[Management of CIN1].
A cervical intraepithelial neoplasia grade 1 (CIN1) is a lesion of basal cells consisting in an architecture disorganization and cytological atypia limited to the lower third of the cervical epithelium. It is considered as a precancerous lesion uterine cervix carcinoma while they spontaneously regress in more than 60% of cases in two years. The problems related to the management of CIN1 as defined by the recommendations established in 2002 are the over-treatment and the great variability of clinical practices. Moreover, the potential of new tests has been investigated since 2002. To establish these new recommendations, the medline database has been consulted and the references essentially published between 2001 and May 2007 have been investigated. Publications were selected and classified according to their level of evidence (LE) in order to establish the grade of recommendations. One of the problems encountered when facing a CIN1 is to misdiagnose a more severe lesion firstly because of the intra- and interobserver variability and secondly because the colposcopy-directed biopsy is not mandatorily representative of the more severe lesion. Nevertheless, because the risk of cancer is extremely low, a conization is not necessary in an asymptomatic woman with a LSIL/ASC-US pap smear in case of CIN1 even if the squamocolumnar junction is not entirely visualized (LE 2/3). The endocervical curettage cannot be recommended in this case because its efficacy is globally poor and unknown in case of CIN1. Concerning the natural history of CIN1, the recent studies, which included more than 1200 women and more than 700 for two of them, confirm that the rate of progression of a CIN1 to a CIN3 or more severe lesion is less than 9% in the two years following the initial diagnosis (LE2). A CIN1 is associated with a risk of evolution to a CIN2 or more severe lesion that is not markedly more important than the risk associated with a LSIL/ASC-US pap smear while the colposcopy is normal or the biopsy is negative (between 8 and 13% whatever the results of the initial colposcopy) (LE 2/3). The recommendation in case of CIN1 is a strict follow-up. A colposcopy and a treatment are necessary in case of persistence or progression of the abnormalities (LE2). Data from trials studying the contribution of HPV testing in case of CIN1 show that its sensitivity is similar to repeat cytology with less referral to colposcopy to detect CIN2 or more severe lesion. These data have been considered to establish follow-up recommendations to manage CIN1: if the exams (cytology and/or HPV testing) at 12 months are negative, patients can be followed by an annual cytology. In case of aggravation of the cytology, a colposcopy is necessary. In case of positive HPV testing or persisting ASC-US/LSIL at 12 months, a repeat control is necessary at 18 months and a treatment is proposed according to colposcopy findings.
Rouzier
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Service de Gynécologie-Obstétrique, Hôpital Tenon, Université Pierre-et-Marie-Curie, Paris-VI, Paris, France. rouzierroman@yahoo.fr
D002584:Cervix Uteri / Q000601:surgery; D003127:Colposcopy; D019092:Conization / Q000009:adverse effects; D003475:Curettage; D005260:Female; D006801:Humans; D015588:Observer Variation; D065006:Papanicolaou Test; D027383:Papillomaviridae / Q000302:isolation & purification; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy*; D014626:Vaginal Smears; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy*