1. Cervical Intraepithelial Neoplasm
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 Metaplasia
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 HSIL ASCUS AGUS
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

8. 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

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

11. 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

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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. Thank You for your attention