Cervical Intraepithelial Neoplasia

Question 1

Define

Answer 1

Premalignant cellular atypia within squamous epithelium of cervix (FIGO stage 0) – this is BEFORE cervical cancer

• HPV (type 16 and 18) is indicated in >95% cases
• Risk Factors – smoking, multiple sexual partners, early age of first intercourse, HIV
• Peak 25-29yo; cancer peak age 45-50yo

Question 2

CIN vaccination and staging

Answer 2

HPV vaccination:

• National vaccination for girls and boys aged 12-13yo If pregnant à invite ≥12w post-partum
• Quadrivalent vaccine (Gardasil ©) against HPV 6, 11, 16, 18

· Smear vaccination invitation:

• Under 25yo: once (invited less than 6m before 25yo)
• 25-50yo: every 3 years
• 50-65yo: every 5 years
• 65+ only if one of your last 3 tests was abnormal
• High-risk (i.e. HIV +ve) every 1 year
• Pregnancy if due when pregnant, delay until ≥3m post-partum

Inadequate results:

1. Inflammation
2. Age-related atrophic change Blood on smear
3. Dysplastic epithelial changes:

Dysplastic epithelial changes:

• ↑ nuclear to cytoplasmic ratio
• ↑ nuclear size
• ↓ cytoplasm
• Abnormal nuclear shape – poikilocytosis
• ↑ nuclear density – koilocytosis

· CIN Grades:

o CIN 1 (low grade) – Mild dysplasia confined to lower 1/3 of epithelium

o CIN 2 (high grade) – Moderate dysplasia affecting 2/3 of epithelial thickness

o CIN 3 (high grade) – Severe dysplasia extending to upper 1/3 of epithelium à risk of stage Ia1 FIGO (see cancer)

Question 3

Signs and symptoms

Answer 3

Symptoms of cervical cancer (PV bleeding – IMB, PCB, PMB) Dyskaryosis = abnormal nucleus

Smear screening; outcome follow-up:

• Borderline/mild dyskaryosis / CIN I -> HPV test à +ve = colposcopy; -ve = routine recall
• Moderate dyskaryosis / CIN II -> Urgent colposcopy (<2w) -> tx
• Severe dyskaryosis / CIN III -> Urgent colposcopy (<2w) -> tx
• Suspected invasive cancer -> Urgent colposcopy (<2w) -> tx
• Inadequate sample -> Repeat (if x3 repeats, refer to colposcopy)

Koilocytosis = HPV infection

Smear advice:

· Speculum is a ‘small plastic tube’

· Cytology available in 2 weeks, explain role of smear (screen for potentially dangerous changes), mild -> HPV test, worst -> colposcopy, inadequate sample x3 -> colposcopy

Question 4

Management

Answer 4

Conservative for CIN1 -> smear in 12 months

o Large Loop Excision of the Transformational Zone (LLETZ) / Loop diathermy

Involves removal of abnormal cells using a thin wire loop that is heated by electric current under LA

SEs: cervical stenosis, cervical incontinence, pyometra, smear follow-up difficulties

Risks à increased risk of miscarriage (bigger lumen to cervix so harder to close fully)

Cone biopsy:

• Used less frequently and under a GA
• Only performed if a large area of tissue needs to be removed
• Other: cryotherapy, laser treatment, cold coagulation, hysterectomy

If hysterectomy for CIN à a vault smear must be done at 6m and 18m

o Follow-up test of cure (6 months later) = smear and HPV test:

• NEGATIVE -> routine recall (3 years irrespective of age)
• POSITIVE -> repeat colposcopy to identify residual/untreated CIN

Question 5

Complication

Answer 5

(incl. general procedural risks such as bleeding and infection):

o Miscarriage and PTL

o CIN can progress to cervical carcinoma (but may also regress spontaneously, esp. when young)