TREATMENT MODALITIES
Treatment strategies for CIN correspond to the degree of neoplasia and adequacy of colposcopy, and tend to vary among clinicians. For invasive cervical cancer, findings such as lymph node dissemination and adjacent organ involvement are key factors in determining which therapy will be selected.16
Cervical Intraepithelial Neoplasia
The treatment options for CIN can be divided into two categories, ablative and excisional. These techniques may be used only when invasive cervical cancer has been excluded.16,42 Cryotherapy and laser ablation are two common ablative techniques. One disadvantage of ablative techniques is that abnormal tissue is destroyed during the procedure, making it impossible for a tissue specimen to be collected and sent for additional evaluation.42,43 Cold knife conization, laser cone excision, and loop electrosurgical excision procedure (LEEP) are all excisional treatments that allow tissue to be collected and further evaluated.44 Although all these procedures can be used for any stage of CIN, excisional procedures are preferred for CIN 2 and CIN 3 lesions because moderate and severe intraepithelial neoplasias have a higher incidence of undetected microinvasive disease within the endocervical canal. Ablative therapy is generally reserved for treating low-grade CIN or small, focal high-grade lesions.42
Ablative techniques. Cryotherapy was the first outpatient treatment developed for CIN and is still widely used due to its ease, low cost, and low complication rate.44 It is an in-office procedure that utilizes nitrous oxide and carbon dioxide to freeze and ablate abnormal cells on the ectocervix. The procedure involves a freeze-thaw-freeze technique that has improved the efficacy of this treatment.16 The main side effects of cryotherapy are mild cramping and copious watery discharge that can last for up to 4 weeks postprocedure.42,45
Laser ablation is not used as commonly as cryosurgery, but is a viable option for women with large CIN lesions or women unwilling to undergo a LEEP. This procedure is performed under either local or general anesthesia and involves the use of a carbon dioxide laser under colposcopic guidance to ablate the transformation zone of the cervix.45 Laser ablation completely destroys the lesion while causing minimal damage to the surrounding, unaffected tissue. After treatment, patients may experience vaginal discharge for approximately 1 to 2 weeks.44,45 Overall, this technique is very expensive and requires a substantial amount of training to achieve maximum effectiveness.44
Excisional techniques. The LEEP is the procedure of choice for treating moderate and high-grade lesions. LEEP uses a wire loop electrode to excise the transformation zone of the cervix. Acetic acid or an iodine solution known as Lugol’s solution is applied to the cervix to delineate the margins of the lesion.42 The majority of these procedures can be done under local anesthesia, but on occasion sedation may be required.44 Complications, although rare, include post-treatment bleeding, infection, cervical stenosis, and cervical incompetence.45
Excisional conization is a procedure that can be performed with a scalpel (cold knife conization) or with a laser (laser cone excision).45 This procedure involves the removal of a cone-shaped portion of the cervix. Following the conization, endocervical curettage may be performed to acquire tissue samples and assess the endocervical canal. Also known as a cone biopsy, the procedure is typically performed under sedation. The types of complications associated with excisional conization are the same as those for LEEP, but the complication rate is higher when cone biopsy is performed.16,45
CERVICAL CANCER
Treatment methods for cervical cancer can be classified according to one of three disease stages: early-stage (IA2-IIA2), locally advanced (IIB-IVA), and advanced disease (IVB). Common treatment options for cervical cancer include radical hysterectomy with pelvic lymphadenectomy, radiation, and chemotherapy.9,17 Patients diagnosed with early-stage disease typically undergo a radical hysterectomy with pelvic lymphadenectomy. Cervical conization is an alternative option for young women who want to preserve fertility and wish to avoid a hysterectomy.45 Women who undergo surgery and are found to have more extensive disease or parametrial invasion are offered adjuvant radiation therapy.9
Patients diagnosed with locally advanced cancer are typically treated with radiation, chemotherapy, or both.17,45 The combination of radiation and chemotherapy in cervical cancer has been shown to increase survival rates in late-stage disease.7 Those diagnosed with advanced or disseminated disease are treated with palliative radiation. Overall, the five-year survival rates for patients diagnosed with early-stage cervical cancer who receive appropriate treatment have proven to be excellent7 (see Table 77,40,46).
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