What Is CIN 2 and How Should It Be Treated?
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22 Gynecology O B .GYN. NEWS • June 15, 2006 What Is CIN 2 and How Should It Be Treated? The debate over whether cervical intraepithelial in the overtreatment of many of them. Dr. Mayeaux also pointed out that in There’s also a question of age, when the United States, CIN 2 and 3 are man- neoplasia grade 2 is a real, distinct entity continues. making the decision to treat cervical le- aged in a similar fashion, primarily be- sions. CIN 2 in adolescents is different than cause the potential for progression is high- BY ROXANNE NELSON er studies show that it is much closer to it is in adults, he explained. Some prelim- er than that of CIN 1 and reliable Contributing Writer CIN 1 or benign disease, so it does not inary results showed that after 1 year, the histologic differentiation in CIN 2 and 3 have real premalignant potential. behavior of CIN 2 in adolescents was the is only moderate. L AS V EGAS — Experts are divided on That raises the question, “Is the diag- same as that of CIN 1. Overall, CIN 3 has about a 12% pro- how aggressively cervical intraepithelial nosis of CIN 2 a reliable or reproducible “If you’re under 20 the risk of invasive gression to cancer, but CIN 2 has about a neoplasia grade 2 should be treated, and diagnosis?” Dr. Spitzer said. cancer is zero,” said Dr. Spitzer. “If you’re 5% progression to cancer. These estimates on whether observation is an acceptable He pointed out that a few studies have in the cohort under age 25, it still is really do vary significantly, and at this time, option, especially in low-risk populations. assessed that question, and one conclud- very low. So not treating CIN 2 in younger most authors, guidelines, and profession- Cervical intraepithelial neoplasia (CIN) ed that interobserver patients really makes al organizations do recommend treatment has been regarded as a preinvasive condi- variation is fair to ‘In adolescents it is often a lot of sense.” for both CIN 2 and 3 lesions. tion, with progressively higher grades be- good for the diagno- However, Dr. Ed- “We do need a better way to tell who is ing associated with an increasing risk of sis of benign condi- transient and the risk of ward John Mayeaux going to progress, and I agree with that,” cancer. As most CIN 1 lesions regress tions, CIN 3, or inva- cancer is small, and our Jr., an associate pro- said Dr. Mayeaux. “The difference in our without treatment, it has been suggested sive cancer, but poor fessor of family med- point of view is that I don’t think we’re that CIN 2 may also have limited potential for the diagnosis of guidelines already say that icine and obstetrics there yet. And until we get there, we don’t to progress to a more invasive disease. CIN 1 or CIN 2. observation for 1 year is and gynecology at know what those changes are going to “The goal of treatment for CIN is to There is also poorer Louisiana State Uni- mean for patient outcome. We still need prevent cancer by eliminating lesions with correlation between acceptable for adolescents.’ versity, Shreveport, to treat it until we reach that point.” true malignant potential,” Dr. Mark colposcopic and his- disagreed with the Given the current variations in equip- Spitzer said at a meeting of the American tologic diagnosis with CIN 2, compared assumption that CIN 2 isn’t a real entity. ment and practice, and the greater po- Society for Colposcopy and Cervical with CIN 1 and CIN 3. “This has been debated before,” he said, tential of CIN 2 to progress, compared Pathology. “And we also want to avoid un- “The problem with CIN 2 is that we “And the data do show that it is different with CIN 1, Dr. Mayeaux recommends necessary treatment of lesions with little don’t really know what it is,” Dr. Spitzer in its progression and regression potential no changes in current treatment proto- or no premalignant potential.” said. Any system of grading an intraep- than CIN 1. It has a biological activity that cols. The data are mixed, said Dr. Spitzer of ithelial lesion, in which there is a lesional is different from both CIN 1 and CIN 3. In rebuttal, Dr. Spitzer pointed out that New York University, New York. Some continuum, is essentially artificial. A grad- “In adolescents it is often transient and while there is no doubt that CIN 2 has studies show that CIN 2 is an intermedi- ing system that is based on light mi- the risk of cancer is small, and our guide- some premalignant potential, overtreat- ate entity that lies between CIN 1 and CIN croscopy is subject to inter- and intraob- lines already say that observation for 1 year ment with the loop electrosurgical exci- 3 and has some premalignant