Both excisional and ablative procedures are acceptable treatment modalities for women with histologically proven CIN 2 or 3 with satisfactory colposcopy (Fig. 19.16D). An excisional procedure is recommended for residual/recurrent CIN 2 or 3.
2.
Ablation is unacceptable for women with a histologic diagnosis of CIN 2 or 3 and unsatisfactory colposcopy.
3.
Cytologic and colposcopic follow-up of CIN 2 or 3 is necessary only in specific circumstances. Acceptable posttreatment follow-up options include cytology alone, every 6 months, combined cytology and colposcopy every 6 months, and HPV DNA testing at 6 to 12 months.
4.
If HPV DNA testing is positive or if the repeat cytology is ASC-US or greater, referral for colposcopy and endocervical sampling is recommended.
5.
If HPV DNA testing is negative or if two consecutive posttreatment cytology results are negative for intraepithelial lesion or malignancy, routine screening for at least 20 years is recommended, and should be annual for at least 5 years. A negative HPV DNA test is an excellent predictor of a normal posttreatment for CIN 2 or 3.
6.
If CIN 2 or 3 is histologically found at the margins of an excised specimen or in an endocervical sample obtained immediately after the procedure, cytologic follow-up with endocervical sampling every 4 to 6 months is preferred. The role of colposcopy in this follow-up option is not clearly defined in the Guidelines, although in practice, cytology and colposcopy will be performed in most clinical settings.
7.
A repeat diagnostic excisional procedure is acceptable. The Guidelines allow for hysterectomy if a repeat diagnostic excisional procedure is not feasible. An undisclosed invasive cancer within the endocervical canal must be excluded prior to hysterectomy.
8.
For women with histologically proven residual/recurrent CIN 2 or 3, the Guidelines permit a repeat excisional procedure or hysterectomy.
1.
For adolescents with a histological diagnosis of CIN 2 or 3 not otherwise specified, the Guidelines state that either treatment or observation by cytology and colposcopy every 6 months for up to 24 months is acceptable provided colposcopy is satisfactory (Fig 19.16E). Allowing for the subjectivity in this histological distinction, observation is preferred for a diagnosis of CIN 2 alone, but treatment is acceptable.
2.
Treatment is recommended for a histologic diagnosis of CIN 3 or if colposcopy is unsatisfactory. Although invasive cervical cancer is very rare in this age group, prospective follow-up of a histological diagnosis of CIN 2 or 3, not otherwise specified, in young women should be limited to those women likely to be compliant with the recommendations.
3.
After 2 consecutive negative for intraepithelial lesion or malignancy results, implying negative cytology and colposcopy with satisfactory colposcopic examinations, adolescents and young women can return to routine cytologic screening. An annual screening interval should be recommended.
4.
Treatment is recommended if CIN 3 is diagnosed histologically or if CIN 2 or 3 persists for 24 months.
1.
Hysterectomy remains the preferred management recommendation for women with a histological diagnosis of AIS on a specimen from a diagnostic excisional procedure (Fig 19.16F).
2.
A histologic diagnosis of AIS from a punch biopsy or a cytological diagnosis of AIS is not sufficient to justify hysterectomy without a diagnostic excisional procedure.
The difficulty in defining colposcopic limits of AIS lesions, the frequent extension of disease within the endocervical canal and the presence of multifocal, “skip-lesions” (i.e., lesions that are not contiguous) compromise conservative excisional procedures.
3.