A committee chaired by Mr Mahmood I Shafi (UK) working closely with Katja Behrens and Thomas Löning from Germany has been developing a consensus document in relation to treatment standards for CIN. This is based on guidance from one of the national screening programmes (NHSCSP) but was refined taking into consideration comments from member federations. Of the 10 standards being assessed, there has been agreement on all ten of the guidelines. These now form the EFC approved standards for treatment. It is hoped that these guidelines will form the basis of an audit into quality standards across the EFC.
1. Whereas there is no obviously superior conservative surgical technique for treating and eradicating cervical intra-epithelial neoplasia (CIN), excision is preferred because of better histopathological assessment
2. Ablative techniques are only suitable when:
- The entire transformation zone is visualised
- There is no evidence of glandular abnormality
- There is no evidence of invasive disease
- There is no discrepancy between cytology and histolog
3. Cryocautery should be used only for low grade CIN and a double freeze thaw freeze technique should be used.
4. When excisional techniques are used for treatment, every effort should be made to remove the lesion in one specimen. The histology report should record the dimensions of the specimen and the status of the resection margins with regard to intraepithelial or invasive disease.
5. For ectocervical lesions, treatment techniques should remove tissue to a depth of 6 mm.
6. A see and treat policy at first visit can be used where audit has identified that CIN is present in the majority of the excised specimens. A target of CIN in ≥90% of the excised specimens should be achieved. Treatment at first visit for a referral of borderline or mild dyskaryosis should be used only in exceptional cases to minimise the possibility of over-treatment.
7. CIN extending to the resection margins at LLETZ excision results in a higher incidence of recurrence but does not justify routine repeat excision as long as:
- The entire transformation zone is visualised
- There is no evidence of glandular abnormality
- There is no evidence of invasive disease
- The women are under 50 years of age
8. Women over the age of 50 years with incomplete excision of CIN at the endocervical margin are at high risk for residual disease. Careful and adequate follow-up endocervical cytology is a minimum requirement. Re-excision is an alternative.
9. Women with adenocarcinoma in situ / CGIN can be managed by local excision for women wishing to retain fertility. Incomplete excision at the endocervical margin requires a further excisional procedure to obtain clear margins and exclude occult invasive disease.
10. Microinvasive squamous cancer FIGO stage Ia1 can be managed by excisional techniques if:
- the excision margins are free of CIN and invasive disease.
If the invasive lesion is excised but CIN extends to the excision margin then a repeat excision should be performed to confirm excision of the CIN and to exclude further invasive disease. This should be performed even in those cases planned for hysterectomy to exclude an occult invasive lesion requiring radical surgery.
- the histology has been reviewed by a specialist gynaecological pathologist
Dr. Mahmood Shafi