The histologic diagnosis and the extent of the lesion always must be determined before treatment is performed. A variety of techniques have been used to treat CIN, including surgical excision, cryosurgery, laser vaporization, and loop electrosurgical excision. All of these modalities have a small (2-4%) risk of hemorrhage, later cervical stenosis, and infertility. Cytologic follow-up at approximately 3-month intervals after I year is appropriate.
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Ablative therapy such as cryosurgery or laser vaporization is appropriate when the following conditions exist:
• There is no evidence of microinvasive or invasive cancer on cytology, colposcopy, endocervical sampling, or biopsy;
• The lesion is located on the ectocervix and can be seen entirely; and
• There is no involvement of the endocervix as determined by colposcopy and endocervical sampling.
Cryosurgery should be used only for small, low-grade lesions that can be easily covered by the cryoprobe. Several large series indicate a 93-96% cure rate for CIN I and II, but a 77-92% cure rate for CIN III.
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Laser vaporization may be chosen for patients who have either large lesions on the exocervix that extend onto the vagina or an irregular “fishmouth” cervix with deep clefts. The major advantage of laser vaporization therapy is the ability to control the depth and width of destruction by direct vision through the colposcope. Destruction of the cervical tissue to a depth of 3.8 mm will ablate all of the involved glands in 99.7% of cases. The standard procedure for laser vaporization is to destroy the tissue to a depth of 7 mm, where 100% of the endocervical glands will have been destroyed. The success rates for laser vaporization range from 83% to 97% for CIN I and II and from 77% to 96% for CIN III. More recent series indicate a greater than 90% cure rate in patients with CIN III. Excisional therapy by conization, laser excision, or loop electrosurgical excision is indicated when the operator determines there is a need for a tissue specimen to rule out invasion, when there is an abnormal finding on endocervical curettage, or when colposcopy is unsatisfactory.
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