Cervical intraepithelial neoplasia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maria Fernanda Villarreal, M.D. [2]

Synonyms and Keywords: CIN; Cervical interstitial neoplasia; Cervical dysplasia; Cervical interstitial neoplasia

Overview

Cervical intraepithelial neoplasia (also known as cervical dysplasia and CIN), is the potentially premalignant transformation and abnormal growth (dysplasia) of squamous cells on the surface of the cervix. Cervical intraepithelial neoplasia was first discovered by Dr. Georgios Nikolaou Papanikolaou, a Greek pathologist, in 1927. There are 4 cytological classifications for cervical intraepithelial neoplasia: Bethesda system, Papanicolaou classification, CIN nomenclature, and dysplasia nomenclature. The most common cytological classification systems for cervical intraepithelial neoplasia is the Bethesda and CIN nomenclature. Cervical intraepithelial neoplasia may be classified according to Bethesda system by cytology description into 3 subtypes: atypical squamous cells, low grade squamous intraepithelial lesion (LGSIL or LSIL), and high grade squamous intraepithelial lesion (HGSIL or HSIL). The pathogenesis of cervical intraepithelial neoplasia is characterized by the premalignant transformation and abnormal growth of squamous cells on the surface of the cervix. The presence of human papillomavirus (HPV) has a crucial role in the pathogenesis of cervical intraepithelial neoplasia. The infection of human papillomavirus (HPV) leads to the first precursor lesion of cervical intraepithelial neoplasia, also known as the koilocyte, which is a squamous epithelial cell that has undergone a number of structural changes. Surgery is the mainstay of therapy for cervical intraepithelial neoplasia. According to the American Society for Colposcopy and Cervical Pathology guidelines, indications for ablative surgery among patients with cervical intraepithelial neoplasia should include: persistent low-grade cervical intraepithelial neoplasia, cervical intraepithelial neoplasia grade II and grade III. Common surgical procedures for cervical intraepithelial neoplasia, include cryocautery, electrocautery, laser cautery, and cervical conization.

Historical Perspective

  • Cervical intraepithelial neoplasia was first discovered by Dr. Georgios Nikolaou Papanikolaou, a Greek pathologist, in 1927.[1]
  • In 1928, the first screening was developed by Aurel Babeș, a Romanian pathologist to diagnose cervical intraepithelial neoplasia.[1]
  • In 1980, human papillomavirus (HPV) was first identified in the pathogenesis of cervical intraepithelial neoplasia.[2]
  • In 1988, the Bethesda system classification method was introduced to categorize histopathological findings of cervical intraepithelial neoplasia according to degrees of severity.

Classification

  • Cervical intraepithelial neoplasia has 4 cytological classifications: Bethesda system, Papanicolaou classification, CIN nomenclature, and dysplasia nomenclature.
  • The most common classification systems for cervical intraepithelial neoplasia is the Bethesda and CIN nomenclature.
  • Cervical intraepithelial neoplasia may be classified according to Bethesda system by cytology description into 3 subtypes:
  • Undetermined significance (ASC-US)
  • Low grade squamous intraepithelial lesion (LGSIL or LSIL)
  • High grade squamous intraepithelial lesion (HGSIL or HSIL)
  • Cervical intraepithelial neoplasia may be classified according to CIN nomenclature by histological severity into 3 subtypes:
  • Cervical intraepithelial neoplasia I (CIN I)
  • Cervical intraepithelial neoplasia II (CIN II)
  • Cervical intraepithelial neoplasia III (CIN III)
  • Cervical intraepithelial neoplasia may be classified according to Papanicolau by cytology description into 5 subtypes:
  • Cervical intraepithelial neoplasia may be classified according to dysplasia nomenclature by cytology description into 5 subtypes:

Pathophysiology

Cytologic findings
Lesion grade
Histologic changes
Bethesda system
Description Microscopic findings
CIN I

Cervical intraepithelial neoplasia I

  • Low-grade lesion squamous intraepithelial lesion (LGSIL)
Cervical intraepithelial neoplasia (2) koilocytosis.jpg
CIN II

Cervical intraepithelial neoplasia II

  • High-grade lesion squamous intraepithelial lesion (HGSIL)
100px-Cervical intraepithelial neoplasia (3) CIN2.jpg
CIN III

Cervical intraepithelial neoplasia III

  • High-grade lesion squamous intraepithelial lesion (HGSIL)
  • Severe atypical cellular changes
  • Greater than two-thirds of the epithelial thickness is usually involved
  • Also known as Carcinoma in situ
451px-Cervical intraepithelial neoplasia (4) CIN3.jpg

Molecular Pathogenesis

Causes

  • Subtypes 16,18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82
  • Subtypes 6, 11, 40, 42, 43, 44, 54, 61, 72, 81

