Repenser la prise en charge des néoplasies intraépithéliales du col de l'utérus : proposition d'une méthode d'évaluation du risque et d'aide à la décision thérapeutique

Recent improve in the understanding of the natural progression of cervical intraepithelial neoplasia (CIN) and in the knowledge of treatments pregnancy related morbidity in addition with progression in mean age of first pregnancy brings out the need to rethink CIN management. Efficient tools are therefore needed to optimize therapeutic indications and destructive techniques have to be reconsidered. Because there is no superior technique for treating CIN in terms of treatment failure, the choice of a treatment method will not depend on this criteria but on the overall consideration of its characteristics, advantages and limitations put in balance with age of women, plan of pregnancy as well as CIN severity, risk of progression and of microinvasion misdiagnosis. The use of a “risk assessment method” based on five criteria: colposcopic impression, transformation zone type and size, age and agreement between cytology and histology would allow for proper evaluation of the risk of microinvasion misdiagnosis. Depending on their severity, each of these five criteria would be graded from 1 to 3. The presence of at least one grade 3 criteria would warrant the need for excisional treatment, preferably large loop excision of the transformation zone, allowing for histological analysis and reliable diagnosis. Ablative technique could be reasonably considered for only one grade 2 criteria or if all criteria are grade 1, reflecting good prognosis. Such risk assessment method requires to be prospectively evaluated.