CIN 2/ CIN 3 / High degree squamous intraepithelial lesion (HSIL) Method and Treatment

CIN 2/ CIN 3 / High degree squamous intraepithelial lesion (HSIL) Method and Treatment

HSIL constitutes approximately 0.7% of all cervical cytology results; however, frequency changes according to the age. When colposcopic investigation is performed on the females, whose smear results are HGSIL, CIN 2, 3 or cancer is detected in 53-66% and when biopsy is received diagnostically, CIN 2, 3 or cancer is detected in 84-97%.

There is routine treatment indication since the risk to proceed to invasive cervical cancer is high in untreated, hystologically verified CIN 2, 3 lesions.

On the other hand, invasive cervix cancer diagnosis is made on approximately 2% of females with HSIL (CIN 2 or CIN 3) currently. Due those reasons, HSIL requires to be evaluated by colposcopy or directly LEEP. Subsequent level is determined according to whether colpoccopic investigation is sufficient and the pregnancy status of the females.

When HSIL is detected, conization and HPY typing should absolutely be performed. According to pathology result achieved after the conization and HPV typing, the patient may be monitored in 3 and 6 months intervals.

Conization as surgical treatment option is the only option for patients desiring to protect fertility. However, if the woman completes her fertility, hysterectomy, in other words removal of the uterus is also one of surgical treatment options. On the other hand, as complication risk is much higher, it is never the first option.
Excisional treatment options should be preferred also in repeating CIN (CIN 1 or CIN 2, 3) cases. In addition to it, performing diagnostic excisional intervention to all patients, in whom verified CIN 2, 3 is detected by biopsy however colposcopic investigation is insufficient, is a must.

It has an exception. Young girls at age 21 and below. HPV typing should be made in this group of patients and the patients should be closely followed up without any surgical procedure.

Patients, In Whom Cervical Dysplasia Is Detected Between Ages 21-25

Another group to talk about and discuss are the patients between ages 21 – 25 classified as “Young Women”. The reason for differently addressing this age group is originating from the fact that the frequency and the rate of progress of cervical dysplasia to cervical cancer in this group is lower.

The patient must absolutely be monitored and the decisions must be taken by HPV test in the patients, in whom LSIL, in other words CIN 1 is detected especially by colposcopy. The problem is the patients coming with HPV type 16 or 18 are from this age group. Colposcopy must be performed on the patient, afterwards the patient must be evaluated according to the result of biopsy received.

At this point, I will provide some more details in order to answer the questions of our patients, who are included in young patient group, read a lot and ask the periods and approaches in flow charts published in the United States of America and also continuously followed by us.

As I emphasized in different parts on this site previously, the treatment charts we follow are often originating from the United States of America and Canada. They are charts belonging to associations such as American Colposcopy Association. There is an excellent health system in these countries. And the consciousness of the patients are much higher.

More importantly, procedures such as colposcopy, which is performed by specially educated gynecologists, are very expensive in the United States of America and they are afforded by private health systems and the government. Therefore, treatment charts try to keep the control periods within balance in order to protect the government and private health system financially on one hand.

As a result, I think that the approaches such as “We’ll call you 1 year later.”, “Let’s have control smear.” in these treatment charts are not very realistic in the conditions of our country. On the other hand, if required to sample, what should be done to the patient, if we assume that the result of biopsy received by an experienced colposcopist observing lesion under colposcopy at age 23 is CIN 3 and HPV typing is Type 16 Positive?

It is quite a difficult question, the patient may not want to undergo conization surgery but as a result, the possibility of CIN 3 to proceed to cervical cancer ranges between 0.5% – 1% at this age group regardless of HPV typing.
(Sasieni P., Castanon A, Parkin DM. How many cervical cancers are prevented by treatment of screen-detected disease in young women? Int J Cancer. 2009: 15;124(2):461-464)

But there is risk!

In terms of this group of patients, talking, giving details, strictly monitoring and absolutely explaining the risks in a clear way especially in the conditions of Turkey are required.

As a result, conization is the best option for the patients with CIN 2 and CIN 3, in other words patients with HGSIL at 25 age and over. HPV typing should absolutely be performed. By this means, the patient may have clearer information in terms of risk management and recurrence risk.

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