Differentiating Cervical Intraepithelial Neoplasia from Other Diseases

Epidemiology and Demographics

Prevalence

  • The prevalence of cervical intraepithelial neoplasia I (CIN I) is approximately 54 cases per 100,000 individuals in the United States.[7]
  • The prevalence of cervical intraepithelial neoplasia II (CIN II) is approximately 255 cases per 100,000 individuals in the United States.[7]
  • The prevalence of cervical intraepithelial neoplasia III (CIN III) is approximately 141 cases per 100,000 individuals in the United States.[7]
  • The prevalence of invasive carcinoma is approximately 24 cases per 100,000 individuals in the United States.[7]

Incidence

  • The incidence of cervical intraepithelial neoplasia I (CIN I) is 160 cases per 100,000 individuals per year in the United States.[8]
  • The incidence of cervical intraepithelial neoplasia II (CIN II) is 120 cases per 100,000 individuals per year in the United States.[8]

Age

  • The median age at diagnosis for cervical intraepithelial neoplasia is 30 years.
  • Cervical intraepithelial neoplasia is more commonly seen in women between 20 to 40 years years old.

Race

  • Hispanic individuals are more likely to develop cervical intraepithelial neoplasia.
  • African American individuals are more likely to develop cervical intraepithelial neoplasia.

Risk Factors

  • The most important risk factor in the development of cervical intraepithelial neoplasia is immunosuppression.
  • Common risk factors in the development of cervical intraepithelial neoplasia, include:[9]

Natural History, Complications and Prognosis

  • The majority of patients with cervical intraepithelial neoplasia remain asymptomatic for years.
  • Early clinical features include abnormal vaginal discharge, dyspareunia, and abnormal vaginal bleeding.
  • If left untreated, 70% patients with cervical intraepithelial neoplasia will regress within one year.
  • 90% of patients with low-grade cervical intraepithelial neoplasia will regress within two years of treatment.
  • 50% of patients with high-grade cervical intraepithelial neoplasia will regress within 2 years without treatment.
  • Progression to cervical carcinoma in situ (CIS)
  • 11% of patients low-grade cervical intraepithelial neoplasia will develop CIS.
  • 22% of patients high-grade grade cervical intraepithelial neoplasia will develop CIS.
  • 1% of patients with low-grade cervical intraepithelial neoplasia will develop cervical cancer.
  • 5% - 13% of patients with high-grade grade cervical intraepithelial neoplasia will develop cervical cancer.

Diagnosis

Diagnostic Criteria

  • The diagnosis of cervical intraepithelial neoplasia is made with the following histopathological findings:
Cytologic findings
Lesion grade
Histologic changes
Bethesda system
Description Microscopic findings
CIN I

Cervical intraepithelial neoplasia I

  • Low-grade lesion squamous intraepithelial lesion (LGSIL)
Cervical intraepithelial neoplasia (2) koilocytosis.jpg
CIN II

Cervical intraepithelial neoplasia II

  • High-grade lesion squamous intraepithelial lesion (HGSIL)
100px-Cervical intraepithelial neoplasia (3) CIN2.jpg
CIN III

Cervical intraepithelial neoplasia III

  • High-grade lesion squamous intraepithelial lesion (HGSIL)
  • Severe atypical cellular changes
  • Greater than two-thirds of the epithelial thickness is usually involved
  • Also known as Carcinoma in situ
451px-Cervical intraepithelial neoplasia (4) CIN3.jpg

Symptoms

  • Cervical intraepithelial neoplasia is usually asymptomatic.
  • Symptoms of cervical intraepithelial neoplasia may include the following:

Physical Examination

  • Patients with cervical intraepithelial neoplasia are usually well-appearing.
  • Digital examination findings of the vagina and cervix, may reveal:

Laboratory Findings

  • Laboratory findings associated with cervical intraepithelial neoplasia, include:

Imaging Findings

  • There are no imaging findings associated with cervical intraepithelial neoplasia.

Other Diagnostic Studies

  • The most important diagnostic study for cervical intraepithelial neoplasia is colposcopy.
  • The most common finding of cervical intraepithelial neoplasia in colposcopy is acetowhite lesions with atypical vessels.
  • Other findings on vaginal colposcopy, include:
  • Greyish-white or yellowish-white lesions
  • Irregular longitudinal vessels
  • Corkscrew or tree appearance
  • Cervical nodularity
  • The table below summarizes the colposcopy findings according to the Swede score
Swede score for interpreting colposcopy findings

Adapted from Principles and Practice of Colposcopy

0 1 2
Uptake of acetic acid 0 or transparent
  • Shady, milky
  • Distinct, stearin-like
Margins and surface 0 or diffuse
  • Sharp, but irregular, jagged
  • "Geographical" satellites
  • Sharp and even
  • Difference in surface level such as "cutting"
Vessels Fine, regular
  • Absent
  • Coarse or atypical
Lesion size < 5mm
  • 5-15 mm
  • Spanning 2 quadrants
  • >15mm or spanning
  • 3-4 quadrants or endocervically undefined
Iodine staining Brown
  • Faintly or patchy yellow
  • Distinct yellow

