AJOG Reviews
2001 Consensus Guidelines for the management of women with cervical intraepithelial neoplasia,☆☆,

https://doi.org/10.1067/mob.2003.633Get rights and content

Abstract

Objective: The study was undertaken to provide consensus guidelines for the management of women with histologically confirmed cervical intraepithelial neoplasia (CIN) that can act as a precursor to invasive cervical cancer and represents one of the most common significant gynecologic diseases of women of reproductive age. Participants: An independent panel of 121 experts in various aspects of the diagnosis and management of cervical cancer precursors, including representatives from 29 participating professional organizations, federal agencies, national and international health organizations, and others were invited by the American Society for Colposcopy and Cervical Pathology (ASCCP). Consensus Process: Guidelines for the management of women with CIN were developed through a multistep process. Draft management guidelines were developed by working groups who performed formal literature reviews and obtained input from the professional community at large by way of an interactive internet-based bulletin board. At the ASCCP Consensus Conference, September 6 through 8, 2001, in Bethesda, Md, all guidelines were discussed, revised, and adopted by formal vote. Conclusion: Evidence-based guidelines have been developed for the management of women with biopsy-confirmed CIN. (Am J Obstet Gynecol 2003;189:295-304.)

Section snippets

General comments

The 2001 Consensus Conference and the process used to develop the Consensus Guidelines have previously been reported.2 Each guideline is rated by using a 2-part grading system.3, 4 The “strength of recommendation” for or against the use of a particular option is indicated by the letters A through E. It is important to recognize that several criteria that included the possibility for harm to a patient if a specific intervention did not take place, the possible complications that could be

General comments

Women with a diagnosis of CIN-1 on a colposcopically directed biopsy represent a heterogeneous group. Numerous studies have documented a high level of intraobserver and interobserver variability in the histologic diagnosis of CIN-1.5, 6, 7 In the National Cancer Institute's ASCUS/LSIL Triage Study (ALTS) clinical trial, only 43% of the cervical biopsies initially diagnosed as CIN-1 were classified as CIN-1 by the expert pathology review committee, 41% were downgraded to normal, and 13% were

Women with satisfactory colposcopic examination

Management options for women with biopsy-confirmed CIN-1 are follow-up without treatment or treatment with the use of ablative or excisional modalities, Table II.Follow-up with a program of either repeat cervical cytology, at 6 and 12 months, or HPV DNA testing for high-risk types of HPV at 12 months, is the preferred management approach for women with biopsy-confirmed CIN-1 and a satisfactory colposcopic examination (AII). When follow-up is used, referral to colposcopy is preferred if a repeat

General comments

The term CIN-2,3 is used to refer to lesions previously referred to as moderate dysplasia (ie, CIN-2) and severe dysplasia/carcinoma in situ (ie, CIN-3).49 Although natural history studies of untreated moderate dysplasia, severe dysplasia, and carcinoma in situ have reported differences in the behavior of these lesions during long-term follow-up, the histologic diagnosis of these entities is poorly reproducible.5, 6, 7, 45 Moreover, follow-up studies have found that despite marginal relative

Posttreatment follow-up of women with CIN-2,3

The risk of recurrent/persistent CIN-2,3 or invasive cervical cancer after treatment is relatively low, but remains higher than the background population risk for many years.61, 78, 79, 80, 81, 82 A large, long-term follow-up study from the United Kingdom reported that the cumulative rate of invasive cervical cancer after 8 years of follow-up among women receiving outpatient treatment for CIN was 5.8 per 1000.79 For comparison, the age-adjusted incidence rate of invasive cervical cancer in the

Initial management of biopsy-confirmed CIN-2,3

Management decisions in women with biopsy-confirmed CIN-2,3 are determined by whether the colposcopic examination is classified as satisfactory or unsatisfactory, Table II. Both excision and ablation of the transformation zone are acceptable for women with biopsy-confirmed CIN-2,3 and a satisfactory colposcopy (AI). However, in patients with recurrent CIN-2,3, excisional modalities are preferred (AII). A diagnostic excisional procedure is recommended for women with biopsy-confirmed CIN-2,3 and

Acknowledgements

We would like to thank all of the participating organizations, conference participants, and the members of the working groups. Names of the conference participants are available online at www.asccp.org and names of the participating organizations are in the Appendix.

References (90)

  • O Oyesanya et al.

    A comparison between loop diathermy conization and cold-knife conization for management of cervical dysplasia associated with unsatisfactory colposcopy

    Gynecol Oncol

    (1993)
  • F Girardi et al.

    Cold-knife conization versus loop excision: histopathologic and clinical results of a randomized trial

    Gynecol Oncol

    (1994)
  • PL Giacalone et al.

    Randomized study comparing two techniques of conization: cold knife versus loop excision

    Gynecol Oncol

    (1999)
  • DR Genest et al.

    A binary (Bethesda) system for classifying cervical cancer precursors: criteria, reproducibility, and viral correlates

    Hum Pathol

    (1993)
  • B Bjerre et al.

    Conization as only treatment of carcinoma in situ of the uterine cervix

    Am J Obstet Gynecol

    (1976)
  • ES Andersen et al.

