Levine_Handbook for Principles and Practice of Gynecologic O

Chapter 4 Preinvasive Lesions of the Genital Tract 93 ment may involve an excisional or ablative procedure. In patients with recurrent CIN (either CIN 1 or CIN 2,3), an excisional treatment modal ity with either LEEP or cold knife cone is recommended. Additionally, a diagnostic excisional procedure is recommended for all women with biopsy-confirmed CIN 2,3 and an unsatisfactory colposcopic examina tion. The risk of recurrent CIN 2,3 or invasive cancer remains elevated for many years after treatment. The 2012 Consensus Guidelines recom mend that women should be followed with cotesting at 12 and 24 months after treatment for CIN 2,3. If any test is abnormal, colposcopy with ECC is recommended. Once two consecutive negative cytology results are obtained, repeat testing at 3 years followed by routine screening is recom mended. When CIN is identified at the margins of a diagnostic excisional procedure, a 4- to 6-month follow-up visit with cytology and endocervical sampling is recommended. Atypical Glandular Cells and Adenocarcinoma In Situ Patients with AGC are at risk for both cervical and endometrial abnormali ties. For women under age 35, colposcopy with ECC should be performed. For women older than 35 or any woman with abnormal vaginal bleeding in the setting of AGC, an endometrial biopsy should be performed in addition to colposcopy and ECC. For women with AGC–NOS who are not found to have high-risk findings, cotesting at 12 and 24 months is recommended. For high-grade (CIN 2+) squamous lesions, standard recommendations can be followed. For negative colposcopic findings after AGC favor neoplasia or AIS on Pap smear, a diagnostic excisional procedure is recommended. Patients with biopsy-proven AIS are known to have both multifocal disease and a risk of invasive adenocarcinoma when thoroughly sampled. Therefore, excision is required for all patients. Hysterectomy is the pre ferred treatment but must be preceded by an excisional biopsy that can exclude invasion requiring a more radical procedure. For women with AIS who desire fertility preservation, a cold knife cone biopsy with negative margins is an acceptable alternative to hysterectomy. Other forms of exci sion procedures may be considered as long as they produce a specimen that is not fragmented. Vulvar and Vaginal Intraepithelial Neoplasia

VIN and VAIN require more individualization and creativity in treat ment. Most VIN is detected at the time of biopsy for a suspicious lesion. Definitive treatment should be complete excision, although positive margins for a low-grade lesion could be observed. Higher-grade VIN should be completely excised with negative margins. VAIN treatment must be more tailored to the disease location and patient. Low-grade lesions can be followed akin to biopsy-proven CIN 1. VAIN 2,3 should be treated, and simple excision is the preferred method as it provides a specimen in which to rule out invasive disease. Topical treatment with intravaginal 5-FU has been used, but it is associated with serious adverse events and is not recommended as an initial choice of therapy. Laser abla tion is a reasonable alternative to excision for diffuse lesions or lesions in regions that are challenging to resect. Copyright © 2020 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.