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Cervical Intraepithelial Neoplasia[CIN]

Cervical Intraepithelial Neoplasia[CIN] written by ¾ç°æÈÆ

Concept:
¨ç invasive cancer but confined to the epithelium
¨è if not treated, may progress into cervical cancer
¨é all dysplasia(metaplasia without mitotic activity) have the potential for progression

Criteria for CIN
¨ç celluar immaturity
¨è celluar disorganization
¨é nuclear abnormalities
¨ê increased mitotic activity

CIN 1: lower ¨÷ of epithelium
CIN 2: middle ¨÷ of epithelium
CIN 3: upper ¨÷ of epithelium

Cervical Anatomy
exocervix: squamous epithelium ¡æ squamous cell carcinoma
endocervix: columnar epithelium & glands ¡æ adenocarcinoma
squamocolumnar junction- µÎ »óÇǰ¡ ¸¸³ª´Â ºÎºÐ
¨ç Nabothian cyst¸¦ °üÂû ÇÒ ¼ö ÀÖ´Ù.
¨è gland openingÀÌ °üÂûµÈ´Ù.
¨é squmous metaplasia¿¡ ÀÇÇØ CINÀÌ »ý¼ºµÈ´Ù.

Human Papilloma Virus as a pathogen
High risk: type 16(most common), 18
Low risk: type 6,11,42,43

Cytologic Classification System
squamous cell abnormalities
Bethesda Dysplasia/CIN system
ASCUS ----------- squamous atypia
HPV atypia
LSIL ----------- mild dysplasia/ CIN 1
----------- mnderate dysplasia/ CIN 2
HSIL ----------- severe dysplasia/ CIN 3
CIS CIN 3
* ASCUS : atypical squamous cell of undetermined significance
LSIL : low-grade squamous intraepithelial lesion
HSIL : high-grade squamous intraepithelial lesion
CIS[intraepithelial Ca. = stage 0]ÀÇ criteria
¨ç all epithelial layer°¡ undifferentiated cell
¨è loss of polarity(+)
¨é basement membrane intact & no stromal invasion
¨ê glandular extension(+/-)

Diagnosis.
¨ç Pap smear : ¿ù°æÀÏ Á¦ 8~12ÀÏ »çÀ̰¡ ÁÁ´Ù
¨è colposcopy
Ix:- all women with abnormal cytology
- all women with previous history of abnormal cytology
- gross suspicous cervical lesion
- history of contact bleeding
- any suspicious lesion of vulva or vagina
Abnormal findings :
-(aceto-)white epithelium : epithelium turns white after application of acetic acid
- punctuation : dilated capillaries terminating on the surface
- mosaic : terminal capillary surrounding circular blocks of acetowhite epitehlium
- leukoplakia : because of keratin abnormality(ÃÊ»ê¿ë¾× µµÆ÷ÇÏÁö ¾Ê¾Æµµ ÇϾé°Ô º¸ÀÓ).
hyperkeratosis, parakeratosis
- iodine negative epithlium
- atypical vessel
Normal findings
- original squamous epithelium(Ç÷°ü¸ð¾ç °üÂûX, ºÐÈ«»ö)
- columnar epithelium(acetic acid µµÆ÷½Ã Æ÷µµ¼ÛÀÌ ¸ð¾ç)
- intact transformation zone
¨é Human papillomavirus[HPV] typing
Ix.
- ¾Ï¼¼Æ÷´Â ¹ß°ßµÇÁö ¾ÊÁö¸¸ ºñÁ¤»óÀûÀÎ ¼¼Æ÷Áø´ÜÀÌ ³ªÅ¸³¯ ¶§
- HPV°¨¿° ¶Ç´Â Ãʱ⠻óÇÇÀÌÇüÁõ »óÅÂ
- ¼¼Æ÷Áø °Ë»ç¿¡¼­ ¾ç¼º ¹ÝÀÀÀ» ³ªÅ¸³ÂÁö¸¸ ÁúÈ®´ë°æÀ¸·Î Áø´ÜÀÌ ºÒ°¡´ÉÇÒ ¶§
- ÀڱðæºÎ¾Ï ¹ß»ýÀÇ À§ÇèÀÌ ³ôÀº ¿©¼º
- ÀڱðæºÎ ¿øÃßÀýÁ¦ ¼ö¼úÈÄ ÃßÀû°Ë»ç
¨ê cervicography
¨ë Schiller test
- mechanism : cervix³ª vaginaÀÇ Á¤»ó »óÇÇ´Â glycogenÀÌ Ç³ºÎÇÏ´Ù.
¡æ iodine solution(Lugol¡¯s solution)¿¡ dark brown color º¸ÀÓ(mahogany color)
- analysis : dysplasia³ª cancer cell
¡æ iodine(-)À̸é schiller test(+) : Âø»öÀÌ ¾È µÊ
- Schiller test (+)ÀÎ °æ¿ì
trauma, eversion, erosion, keukoplakia, benign inflammation, columnar epithelium,
squamous metaplasia, focus of carcinoma
¨ì biopsy(Dx. & Tx.)
punch Bx. : È®Áø ¹æ¹ý
Ix. : abnormal Pap smear(class II ÀÌ»ó)
cervixÀÇ visible lesion(+)
method : directed punch Bx.
multiple punch Bx. ¡æ 12½Ã, 6½Ã ¹æÇâ
conization of cervix : °¡Àå Á¤È®. È®Áø ¹æ¹ý
Ix.
Dx.(cold knife cone)
- colposcopy¿¡¼­ S-C junctionÀÌ º¸ÀÌÁö ¾ÊÀ» ¶§
- lesionÀÌ canal ¾ÈÀ¸·Î extendµÇ°í upper limit°¡ º¸ÀÌÁö ¾ÊÀ» ¶§
- Pap smear, colposcopic finding, directed biopsy°¡ ÀÏÄ¡ÇÏÁö ¾ÊÀ» ¶§
- endocervical curettage (+)
- microinvasiveness°¡ ÀÇ½ÉµÉ ¶§
- colposcopy ½ÃÇàÇÒ ¼ö ¾ø°í Schiller test(+) area°¡ ¾ø´Â °æ¿ì
Tx.(hot conization)
- chronic cervicitis
- CIN(dysplasia, CIS)