    The reliability of preconization diagnostic evaluation in patients with cervical intraepithelial neoplasia and microinvasive carcinoma

    Gynecol Oncol

    (1995)
  • BD Duggan et al.

    Cold-knife conization versus conization by the loop electrosurgical excision procedure: a randomized, prospective study

    Am J Obstet Gynecol

    (1999)
  • RW Naumann et al.

    LLETZ is an acceptable alternative to diagnostic cold-knife conization

    Gynecol Oncol

    (1994)
  • F Gardeil et al.

    Persistent intraepithelial neoplasia after excision for cervical intraepithelial neoplasia grade III

    Obstet Gynecol

    (1997)
  • P Vedel et al.

    Five-year follow up of patients with cervical intra-epithelial neoplasia in the cone margins after conization

    Eur J Obstet Gynecol Reprod Biol

    (1993)
  • WH Kobak et al.

    The role of endocervical curettage at cervical conization for high-grade dysplasia

    Obstet Gynecol

    (1995)
  • NP Yost et al.

    Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions

    Obstet Gynecol

    (1999)
  • JP. Connor

    Noninvasive cervical cancer complicating pregnancy

    Obstet Gynecol Clin North Am

    (1998)
  • WR Robinson et al.

    Management of cervical intraepithelial neoplasia during pregnancy with LOOP excision

    Gynecol Oncol

    (1997)
  • DR Tate et al.

    Recurrence of cervical dysplasia in the human immunodeficiency virus- seropositive patient

    Obstet Gynecol

    (2001)
  • K Holcomb et al.

    The efficacy of cervical conization in the treatment of cervical intraepithelial neoplasia in HIV-positive women

    Gynecol Oncol

    (1999)
  • TC Wright et al.

    Cervical intraepithelial neoplasia in women infected with the human immunodeficiency virus: outcome after loop electrosurgical excision

    Gynecol Oncol

    (1994)
  • M Maiman et al.

    Vaginal 5-fluorouracil for high-grade cervical dysplasia in human immunodeficiency virus infection: a randomized trial

    Obstet Gynecol

    (1999)
  • O Reich et al.

    Cervical intraepithelial neoplasia III: long-term outcome after cold- knife conization with clear margins

    Obstet Gynecol

    (2001)
  • WP Soutter et al.

    Invasive cervical cancer after conservative therapy for cervical intraepithelial neoplasia

    Lancet

    (1997)
  • JV Brown et al.

    Invasive carcinoma after cone biopsy for cervical intraepithelial neoplasia

    Gynecol Oncol

    (1991)
  • A Ferenczy et al.

    Loop electrosurgical excision procedure for squamous intraepithelial lesions of the cervix: advantages and potential pitfalls

    Obstet Gynecol

    (1996)
  • E Paraskevaidis et al.

    Incomplete excision of CIN in conization: further excision or conservative management?

    Eur J Obstet Gynecol Reprod Biol

    (1994)
  • S Jain et al.

    Negative predictive value of human papillomavirus test following conization of the cervix uteri

    Gynecol Oncol

    (2001)
  • Y Nagai et al.

    Persistence of human papillomavirus infection after therapeutic conization for CIN 3: is It an alarm for disease recurrence?

    Gynecol Oncol

    (2000)
  • BA Jones et al.

    Quality management in gynecologic cytology using interlaboratory comparison

    Arch Pathol Lab Med

    (2000)
  • TC Wright et al.

    2001 Consensus Guidelines for the management of women with cervical cytological abnormalities

    JAMA

    (2002)
  • USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus

    MMWR

    (1999)
  • MA. Kish

    Guide to development of practice guidelines

    Clin Infect Dis

    (2001)
  • AJ Robertson et al.

    Observer variability in histopathological reporting of cervical biopsy specimens

    J Clin Pathol

    (1989)
  • SM Ismail et al.

    Observer variation in histopathological diagnosis and grading of cervical intraepithelial neoplasia

    BMJ

    (1989)
  • MH Stoler et al.

    Interobserver reproducibility of cervical cytologic and histologic interpretations: realistic estimates from the ASCUS-LSIL Triage Study

    JAMA

    (2001)
  • AG. Ostor

    Natural history of cervical intraepithelial neoplasia: a critical review

    Int J Gynecol Pathol

    (1993)
  • R Klaes et al.

    Overexpression of p16(INK4A) as a specific marker for dysplastic and neoplastic epithelial cells of the cervix uteri

    Int J Cancer

    (2001)
  • DC Connolly et al.

    Loss of fhit expression in invasive cervical carcinomas and intraepithelial lesions associated with invasive disease

    Clin Cancer Res

    (2000)
  • Cited by (299)

    • Cancers of the Cervix, Vulva, and Vagina

      2019, Abeloff’s Clinical Oncology
    View all citing articles on Scopus

    This set of guidelines was supported by grant number 1 R13 CA96190-01 from the National Cancer Institute.

    ☆☆

    Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute or the participating societies and organizations.

    Reprint requests: Thomas C. Wright, Jr, MD, Room 16-404, P&S Building, 630 W 168th St, New York, NY 10032. E-mail: [email protected]

    View full text