potential al- server variations in reporting, and treating is acceptable for adolescents with CIN 2,” sion procedure can also have conse- though not as great as that of CIN 3. Oth- all patients with CIN 2 will clearly result Dr. Mayeux said. quences. ■ Drugs, Ultrasound May Be New Alternatives to Hysterectomy BY GIANCARLO LA GIORGIA ment over the other, Dr. Andrews was routine within a week after treatment. out before they complete their treat- Contributing Writer frank: “I think it’s a big mistake for inter- HIFU was the next-generation therapy ment” he said, noting that not all patients ventional radiologists to tell patients au- Dr. Andrews discussed at greatest length. will want to go through three or more 3- T ORONTO — Treating uterine fibroids thoritatively that they should have an em- It is a form of highly focused acoustic en- hour sessions inside a noisy, cramped may eventually be as simple as prescribing bolization, instead of [a surgical] treatment. ergy, delivered transcutaneously (without MRI machine. a pill, or zapping the benign growths with “Similarly, unless a gynecologist is re- puncturing the skin) via an array of ul- He also argued that the FDA’s strict re- high-intensity focused ultrasound—two ally well versed in embolization and pa- trasound transistors onto a single point strictions during trials—that investigators of several promising nonsurgical alterna- tient selection, they should not tell pa- within the body measuring 3 mm by 8 could not treat any fibroid within a cen- tives to the roughly 300,000 fibroid-relat- tients that they are not embolization mm—about the size of a grain of rice. timeter and a half of normal uterine tis- ed hysterectomies performed annually in candidates. I think it needs to be a col- In MR-guided HIFU procedures (grant- sue—was “a guarantee for failure,” and the United States. laborative effort.” ed FDA approval in 2004), the uterine re- the main reason for the treatment’s paltry “[Hysterectomy] is the gold standard in After hysterectomy, myomectomy and gion is scanned for fibroids and divided 14% fibroid volume reduction. fibroid treatment. ... The problem is that UFE are the main into planes at differ- His department at the University of it’s a big operation, and the patient loses recommended fi- ‘The beauty of HIFU is that ent depths. Washington, which recently acquired an her uterus. For some women, that just is broid therapies, both All visible fibroid ultrasound-guided machine (“faster than not an acceptable solution,” said Dr. R. with their own bene- it’s completely noninvasive. cells at a given depth MR, but not yet FDA-approved”) for clin- Torrance Andrews in an interview after fits and disadvan- It’s the “Star Trek” of are individually ab- ical study, has chosen not to offer any his presentation at the annual meeting of tages. lated before moving HIFU treatments until more data become the Society of Interventional Radiology. Myomectomy is a medical intervention . on to the next plane, available. Uterine fibroids, or leiomyomas, may targeted, surgical and is going to have a very and the process is re- Dr. Andrews noted the buzz surround- cause infertility or premature delivery procedure that re- peated until the en- ing asoprisnil, a selective progesterone-re- and in rare cases may become malignant. moves all visible fi- important role to play.’ tire volume has been ceptor modulator that has been shown to They affect about 30% of reproductive- broids and the symp- treated. significantly shrink fibroids and reduce age women, most commonly between toms they cause. However, recovery takes “The beauty of HIFU is that it’s com- their symptoms with minimal side effects the ages of 35 and 45 years, and particu- several weeks, and any abnormal tissue pletely noninvasive. It’s the ‘Star Trek’ of during phase III trials. However, a new larly African American women, whose not seen during the procedure can grow medical intervention ... and is going to drug application, expected in late 2005, has incidence rate is up to nine times higher back. Half of all myomectomy patients have a very important role to play, not just not yet been filed with the FDA. than that of white women. have fibroid recurrence within 5 years. for fibroids, but for all kinds of tumors,” He also briefly discussed various thermal Dr. Andrews, chief of vascular and in- Fibroid embolotherapy offers more dif- Dr. Andrews said. ablation techniques, developed mainly be- terventional radiology at the University of fused, long-lasting treatment, with a re- Despite its vaunted potential, Dr. An- tween 2000 and 2003. The basis of each is Washington Medical Center, Seattle, dis- currence rate of about 15% after 5-7 years.