Editorial Note
Cervical intraepithelial lesions show a trend of younger onset age. Balancing tumor safety prevention and control with fertility preservation has become a key clinical challenge in gynecology. With the continuous update of domestic and international diagnosis and treatment guidelines, the stratified management concept for low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL) has been continuously improved. Nevertheless, clinical practice still features inconsistent diagnosis and treatment criteria, overtreatment and undertreatment. Controversies remain prominent especially regarding the intervention indications, surgical selection and conization scope control for cervical intraepithelial neoplasia grade 2/3 (CIN2/3).
As part of the exclusive interview program Director’s Talk on Obstetrics and Gynecology Network, Professor Liang Jing from China-Japan Friendship Hospital was specially invited. Combining clinical practice, she systematically elaborates the standardized diagnosis and treatment procedures for cervical lesions, the stratified management principles for lesions of different grades, individualized conization schemes for patients with fertility needs, as well as ideas for young physician training and quality control system construction. This provides clinical references for balancing oncological safety and reproductive health.
Obstetrics and Gynecology Network：
You have formed distinctive expertise in fertility-sparing management of cervical lesions and early cervical cancer. Could you share how you led your team to establish standardized diagnosis and treatment workflows, enabling young physicians to uphold the bottom line of oncological safety while better protecting patients’ fertility and quality of life?
Professor Liang Jing：
First, strictly control screening and triage at the source. Centering on HPV screening combined with cytology for stratified management, we accurately distinguish patients requiring intervention from those only needing follow-up. This avoids missed diagnosis, misdiagnosis and overtreatment from the very beginning, and helps young physicians establish standardized clinical thinking.
Second, standardize colposcopic biopsy procedures. Physicians are required to accurately classify the type of cervical transformation zone first, instead of mechanically performing blind four-quadrant biopsy. Targeted biopsy is only conducted at sites with obvious abnormal signs. This not only improves diagnostic accuracy and prevents missed lesions, but also reduces unnecessary trauma and preserves cervical function and reproductive potential.
Third, adhere to individualized diagnosis and treatment and reject a “one-size-fits-all” approach. For patients with high-grade cervical lesions, comprehensive consideration is given to age, fertility plans, psychological status and life demands. Dynamic monitoring is adopted for eligible patients under follow-up; physical therapy is prioritized for those requiring treatment to control lesions while minimizing cervical damage and protecting fertility.
Fourth, establish a fertility-sparing diagnosis and treatment system for early cervical cancer based on evidence-based medicine. Referring to authoritative studies including ConCerv, SHAPE and GOG278, we have formulated stratified fertility-sparing surgical protocols ranging from conization to fertility-sparing radical surgery, meeting the needs of young patients at different stages and with varying fertility requirements. Whole-process postoperative follow-up and fertility guidance are provided to realize full-cycle management.
In training young physicians, we set two non-negotiable bottom lines: first, complete lesion resection must be ensured to safeguard oncological safety; second, strictly control surgical scope and refrain from blind extended resection, so as to avoid cervical insufficiency caused by overtreatment that impairs long-term life quality and fertility.
Relying on the Beijing Gynecological Medical Quality Control Center, we conduct monthly case reviews to summarize problems such as overtreatment, undertreatment and non-standard operations. All staff participate in learning and rectification to solidify clinical norms and accelerate the professional growth of young physicians.
At present, our team has built a standardized, unified and refined full-process diagnosis, treatment and quality control system for cervical diseases. It ensures therapeutic efficacy while maximally protecting the reproductive and physical-mental health of young patients.
Obstetrics and Gynecology Network：
With the continuous updating of the latest domestic and international guidelines, the stratified management concept for cervical intraepithelial lesions is evolving. Please share the current standardized stratified diagnosis and treatment principles as well as clinical management strategies for different grades of cervical lesions.
Professor Liang Jing：
Stratified clinical management of cervical precancerous lesions still lacks standardization in daily practice. Lesions of all grades may either progress or regress. Improper management tends to lead to overtreatment. Clinically, cervical intraepithelial lesions are now uniformly classified into LSIL and HSIL.