The total Swede Score ranges between 0 and 10. A score of more than 5 is reported to identify all high grade lesions (HGL), and ≥8 to have a specificity of 90% for HGL. A score less than <5 is suggested to not require biopsy because of low risk of cancer, a score between 5-7 to require biopsy A score ≥8 again not to require biopsy because it is likely more efficient to intervene (e.g. excision directly)

Video

Treatment

Medical Therapy

  • Medical treatment for cervical intraepithelial neoplasia, include:
  • Observation
  • Observation is indicated for cervical intraepithelial neoplasia lesions that are:
  • Highly likely to regress
  • High grade lesions associated with a high risk of developing cervical cancer
  • The management of cervical intraepithelial neoplasia will depend on patients age:
  • Patients with cervical intraepithelial neoplasia between 21-24 years
  • Patients with cervical intraepithelial neoplasia above 25 years

Surgery

  • Surgery is the mainstay of therapy for cervical intraepithelial neoplasia.[11]
  • According to the American Society for Colposcopy and Cervical Pathology guidelines, indications for ablative surgery among patients with cervical intraepithelial neoplasia should include:
  • Persistent low-grade cervical intraepithelial neoplasia
  • Cervical intraepithelial neoplasia grade II and grade III
  • Common surgical procedures for cervical intraepithelial neoplasia, include:

Prevention

References

  1. 1.0 1.1 Georgios Nikolaou Papanikolaou Wikipedia. https://en.wikipedia.org/wiki/Georgios_Papanikolaou Accessed on March 29, 2016
  2. Herfs M, Crum CP (2013). "Laboratory management of cervical intraepithelial neoplasia: proposing a new paradigm". Adv Anat Pathol. 20 (2): 86–94. doi:10.1097/PAP.0b013e3182862aab. PMID 23399794.
  3. Arends MJ, Buckley CH, Wells M (1998). "Aetiology, pathogenesis, and pathology of cervical neoplasia". J. Clin. Pathol. 51 (2): 96–103. PMC 500501. PMID 9602680.
  4. Braaten KP, Laufer MR (2008). "Human Papillomavirus (HPV), HPV-Related Disease, and the HPV Vaccine". Rev Obstet Gynecol. 1 (1): 2–10. PMC 2492590. PMID 18701931.
  5. Skinner SR, Wheeler CM, Romanowski B, Castellsagué X, Lazcano-Ponce E, Del Rosario-Raymundo MR, Vallejos C, Minkina G, Pereira Da Silva D, McNeil S, Prilepskaya V, Gogotadze I, Money D, Garland SM, Romanenko V, Harper DM, Levin MJ, Chatterjee A, Geeraerts B, Struyf F, Dubin G, Bozonnat MC, Rosillon D, Baril L (May 2016). "Progression of HPV infection to detectable cervical lesions or clearance in adult women: Analysis of the control arm of the VIVIANE study". Int. J. Cancer. 138 (10): 2428–38. doi:10.1002/ijc.29971. PMC 4787275. PMID 26685704.
  6. Krawczyk E, Suprynowicz FA, Liu X, Dai Y, Hartmann DP, Hanover J, Schlegel R (September 2008). "Koilocytosis: a cooperative interaction between the human papillomavirus E5 and E6 oncoproteins". Am. J. Pathol. 173 (3): 682–8. doi:10.2353/ajpath.2008.080280. PMC 2527066. PMID 18688031.
  7. 7.0 7.1 7.2 7.3 Dunne EF, Unger ER, Sternberg M, McQuillan G, Swan DC, Patel SS, Markowitz LE (2007). "Prevalence of HPV infection among females in the United States". JAMA. 297 (8): 813–9. doi:10.1001/jama.297.8.813. PMID 17327523.
  8. 8.0 8.1 Henk HJ, Insinga RP, Singhal PK, Darkow T (2010). "Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population". J Low Genit Tract Dis. 14 (1): 29–36. doi:10.1097/LGT.0b013e3181ac05e9. PMID 20040833.
  9. Brisson J, Morin C, Fortier M, Roy M, Bouchard C, Leclerc J, Christen A, Guimont C, Penault F, Meisels A (1994). "Risk factors for cervical intraepithelial neoplasia: differences between low- and high-grade lesions". Am. J. Epidemiol. 140 (8): 700–10. PMID 7942772.
  10. García-Closas R, Castellsagué X, Bosch X, González CA (2005). "The role of diet and nutrition in cervical carcinogenesis: a review of recent evidence". Int. J. Cancer. 117 (4): 629–37. doi:10.1002/ijc.21193. PMID 15912536.
  11. Martin-Hirsch PL, Paraskevaidis E, Kitchener H (2000). "Surgery for cervical intraepithelial neoplasia". Cochrane Database Syst Rev (2): CD001318. doi:10.1002/14651858.CD001318. PMID 10796771.

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