Treatment for CIN and Carcinoma in Situ
Treatment of cervical intraepithelial neoplasia (CIN), including carcinoma in situ, depends on the type and extent of abnormal changes. Some of the treatments for CIN are also used for early-stage cancer.
- CIN I often goes away on its own. Careful follow up is required to make certain that the Pap smear and colposcopic exam return to normal.
- CIN II or CIN III may turn into invasive cancer if the suspicious area is not removed. This is often done using an outpatient technique called loop electrosurgical excision procedure (LEEP). [See next section.]
- If extensive areas of CIN II or III cannot be entirely seen with colposcopy or if they spread into the mucous membrane in the cervical canal, a more aggressive procedure called conization (cone biopsy) may be required.
Treatment for Adenocarcinoma in Situ. An adenocarcinoma is cancer inside tissue that looks like or functions as a gland. (A gland is a group of cells that secretes a substance to be used by or removed from the body.) Adenocarcinomas tend to be more aggressive than the more common squamous carcinoma in situ, which grow in the lining of tissue (mucous membrane). Some evidence suggests that adenocarcinomas develop in numerous sites rather than a single location. Hysterectomy is generally recommended. In women who wish to retain fertility, cone biopsies may be performed, although this procedure sometimes causes sterility and it does not always remove all adenocarcinomas.
Follow-Up. Patients treated for CIN require monitoring. Testing for human papillomavirus (HPV) may prove to be useful in determining whether repeat colposcopies may or may not be needed. One study strongly suggested that if both HPV and Pap smear tests are normal on two consecutive visits, then most likely treatment was successful. If either the HPV or Pap smear is abnormal, then it may be reasonable to consider another colposcopy.
Loop Electrosurgical Excision Procedure
Loop electrosurgical excision procedure (LEEP), also called large loop excision of the transformation zone (LLETZ), uses a high frequency electrical current to cut away diseased tissue.
- A local anesthetic is applied to the cervix, and a wire loop is inserted into the vagina.
- A button-sized slice of tissue is removed from the cervix for examination.
- A deeper slice is used to evaluate the endocervical canal.
The procedure requires only one office visit. Extensive and deep sections of damaged tissue can be effectively removed and very high cure rates with just one treatment are possible. When used for dysplasia, it appears to be as effective as more invasive procedures.
Some experts feel that the only downside of LEEP is its simplicity. In other words, doctors may be tempted to use it for more serious conditions best treated by conization. It also may impair the ability to detect hidden invasive cancer. Patients should be monitored closely if the biopsies on the cervical tissue removed by LEEP suggest that the cells may become invasive.
LLETZ is becoming increasingly popular as a treatment for CIN. However, women of child-bearing age should be aware that it may later cause pregnancy- and birth-related problems, such as preterm delivery and low birth weight. Women who have this procedure may also be more likely to break their water too early (premature rupture of membranes). Experts recommend that doctors be cautious in using LLETZ, and other surgical procedures, for young women with mild cervical abnormalities.
Conization
Conization is a surgical procedure that removes suspicious sections of cells covering an abnormally large area, or those extending into the cervical canal. Conization is preferred over LEEP or LLETZ for lesions that are so extensive that they require a larger biopsy for their complete removal. As in LEEP, patients should be monitored closely if patients are infected with HPV virus or the biopsies on the cervical tissue removed show aggressive-grade cells.
The surgery can be performed under general anesthesia in the operating room with either traditional surgical instruments or with lasers. Use of laser surgery has reported success rates of up to 96% with infrequent complications.
A technique called frozen section examination (FSE) freezes the margins of the area being removed. Studies suggest that FSE allows immediate and precise evaluation of areas that may harbor invasive cancer cells, and may be an important addition to this procedure in women with high-grade CIN.
With conization, the ability to become pregnant can be preserved in many (but not all) cases. In women who do become pregnant, some studies have indicated that this procedure increases the risk for low-birth weight infants, so careful prenatal care is essential. Conization can also increase the risk for preterm delivery and cesarean section. Patients electing this treatment must be certain to undergo diligent follow-up evaluations.
Cryosurgery
Cryosurgery is not usually feasible for large and extensive abnormal areas. The procedure removes abnormal, but noncancerous, tissue by freezing it. Cryosurgery can be performed in a doctor's office in 15 minutes without medication.
- The vagina is opened with a speculum and a probe transmits gas (either nitrous oxide or carbon dioxide), which freezes the surface of the cervix.
- The gas is applied for three minutes or until ice crystals form on the targeted tissue.
- After waiting 3 minutes, freezing can be repeated for another three minutes.
Click the icon to see an image of cervical cryosurgery.
Side effects from this procedure include cramping, sometimes painful, for a few hours or days and a heavy, watery discharge for 2 - 4 weeks. The discharge can be irritating, have a bad odor, and may be blood-tinged. Symptoms that may indicate serious complications are fever and chills, heavy clotted bleeding, or extreme pain in the abdomen or back.
The patient may experience a temporary change in menstrual periods. The menstural periods may be heavier or lighter or come later or earlier. Tampons, douching, bathing, swimming, and intercourse should be avoided for several weeks after cryosurgery to prevent infection.
Patients undergoing this treatment must be willing to commit to regular follow-up examinations.