1. Diagnostic and Therapeutic Principles for Low-Grade Lesions
A professional consensus has been reached on the management of low-grade lesions: patients confirmed as low-grade lesions via cytology, HPV testing and colposcopic biopsy do not require further surgical intervention and only need regular follow-up.
A small number of patients with severe anxiety or unable to maintain regular follow-up due to personal and family circumstances may receive moderately relaxed management. In our hospital, additional treatment is generally not recommended for low-grade lesions, provided that colposcopic biopsy is accurate with complete visualization and standardized sampling of Type I or Type II transformation zones.
On the premise of accurate diagnosis, regular follow-up is the main strategy for low-grade lesions:
- Follow-up frequency: Repeat cytology combined with HPV testing every 6–12 months.
- Management after negative conversion: Resume routine follow-up every 3–5 years after 2 to 3 consecutive negative results.
- Management of abnormal findings: Re-evaluation is required for recurrent abnormalities during follow-up, and cervical conization is performed when necessary.
2. Diagnostic and Therapeutic Principles for High-Grade Lesions
Controversies remain widespread in the management of high-grade lesions, and refined stratified protocols have been established currently.
CIN3
Professional consensus confirms that all CIN3 cases require cervical conization for further definitive diagnosis and treatment.
CIN2
Although CIN2 is categorized as a high-grade lesion, approximately 60% may regress to low-grade lesions. Universal surgical resection counts as overtreatment, especially for young nulliparous women, as it may cause cervical injury, adhesion and insufficiency, increasing the risks of preterm birth and miscarriage. Therefore, stratified management of CIN2 is critically important.
Stratified criteria:✦ CIN2 with positive p16 staining: classified as high-grade lesion✦ CIN2 with negative p16 staining: managed as low-grade lesion with regular follow-up Age-stratified therapeutic protocols:(1) Patients under 25 years old with CIN2Such patients have a high probability of lesion regression, so conization should be considered with great caution.✦ Focal CIN2: Regular cytology and HPV follow-up every 6 months after full communication with the patient.✦ Optional physical therapy: Microwave, laser, photodynamic therapy, focused ultrasound and other methods that do not impair cervical function.✦ Our hospital principle: Conization is not actively recommended. (2) Patients aged 25 years and above with CIN2Comprehensive decision-making based on fertility demand, surgical willingness, lesion scope and satisfaction of transformation zone visualization:✦ Type I/II transformation zone with focal lesions: Physical therapy such as photodynamic therapy, focused ultrasound and laser is prioritized to reduce cervical damage and avoid resecting normal tissue unnecessarily.✦ Type III transformation zone (invisible upper lesion boundary) or diffuse lesions (involving ≥2 quadrants): Cervical conization is recommended for safer treatment. Follow-up after treatmentClose follow-up is required 6–12 months after all treatments to evaluate surgical margin clearance and HPV clearance, and formulate subsequent personalized management and pregnancy planning. Pregnancy is generally feasible 6 months after surgery. 3. Key Points in Doctor–Patient Communication
Given the controversies surrounding CIN2 management, full communication with patients is essential. Patients should be informed of available options including observation, conservative treatment and conization. Joint decision-making considering patients’ psychological, family and social conditions is advocated instead of physician-dominated judgment, so as to reduce medical disputes.
Obstetrics and Gynecology Network：
For young women with fertility demands, how to achieve the optimal balance between oncological safety and cervical function preservation in terms of resection scope, depth and surgical selection for CIN2/3 conization?
Professor Liang Jing：
Cervical conization is “a minor surgery with profound expertise”. Many patients with cervical lesions eventually require conization. Though regarded as a minor procedure, it demands sophisticated operational skills. Cervical morphology varies greatly among individuals — cervical diameter ranges from less than 1 cm to over 2 cm, and transformation zones are classified into Type I, II and III. Therefore, surgical plans must be individualized.
1. Conization Strategies for Different Transformation Zones
Type I Transformation Zone
Lesions are fully visualized, and excessive conization depth is unnecessary. LEEP is commonly adopted with careful selection of electrode tips: small conical tips with lower cone height or small mushroom-shaped tips are preferred to resect only the superficial cervical lesion layer. This approach features low conization height, maximally preserves fertility, rarely damages the internal cervical os, and prevents postoperative cervical adhesion and cervical insufficiency, making it an ideal surgical method.
