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 Cervical Conization

1.1. Cold knife conization (CKC)Cold knife conization (CKC)

2.2. Loop electrosurgical procedure (LEEP), Loop electrosurgical procedure (LEEP), also known as large loop excision of the also known as large loop excision of the transformation zone (LLETZ)transformation zone (LLETZ)

3.3. Laser conizationLaser conization

** Hysterectomy should ** Hysterectomy should notnot be performed be performed as the initial treatment for CIN 2/3as the initial treatment for CIN 2/3

Complications of LEEP/CKCComplications of LEEP/CKC

• Intraoperative or postoperative bleedingIntraoperative or postoperative bleeding• InfectionInfection• Cervical stenosisCervical stenosis• InfertilityInfertility• Pregnancy loss/Preterm birth:Pregnancy loss/Preterm birth:

- CKC = 14% preterm birth rate- CKC = 14% preterm birth rate- LEEP = 11% preterm delivery rate- LEEP = 11% preterm delivery rate

PrognosisPrognosis

Untreated CIN 3Untreated CIN 3::

• Risk of cancer is 20% at 10 years and 31% Risk of cancer is 20% at 10 years and 31% at 30 yearsat 30 years

Treated CIN 3Treated CIN 3::

• Risk of cancer is 0.3% at 10 years and Risk of cancer is 0.3% at 10 years and 0.7% at 30 years0.7% at 30 years

McCredie McCredie et alet al., ., Lancet OncLancet Onc, 2008, 2008

HysterectomyHysterectomy

• Hysterectomy should Hysterectomy should NOTNOT be performed as be performed as initial treatment for CIN 2/3initial treatment for CIN 2/3

• Hysterectomy indicated if:Hysterectomy indicated if: - Positive margins for CIN 2/3 and repeat - Positive margins for CIN 2/3 and repeat

excision not technically possible excision not technically possible - Cervix/vagina scarring limiting follow-up exam- Cervix/vagina scarring limiting follow-up exam - Persistent/recurrent CIN 2/3- Persistent/recurrent CIN 2/3* Consider frozen cone before hysterectomy if * Consider frozen cone before hysterectomy if

positive marginspositive margins

Case #1Case #1

• What if patient were pregnant with CIN3?What if patient were pregnant with CIN3?

PregnancyPregnancy

• Do Do NOTNOT treat CIN 2/3 during pregnancy treat CIN 2/3 during pregnancy• Perform excision only if cancer suspectedPerform excision only if cancer suspected• Up to 70% regress in postpartum periodUp to 70% regress in postpartum period• Significant bleeding and risk of preterm Significant bleeding and risk of preterm

labor if treated during pregnancylabor if treated during pregnancy• ECC should never be performed during ECC should never be performed during

pregnancypregnancy• Repeat cytology and colposcopy 6 to 12 Repeat cytology and colposcopy 6 to 12

weeks postpartumweeks postpartum

Case #2Case #2

• 45 yo 45 yo • Routine Pap test shows atypical glandular Routine Pap test shows atypical glandular

cells?cells?

• Work-up?Work-up?

Case #2Case #2

• Colposcopy: negativeColposcopy: negative• Endocervical curettage: adenocarcinoma-in-Endocervical curettage: adenocarcinoma-in-

situ situ • Endometrial biopsy: negativeEndometrial biopsy: negative

• Next steps?Next steps?

Case #2Case #2

• Cone biopsy: adenocarcinoma-in-situ with Cone biopsy: adenocarcinoma-in-situ with positive marginspositive margins

• Next steps?Next steps?

Case #2Case #2

• Repeat cone biopsy: no residual diseaseRepeat cone biopsy: no residual disease

• Next step?Next step?

Case #2Case #2

• Hysterectomy: no residual diseaseHysterectomy: no residual disease

Adenocarcinoma-in-Situ (AIS)Adenocarcinoma-in-Situ (AIS)

• Atypical glandular cells without invasionAtypical glandular cells without invasion• Precursor to adenocarcinoma of the cervix Precursor to adenocarcinoma of the cervix

(25% of cervical cancers)(25% of cervical cancers)• HPV infection is required (similar to HPV infection is required (similar to

squamous lesions)squamous lesions)• 10 - 13% of patients have multi-focal 10 - 13% of patients have multi-focal

disease (“skip lesions”)disease (“skip lesions”)• 50% of patients have concomitant 50% of patients have concomitant

squamous dysplasia or cancersquamous dysplasia or cancer

Adenocarcinoma-in-Situ (AIS)Adenocarcinoma-in-Situ (AIS)

• Recommend CKC over LEEP due to higher Recommend CKC over LEEP due to higher probability of negative margins and no probability of negative margins and no thermal artifactthermal artifact

• Standard treatment for AIS is hysterectomy Standard treatment for AIS is hysterectomy once child-bearing is completeonce child-bearing is complete

• If positive cone margins, recommend If positive cone margins, recommend repeat cone prior to hysterectomy to repeat cone prior to hysterectomy to reduce the possibility of missing an occult reduce the possibility of missing an occult cancer and performing incorrect procedurecancer and performing incorrect procedure

Thank You