General
consideration:
1.
CIN is most like to begin either during menarche or following pregnancy,
when metaplasia is most active.
2.
A woman who has reached menopause without developing CIN has little
metaplasia and is at a low risk.
3.
HPV (human papillomavirus) plays an important role in the development of
CIN.
Clinical
features:
1.
Asymptomatic
2.
Presents only as an abnormal pap smear
3.
Postcoital bleeding or spotting but his may be related to cervicitis
found in association with the CIN.
Diagnosis:
1.
The pap test
a. not to douche for
48hr
b. not to vaginal creams for
1 wk
c. abstain form coitus for
24hr
2.
Colposcopy and biopsy
3.
Human papilloma virus - a means of secondary assessment of abnormal
cytology
4.
Cervicography - a secondary means of assessment of patient with pap test
result, and use to identify lesions
Cervix intraepithelial neoplasm
Treatment:
1.
Before treatment:
(1) The
histologic diagnosis must be accurate.
(2) The
extent of the lesion must be determined.
2.
Ablative techniques:
(1)
Cryotherapy:
Indications
a. CIN I
- II
b. Small
lesion
c.
Ectocervical location only
d.
Negative endocervical curettage
e. No
endocervical gland involvement on biopsy
(2) Laser
vaporization therapy:
Indications
a. Large
lesions that the cryoprobe cannot adequately cover.
b.
Irregular cervix with a "fish month" appearance an deep clefts
c.
Extension of disease to the vagina or satellite lesions on the vagina
d.
Lesions with extensive glandular involvement in which the treatment must
beyond the deepest gland cleft.
(3) Loop
electrosurgical excision:
Contraindications
a.
patient anxiety
b.
contraindication to local anesthesia or vasoconstrictor
c.
extremely large lesions
d.
vaginal extension
e.
obvious clinical carcinoma
(4)
Conization:
Indications
a. Limits
of the lesion cannot be visualized with colposcopy.
b. The
squamocolumnar junction (SCJ) is not seen at colposcopy.
c. Endocervical curettage histologic findings are positive for CIN
2 or CIN 3.
d. There
is a lack of correlation between cytology, biopsy, and colposcopy
results.
e.
Microinvasion is suspected based on biopsy, colposcopy, or cytology
results.
f. The
colposcopist is unable to rule out invasive cancer.
(5)
Hysterectomy:
Indications
a.
microinvasion
b.
cervical intraepithelial neoplasia at limits of conization specimen
c. poor
compliance with follow-up
d. other
gynecologic problems requiring hysterectomy, such as fibroids, prolapse,
endometriosis and pelvic inflammatory disease
e. cancer
phobia
f. CIN I,
II are not indications of hysterectomy.
3.After
treatment - complications:
(1)
Cryotherapy:
a.
Cervical stenosis
b.
Post-treatment bleeding
c.
Infection
(2) Laser
vaporization therapy
a. clear vaginal discharge:
3-5 days
b.
spotting
(3) Loop
electrosurgical excision
a.
Intraoperative hemorrhage
b.
Post-operative hemorrhage
c.
Cervical stenosis
(4)
Hysterectomy
a.
bleeding
b.
infection
c. death
Follow-up: by pap smeas
1. an
inherent recurrence rate: up to 10%
2. at
approximately 3-month intervals for 1 year
Prognosis
1. each
of the recommended therapies, if properly applied, provides care in at
least 90% of patient after one treatment (some patients require as many
as four appllications)
2. With
proper follow-up and treatment, over 99% of women with CIN are
ultimately cured with preservation of reproductive function.
*Pap smear應取到endocervical
cell才算合格的採樣，採樣時宜用木棒(spatula)不宜用棉枝(cotton swah)。採樣錯誤常發生在只取到後穹隆內的子宮頸脫落細胞。