Type II Transformation Zone
Most lesions are visible, and management is case-based:✦ If no lesion extends into the cervical canal, low-cone-height tips or mushroom-shaped tips can still be used.✦ If lesions involve the cervical canal with poor visualization, slightly higher LEEP tips are required. The recommended cone height is controlled at 10–15 mm, which ensures complete lesion resection without compromising cervical function and subsequent fertility. If electrosurgical knife or cold knife is used instead, preoperative marking is necessary to avoid blind excessive cutting depth. Type III Transformation Zone
Lesions are mostly hidden inside the cervical canal. The core principle is narrow cone base and adequate cone height:✦ Cone base width: Extend 3 mm outside the iodine-negative area without unnecessary widening.✦ Cone height selection: Slender tips are used for circular resection deep into the cervical canal. For patients with large cervical diameter and Type III transformation zone, resect superficial lesions first with small mushroom-shaped tips, then address endocervical lesions with deep conical tips.✦ Recommended cone height: Approximately 18 mm; for patients with fertility demands, preferably no more than 20 mm to prevent severe cervical damage. 2. Layered Resection and Special Management of Carcinoma In Situ
- Layered Resection: Suitable for CIN3 and lower-grade precancerous lesions. Resect superficial broad lesions first with mushroom-shaped or small conical tips, then address deep endocervical lesions with thin conical tips. This method ensures complete lesion removal while reducing injury to peripheral cervical muscle tissue, serving as valuable clinical experience.
- Carcinoma In Situ: Layered resection is not recommended. En bloc specimen resection is mandatory to ensure accurate pathological evaluation.
3. Precautions for LEEP and Cold Knife Conization
LEEP: Minimally invasive, precise and less traumatic. With over 20 years of clinical application in our hospital, the pathology department is fully experienced in handling cellular deformation caused by LEEP thermal radiation without diagnostic errors.
Cold Knife Precautions:Cold knife can be adopted if the local pathology department lacks experience with LEEP. However, without standardized dedicated tips, cold knife tends to result in excessive resection scope: - Mark the cone base range with staining solution preoperatively.
- Measure cone height intraoperatively with a probe to strictly control cutting depth.
4. Fertility Preservation and Postoperative Management
Close attention should be paid to fertility risks for patients with Type III transformation zone and deep conization:
- Fully communicate with patients preoperatively about potential cervical impacts of surgery.
- Detect cervical canal length and morphology before pregnancy preparation.
Cervical cerclage can be performed prophylactically during pregnancy for patients at high risk of cervical insufficiency to reduce the probability of early miscarriage.
Summary
The core of diagnosing and treating cervical lesions and early cervical cancer lies in precision stratification, individualized treatment, standardized surgical procedures and full-cycle follow-up management. Strict adherence to graded diagnosis and treatment principles and optimization of conization scope and depth according to cervical transformation zone type can thoroughly control lesions while maximally preserving cervical function and lowering the risks of fertility-related complications. Standardized workflows, surgical norms and regular case quality control reviews help young physicians establish standardized clinical thinking rapidly and achieve homogenized and refined clinical services.
Expert Profile
Professor Liang JingDirector, Department of Obstetrics and Gynecology, China-Japan Friendship HospitalChief Physician, Doctoral Supervisor ✦ Vice Chairman and Secretary-General, Reproductive Health Branch of Chinese Preventive Medicine Association✦ Vice Chairman, Minimally Invasive Medicine Committee of Chinese Medical Doctor Association✦ Standing Committee Member, Obstetrics and Gynecology Branch of China International Exchange and Promotion Association for Medical and Healthcare✦ Standing Committee Member, Gynecology Committee of China Medical Education Association✦ Vice Chairman, Reproductive Medicine Committee of Beijing Traditional Chinese Medicine Association✦ Standing Committee Member, Precision Gynecologic Oncology Branch of Beijing Obstetrics and Gynecology Society✦ Committee Member, Gynecologic Oncology Branch of Beijing Medical Association✦ Committee Member, Gynecologic Endoscopy Branch of Beijing Medical Association✦ Winner of the 3rd National Famous Doctor · Young Talent Award
Editor-in-Charge: QinghuanReviewer: Ma Ye
