Cervical intraepithelial neoplasia (CIN)

INTRODUCTION:

• Cervical intraepithelial neoplasia (CIN) is a precancerous condition in which abnormal cells grow on the surface of the cervix

ETIOLOGY AND RISK FACTORS:

• Women who become infected by a “high risk” type of HPV, such as 16, 18, 31, or 33
  • HPV  types 16 or 18 produce E6 and E7 proteins, which induce the expression of cellular p53 and p110Rb oncogenes, respectively
• Women who are immunodeficient
• Women who give birth before age 17
• Smoking cigarettes
• Having sex with multiple partners
• Becoming sexually active before age 18
• Becoming infected with the human immunodeficiency virus (HIV)
• Poor socioeconomic status.
• Multiparity with poor birth spacing between pregnancies.
• Poor personal hygiene. 

SIGNS AND SYMPTOMS:

• There are no specific symptoms of cervical intraepithelial neoplasia alone
• Symptoms of cervical cancer
• Abnormal or post-menopausal bleeding
• Abnormal discharge
• Changes in bladder or bowel function
• Pelvic pain on examination
•  CIN cervix may transform into invasive carcinoma is 10 years

STAGING:

Histology Grade	Cytology	Description
–	–	Normal cervical epithelium
CIN 1(Grade I)	LSIL	Represents only mild dysplasia, or abnormal cell growth.   It is confined to the basal 1/3 of the epithelium -Usually corresponds to infection with HPV and has a high rate of regression back to normal cells and can usually be managed expectantly
CIN 2/3	HSIL	-Represents a mix of low and high-grade lesions not easily differentiated by histology. Best Managed with Colposcopy and LEEP -Formerly subdivided into CIN2 and CIN3. -HSIL+ encompasses HSIL, AGC, or cancer
CIN 2(Grade II)		Represents a mix of low and high-grade lesions not easily differentiated by histology. Moderate dysplasia confined to the basal 2/3 of the epithelium -CIN 2+ encompasses CIN 2,3, AIS, or cancer 5% risk to transform to malignancy
CIN 3(Grade III)		Severe dysplasia with undifferentiated neoplastic cells that span more than 2/3 of the epithelium, and may involve the full thickness. This lesion may sometimes also be referred to as cervical carcinoma in situ. CIN 3+ encompasses CIN3, adenocarcinoma in situ (AIS), or cancer

DIAGNOSIS:

• Pap smear
• colposcopy to examine the cervix and surrounding structures
• A biopsy may be performed to remove tissue samples for examination in a laboratory.
•  A DNA test may be ordered to see whether a high-risk form of HPV is present.

MANAGEMENT:

Removal (resection) procedures include:

• Loop electrosurgical excision procedure (LEEP)—
• Uses a small, electrically charged wire loop to remove tissue.
• Remove tissue samples for further analysis
• Complications following the procedure are:
• Delayed bleeding
• Narrowing of the cervix (stenosis).
• Cold knife cone biopsy (conization)—
• This is a surgical procedure in which a cone-shaped piece of tissue containing the lesion is removed.
• Conization can provide a sample of tissue for further testing.Thus used in Grade III with no colposcopy
• Higher risk of complications, including cervical stenosis and postoperative bleeding.
• Hysterectomy: In aged female with grade III CIN
• CIN grade III followed by pap smear should be confirmed by Colposcopy directed biopsy
• Ablation and resection
• Effective in about 90% of all cases, with a 10% chance of recurrence of CIN after treatment.
• Patients are advised to have follow-up Pap tests every 3 to 6 months for 1 to 2 years after treatment. 

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