Management According to Histology
• Observation and follow-up without treatment is appropriate for CIN 1 and includes any of the following: repeat Pap in 6 and 12 months; colposcopy and repeat Pap in 12 months; or HPV DNA testing in 12 months.
• Ablative modalities can be used for CIN 1, 2, and 3. These include cryotherapy (freez-ing), laser vaporization, and electrofulguration.
• Excisional procedures can be used for CIN 1, 2, and 3. These include LEEP (loop elec-trosurgical excision procedure) or cold-knife conization.
• Hysterectomy is only acceptable with biopsy-confirmed, recurrent CIN 2 or 3.
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USMLE Step 2 l Gynecology
| Biopsy | Follow-up options | Biopsy | ||||||||||||||
| Observation | ||||||||||||||||
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| Repeat Pap, colposcopy |
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| and Pap, HPV-DNA | ||||||||||||||||
| Ablative Therapy | ||||||||||||||||
| CIN 1 | ||||||||||||||||
| Cryotherapy, laser, electrofulguration | CIN 2
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| CIN 3 |
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| Excisional Procedure | ||||||||||||||||
| LEEP, cold-knife cone | ||||||||||||||||
| Hysterectomy | ||||||||||||||||
| Only recurrent CIN 2 or CIN 3 | ||||||||||||||||
Figure II-4-10. Cervical Dysplasia: Management According to Histology
Follow-Up. Patients treated with either ablative or excisional procedures require follow-up repeat
Pap smears, colposcopy and Pap smear, or HPV DNA testing every 4 to 6 months for 2 years.
Invasive Cervical Cancer
A 43-year-old woman complains of intermenstrual postcoital bleeding for the past 6 months between regular menstrual cycles that occur every 28 days. On pelvic examination a 3-cm exophytic mass is seen from the anterior lip of the cervix. The rest of the pelvic examination, including a rectovaginal examination, is normal.
Definition. Cervical neoplasia that has penetrated through the basement membrane.
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Presentation. Patients with invasive cervical cancer can present with postcoital vaginal bleed-ing. Other symptoms of cervical cancer include irregular vaginal bleeding and, in advanced stage, lower extremity pain and edema.
Epidemiology. Cervical carcinoma is the third most common gynecologic malignancy with amean age at diagnosis of 45 years.
Diagnostic Tests/Findings
• Cervical biopsy. The initial diagnostic test should be a cervical biopsy, in which themost common diagnosis is squamous cell carcinoma.
• Metastatic workup. Once a tissue diagnosis of invasive carcinoma is made, a metastaticworkup should be done that includes pelvic examination, chest x-ray, intravenous pyelo-gram, cystoscopy, and sigmoidoscopy.
• Imaging studies. Invasive cervical cancer is the only gynecologic cancer that is stagedclinically; an abdominal pelvic CT scan or MRI cannot be used for clinical staging.
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Chapter 4 l Disorders of the Cervix and Uterus
Staging. Staging is clinical based on pelvic examination and may include an intravenous pyelo-gram (IVP).
Stage 0: Carcinoma in-situ (CIS). The basement membrane is intact.
Stage I: Spread limited to the cervix. This is the most common stage at diagnosis.
Ia1. Invasion is ≤3 mm deep (minimally invasive)
Ia2. Invasion is >3 but ≤5 mm deep (microinvasion)
IB. Invasion is >5 mm deep (frank invasion)
Stage II: Spread adjacent to the cervix
IIa. Involves upper two thirds of vagina
IIb. Invasion of the parametria
Stage III: Spread further from the cervix
IIIA. Involves lower one third of vagina
IIIB. Extends to pelvic side wall or hydronephrosis
Stage IV: Spread furthest from the cervix
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IVA. Involves bladder or rectum or beyond true pelvis
IVB. Distant metastasis
Management. Patients treated surgically are evaluated for risk factors for metastatic diseaseand tumor recurrence. These include metastatic disease to the lymph nodes, tumor size >4 cm, poorly differentiated lesions, or positive margins. Patients with these findings are offered adjuvant therapy (radiation therapy and chemotherapy).
• Specific by stage:
Stage Ia1: Total simple hysterectomy, either vaginal or abdominal Stage Ia2: Modified radical hysterectomy
Stage IB or IIA: Either radical hysterectomy with pelvic and paraaortic lymphad-enectomy (if premenopausal) and peritoneal washings or pelvic radiation (if postmenopausal). In patients who can tolerate surgery, a radical hysterectomy is preferred; however, studies have demonstrated equal cure rates with radiation or surgical treatment.
Stage IIB, III, or IV: Radiation therapy and chemotherapy for all ages.
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