Cervical Intraepithelial
Neoplasia
Prof. Sabera Khatun
Chairman
Department of Gynaecological Oncology
Bangabandhu Sheikh Mujib Medical University
Shahbag-1000, Dhaka
Every two minutes one women
die of cervical cancer
Cervical intraepithelial neoplasia (CIN)
Cervical intraepithelial neoplasia (CIN)- Formerly
called dysplasia, means disordered growth and
development of the epithelial lining of the cervix.
Classicification- there are various degrees of CIN
a. CIN I- Mild dysplasia or CIN I is defined as
disordered growth of the lower one third of the
epithelial lining of cervix.
b. CIN II- Moderate dysplasia is defined as the
abnormal growth and maturation of the lower two
thirds of the lining epithelium of cervix.
c. CIN III – Severe dysplasia is defined as the abnormal
growth and maturation of more than lower two
thirds of the lining epithelium of cervix
d. CIS – the term CIS was introduced in 1932 to
denote those lesion in which the undifferentiated
carcinomatous cells involve the full thickness of the
epithelium without disruption of the basement
Prevalence
Cervical Intraepithelial Neoplasia (CIN) prevalence depends on:
Socioeconomic characteristics
Geographical area of population
1.05% in family planning clinic
13.7% in STD clinic
In USA 1.2/1000-CINI
1.5/1000-CINII,III
Age Incidence:
CIN - Most common in 20s
CIS - in 25-35 years
Invasive - after 40s
HPV infection
CIN
Classification – depend upon the thickness of
epithelium showing undifferentiated cells
• CIN I
• CIN-II
• CIN-III
History of CIN
In Fifties –Dysplasia
New Terminology – introduced in 1975
Cervical Introepithelial Neoplasia(CIN)
CIN
• Histological features of differentiation, maturation
and stratification of the cells.
• Nuclear abnormalities used to judge whether there
is CIN.
Grading of CIN
Based on the proportion of thickness of epithelium.
Showing mature and differentiated cells.
The thickness of epithelium with
undifferentiated cells higher the Grades
CIN I
• More maturated cells
• Undifferentiated cells (abnormal nucleus with
abnormal mitotic figure) limited to lower 1/3rd of
epithelium
CIN II – Undifferentiated cells are limited
to lower 2/3rd of cervical
epithelium.
CIN III – Undifferentiated cells are seen in
the full thickness of cervical
epithelium.
Natural History
Best Study
Holowaty, shows 10 years follow-up
Results
CIN I
87.8% Normal
Revert back
2.8% CIN III
Progressed
.4% Invasive cancer
Most recent study on CIN I of 1000
patients
CIN I are the most suitable preinvasive disease for
follow up
At 12 months- 80% Regressed to normal.
16% Persistent CIN I
4% Progressed to higher
grade lesion
CIN II (Difficult to follow up)
• 70% Regress to normal in women < 25 years
• 22% Progress CIN III
• 5% Progress to invasive cancer.
CIN III
In the absence of treatment
32% Regress to normal
56% Persistent CIN III
12% Progress to invasive cancer
Diagnosis
Standard Methods of diagnosis
1. Cytology (Pap’s)
2. Colposcopy
3. Histology
If properly combined or integrated these 3 tests can
detect practically all cervical lesions.
Cytology
• Analysis of sample of cells exfoliated from cx after
staining by papanicolaou technique.
How the cells are collected?
1. From ectocervical epithelium by wooden spatula
2. From endocervical epithelium by brush
• Screening by cytology – Mortality form
cervical cancer has significantly reduced .
• High specificity –(70-95%)
• Sensitivity (-50%)
• False negative rate (-55%)
HPV testing
• New adjunctive method of screening.
• High sensitivity (80-100%)
• Low specificity.
• High positive predictive value after 30 yrs of age.
• Not widely available due to high cost
• Primary screening test in Netherland and Turkey
Colposcopy
Direct visual examination of cervix in magnification
after application of 3-5% acetic acid
• Colour change
• Border and surface of lesion
• Vascular pattern of lesion
• Size of extension of lesion
• Endo cervical extension
• Vaginal extension
• Selection of most appropriate site of biopsy
Histopathology
• Final diagnosis of CIN is by histopathology
• Sample of tissue obtained by biopsy
• If no lesion seen in ectocervix then endocervical
curettage
A close coordination between cytologist, colposcopist
and histopathologist is the utmost importance.
Normal
Low grade CIN
High grade CIN
• Symptoms –No specific symptoms
• Management – Trend to conservative treatment
• Most lowgrade lesion (CIN I) is the expression of
HPV infection.
• Treatment –unnecessary
• Will regress spontaneously
Some CIN I needs treatment because
• .5-1% may progress to high grade lesion
• Already existing high grade lesion may be missed
• Loss to follow up
Methods of treatment -Cryotherapy
Cold Coagulation
High grade lesion (H-SIL) (CIN II & III)
• Expectant management –not acceptable
• Methods of treatment –LEEP
Conization
Follow up-CIN I
• At 6 months after treatment
• At 12 months after treatment
• At 24 months after treatment
• If all negative return to routine screening
Follow up CIN II & III
• Similar but continued annually for 9 yrs
• If negative then return to routine screening
Chance of recurrence – within 2 yrs
may be within 20 yrs
Methods of follow-up
• Cytology
• Cytology + colposcopy
• Cytology + HPV identification
THANK YOU