epidemiology of cervical Ca.
- mild dysplasia ¡æ CIS : 7yr
- severe dysplasia ¡æ CIS : 1yr
- CIS ¡æ invasive Ca. : 10yr

very mild carcinoma microinvasive clinical
dysplasia in situ carcinoma cancer
7 14 3 2.5
15% 50~60% 100% 40%
transit time(yr)
percent of pt.
25 32 44 47
progressing
mean age(yrs)


CIS
invasive cervical Ca.ÀÇ Àü´Ü°è : 20~30´ë »çÀÌ¿¡ ¹ß»ý
Ä¡·áÇÏÁö ¾ÊÀ¸¸é 1/3~2/3¿¡¼­ invasive Ca.·Î ÁøÇà
80% < SCJ¿¡¼­ ¹ß»ý
90% < HPV °ËÃâ
follow-up : Pap smear¸¦ 2ȸ/yr

Ä¡·á :
mild~moderate dysplasia
- cone Bx., multiple Bx., endocervical curettage
: young women
- /U with Pap smear, conization, cervix amputation
severe dysplasia, CIS
- R/O invasive Ca. ¡æ cone Bx., multiple Bx., endocervical curettage
- ÀÓ½ÅÇÏ±æ ¿øÇϸé conization ¡æ F/U with Pap smear & colposcopy
- hysterectomy


Treatment Á¾·ù ¹× ÀûÀÀÁõ
¨ç Cryotherpy
destroys the surface epithelium of cervix by crystallizing the intracellular water

Criteria
- CIN grade 1-2
- small lesion
- ectocervical location only
- negative endocervical curretage
- no endocervical gland involvement on biopsy
¨è Conization
Conization is indicated for dx. in women with HSIL onthe Pap test under the following condition:
- limits of the lesion cannot be visualized with colposcopy
- SCJ is not seen at colposcopy
- endocervical curettage histologic findings are positive for CIN 2 or CIN 3
- lack of correlation between cytology, biopsy and colposcopy results
- microinvasion is suspected based on biopsy, colposcopy, cytology results
- colposcopist is unable to rule out invasive cancer.
¨é Laser
Ix.
- large lesions that the cryoprobe cannot adequately cover
- irregular cervix with a "fish mouth" apperance and deep clefts
- extension of diease to the vagina or satellite lesions on the vagina
¨ê LEEP( loop electrosurgical excision procedure)
contra-Ix.
- patient anxiety
- extremely large lesion
- vaginal extension
- clinical carcinoma