Management of Cervical Intraepithelial Neoplasia (CIN) Grade 2
Active surveillance is the preferred management option for CIN2, particularly in women younger than 25 years, while immediate treatment should be reserved for specific high-risk cases. 1
Patient Selection for Active Surveillance vs. Treatment
Active Surveillance Recommended:
- Women younger than 25 years with CIN2 should preferentially undergo active surveillance rather than immediate treatment 1, 2
- Women aged 25 years and older can be offered active surveillance if they meet appropriate criteria 1
- Patients who wish to preserve fertility should be considered for active surveillance to avoid potential obstetric complications associated with excisional procedures 2
- Approximately 50-60% of CIN2 lesions spontaneously regress without treatment, with higher regression rates (60%) in women under 30 years 2, 3
Immediate Treatment Recommended:
- Women with immunosuppression should receive immediate treatment rather than surveillance 1, 2
- Women with previous treatment for cervical dysplasia should undergo immediate treatment 1
- Cases where the squamocolumnar junction or upper limit of the lesion is not fully visible 1
- Patients unlikely to comply with intensive follow-up protocols 1
- Presence of glandular abnormalities (excluded from active surveillance protocols) 1
Risk Factors That May Favor Treatment:
- Large lesion size or involvement of more than 2 quadrants 1, 2
- Presence of expansile CIN or crypt involvement 1
- HPV-16 or HPV-18 genotypes (if available) 1, 2
- High-grade index cytology 1
- Women older than 30 years (higher long-term risk of invasion) 1, 2
Active Surveillance Protocol
Follow-up Schedule:
- Co-testing or high-risk HPV testing with reflex cytology if positive every 6 months 1
- Colposcopic assessment at least once every 6 months 1
- Histological biopsy at least every 6 months if persistent or progressive disease is suspected 1
- If high-risk HPV positive with evidence of regression on cytology/colposcopy, histological biopsy at least every 12 months 1
Duration and Endpoints:
- Local excisional treatment should be offered at 24 months if CIN2 persists 1
- Approximately 90% of lesions that progress or regress do so within 12 months 1
- Two consecutive high-risk HPV negative tests 12 months apart are required to discharge a woman back to routine screening 1
Management of Progression:
- If there is evidence of progression to CIN3 or worse at any point, immediate treatment with local excision of the transformation zone is indicated 1
- The cumulative risk of progression to CIN3 or worse at 24 months is approximately 33.3% 1
Long-term Considerations
Risk of Invasive Cancer:
- The 20-year cumulative risk of invasive cancer is higher with active surveillance (2.65%) compared to immediate treatment (0.76%) 1
- This risk difference is more pronounced in women older than 30 years (5.30% vs 1.52% in women under 30) 1, 2
Obstetric Outcomes:
- Women of reproductive age should be counseled that their risk of preterm birth is lower if the lesion regresses but higher if progression occurs requiring later treatment 1
- Active surveillance can help avoid unnecessary excisional procedures that may impact future pregnancy outcomes 2, 4
Follow-up After Surveillance:
- After two consecutive negative high-risk HPV tests 12 months apart, women can return to routine 3-year recall 1
- If high-risk HPV testing remains negative at 3 years after discharge, women can return to routine recall with extended intervals 1
- Any subsequent positive high-risk HPV test should prompt immediate colposcopy referral regardless of cytology results 1
Patient Counseling
- Provide clear information about the natural history of CIN2, including high regression rates (50-60%) 2, 3
- Discuss the importance of adherence to follow-up protocols (non-compliance rates around 10%) 1, 3
- Document the discussion of risks and benefits and mutual agreement on the management plan 1, 4
- Explain that active surveillance requires more frequent visits but may avoid unnecessary treatment 2, 4