Atlas of Colposcopy: Principles and Practice

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Cervical premalignant lesions can be treated either by an ablative method (cryotherapy or thermal ablation) or by excision, depending on certain criteria, which are discussed later.
The basic principles of treatment of cervical intraepithelial neoplasia are the following.
  • The entire transformation zone undergoes HPV-induced clonal change and is at risk of developing CIN. Therefore, the whole transformation zone should be treated (ablated or excised), irrespective of the size of the lesion.
  • High-grade CIN lesions often extend into the crypts present in the transformation zone. The depth of the crypts can be up to 5 mm. During ablative treatment, the tissue destruction must extend up to 7–8 mm to ensure complete clearance of disease. Similarly, during excisional treatment the cone should be fashioned in such a way that the entire transformation zone, including the full length of the crypts, is removed.
  • CIN1 and HPV changes detected on histology or colposcopy need not be treated, because they rarely progress to higher grades. Low -grade lesions should be treated only if the lesions increase in size or in severity during follow-up, persist beyond 2 years, or are associated with high-grade cytological abnormalities; low-grade lesions/CIN1 lesions may be treated when follow-up is not guaranteed.
  • CIN2 and CIN3 lesions should always be treated except in very young women (younger than 25 years).
  • The decision to treat a CIN lesion may be based on colposcopic findings (“see and treat”) without waiting for histological verification.
  • Ablative or excisional treatment can be performed for VIA- or HPV -positive women without colposcopic or histological verification (“screen and treat”) in situations where these diagnostic services are not available.

Role of hysterectomy to treat CIN/AIS
Hysterectomy should not be performed as initial treatment for CIN/AIS lesions. Hysterectomy is indicated if the endocervical margin of the excised cone after LLETZ or cold-knife conization is positive for CIN2/CIN3/AIS and a repeat excision is not technically possible. Hysterectomy may be performed for benign indications coexisting with CIN lesions only if the upper limit of the lesion is visible and there is no suspicion of invasive cancer.

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