology and Definition • CIN I • Mild dysplasia ( lower 1/3 of epithelium ) • CIN II • Moderate dysplasia ( 2/3 of epithelium ) • CIN III • Severe dysplasia ( upper 1/3 of epithelium / CIS ) • Dysplasia • Disorder maturation / Nuclear hyperchromatism • Increased N/C ratio / Pleomorphism / Mitosis

  7. CIN I • Disease Profile • Self limited sexually transmitted HPV infection • 60% regress spontaneously • 30% persistent • 10 ~ 15% progress to CIN II / III • 1% progress to invasive cancer

  8. Treatment • Ablation ( cryotherapy / laser) • Excision ( LEEP / Knife conization ) • Follow up without treatment • Pregnant women • Immunosuppressed women • Adolescents

  9. CIN II / III • Disease Profile • 43% untreated CIN II spontaneous regression • 32% untreated CIN III spontanenous regression • 35% CIN II will persist • 56% CIN III will persist • 22% CIN II progress to CIS or invasive cancer • 14% CIN II progress to CIS or invasive cancer

  10. Treatment • Ablation ( cryotherapy / laser) • Excision ( LEEP / Knife conization ) • Follow up without treatment • Pregnant women • Adolescents

  11. ASCUS • Represent reactive / reparative changes secondary to inflammation • 5% of routine Pap smears • Treatment • Repeat Pap smear in 4 ~ 6 months • Colposcopy if repeat Pap shows ASCUS

  12. AGUS • Suspected glandular lesion that can’t be classified as reactive or neoplastic • Higher risk of neoplasia ( adenocarcinoma ) • 0.5 ~2.5% of routine Pap smear • Treatment • Colposcopy • Conization + ECC

  13. Colposcopy • Acetic acid • coagulation of nuclear protein preventing light to pass through the epithelium • Higher nuclear density and higher concentration of protein => white intensity increase

  14. Schiller / Lugol’s Iodine • Normal, mature squamous epithelium contains abundant glycogen • Produce dark brown stain • Abnormal epithelium contains relatively little or no glycogen • Remain relative unstained

  15. Cryotherapy • Indication • Cytology / Colposcopy / ECC => No microinvasion • Lesion in ectocervix • Criteria • CIN I / II • Small lesion • Ectocervix • ECC negative • No endocervical gland involvement

  16. Conization • Indication • Unsatisfactory colposcopy • Evidence of premalignant or malignant glandular epithelium • Microinvasion on biopsy / colposcopy / Pap smear • HSIL ( CIN II / CIN III ) • Uncertainty regarding presence of microinvsaion or invasion following direct biopsy for CIn • Inconsistent Pap smear and colposcopy

  17. Cold Knife • Indication • Lesion extend to endocervical canal and extent not possible to confirm • Extent exceeds capability of LEEP ( 1.5 cm ) • Cytology shows atypical glandular cells • Colposcopy suggest glandular dysplasia or adenocarcinoma • Abnormal endocervical curretage

  18. Thank You for your attention

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