Case Presentations:
Pre-Invasive Cervical Neoplasia
Kathleen M. Schmeler, M.D.
Assistant Professor
Department of Gynecologic Oncology
Case #1
• 25 yo
• Smokes 1 pack of cigarettes per day
• Routine Pap test: high-grade squamous
intraepithelial lesion (HSIL)
• Next step?
Case #1
• Cervical biopsy: CIN 3
• Endocervical curettage: CIN 3
CIN 2/3
• 5% of women undergoing Pap tests in the USA
• Typically diagnosed between age 25 and 35
years
• Progresses to cancer 8 to 13 years after a
diagnosis of CIN 2/3
• Caused by persistent infection with high-risk
HPV subtypes
• HPV infection is necessary but not sufficient to
develop CIN 2/3
CIN 2/3 Co-Factors
• HIV infection
• Immunosuppressive therapy (renal
transplant, chemotherapy)
• Cigarette smoking
Case #1
• Treatment for CIN 2/3?
Cervical Conization
1. Cold knife conization (CKC)
2. Loop electrosurgical procedure (LEEP),
also known as large loop excision of the
transformation zone (LLETZ)
3. Laser conization
** Hysterectomy should not be performed
as the initial treatment for CIN 2/3
Complications of LEEP/CKC
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Intraoperative or postoperative bleeding
Infection
Cervical stenosis
Infertility
Pregnancy loss/Preterm birth:
- CKC = 14% preterm birth rate
- LEEP = 11% preterm delivery rate
Prognosis
Untreated CIN 3:
• Risk of cancer is 20% at 10 years and 31%
at 30 years
Treated CIN 3:
• Risk of cancer is 0.3% at 10 years and
0.7% at 30 years
McCredie et al., Lancet Onc, 2008
Hysterectomy
• Hysterectomy should NOT be performed as
initial treatment for CIN 2/3
• Hysterectomy indicated if:
- Positive margins for CIN 2/3 and repeat
excision not technically possible
- Cervix/vagina scarring limiting follow-up exam
- Persistent/recurrent CIN 2/3
* Consider frozen cone before hysterectomy if
positive margins
Case #1
• What if patient were pregnant with CIN3?
Pregnancy
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Do NOT treat CIN 2/3 during pregnancy
Perform excision only if cancer suspected
Up to 70% regress in postpartum period
Significant bleeding and risk of preterm
labor if treated during pregnancy
ECC should never be performed during
pregnancy
Repeat cytology and colposcopy 6 to 12
weeks postpartum
Case #2
• 45 yo
• Routine Pap test shows atypical glandular
cells?
• Work-up?
Case #2
• Colposcopy: negative
• Endocervical curettage: adenocarcinoma-insitu
• Endometrial biopsy: negative
• Next steps?
Case #2
• Cone biopsy: adenocarcinoma-in-situ with
positive margins
• Next steps?
Case #2
• Repeat cone biopsy: no residual disease
• Next step?
Case #2
• Hysterectomy: no residual disease
Adenocarcinoma-in-Situ (AIS)
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Atypical glandular cells without invasion
Precursor to adenocarcinoma of the cervix
(25% of cervical cancers)
HPV infection is required (similar to
squamous lesions)
10 - 13% of patients have multi-focal
disease (“skip lesions”)
50% of patients have concomitant
squamous dysplasia or cancer
Adenocarcinoma-in-Situ (AIS)
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Recommend CKC over LEEP due to higher
probability of negative margins and no
thermal artifact
Standard treatment for AIS is hysterectomy
once child-bearing is complete
If positive cone margins, recommend
repeat cone prior to hysterectomy to
reduce the possibility of missing an occult
cancer and performing incorrect procedure
Thank You