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Key Features

Essentials of Diagnosis

  • The presumptive diagnosis is made by an abnormal Papanicolaou smear from an asymptomatic woman with no grossly visible cervical changes

  • Diagnosed by colposcopically directed biopsy

General Considerations

  • The squamocolumnar junction of the cervix is an area of active squamous cell proliferation

  • This junction is located on the exposed vaginal portion of the cervix in childhood

  • An area of metaplasia (transformation zone) is created during puberty when the squamous margin begins to encroach on the single-layered, mucus-secreting epithelium

  • Infection by the human papillomavirus (HPV) may lead to cellular abnormalities, which over time may develop into squamous cell dysplasia or cancer

  • There are varying degrees of dysplasia, defined by the degree of cellular atypia; all atypia must be observed and treated if persistent or worsening

Clinical Findings

  • There are no specific symptoms or signs of CIN

Diagnosis

  • The presumptive diagnosis is made by cytologic screening (Papanicolaou smear) of an asymptomatic patient with no grossly visible cervical changes

  • All visible abnormal cervical lesions should be biopsied

  • Colposcopy is indicated when HPV screen is positive

Treatment

  • Treatment varies depending on the degree and extent of CIN

  • Biopsies should precede treatment, except in cases of HSIL where it may be appropriate to proceed directly to a loop electrosurgical excision procedure (LEEP)

  • Cryosurgery is effective for noninvasive small lesions visible on the cervix without endocervical extension

  • CO2 laser

    • Minimizes tissue destruction

    • May be used with large visible lesions

    • Involves the vaporization of the transformation zone on the cervix and the distal 5–7 mm of endocervical canal

  • Loop excision (ie, LEEP)

    • When the CIN is clearly visible in its entirety, a wire loop can be used for excisional biopsy

    • Cutting and hemostasis are achieved with a low-voltage electrosurgical machine

  • Conization of the cervix

    • Surgical removal of the entire transformation zone and endocervical canal

    • Should be reserved for cases of severe dysplasia (CIN III) or carcinoma in situ, particularly those with endocervical extension

    • Can be performed with scalpel, CO2 laser, needle electrode, or large-loop excision

Outcomes

Follow-Up

  • Because recurrence is possible—especially in the first 2 years after treatment—and because the false-negative rate of a single cervical cytologic test is 20%, close follow-up after colposcopy and biopsy is imperative

  • Following any excisional or ablative procedure, co-testing (cytology and HPV DNA) should be repeated at 12-month intervals for 2 years

  • If CIN II or III is identified at the margins of an endocervical curettage procedure, however, repeat cytology with endocervical curettage is preferred at 4–6 months

  • If follow-up testing is normal, routine cytologic screening can be resumed

  • Colposcopy and endocervical sampling should be performed for ...

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