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A high risk patient, after conization and following abortion, was supervised vaginosonographically from the 12th gestational week. The premature shortening of the cervix, but also its almost pain-free opening, were observed with the help of this method. It seems that the lower part of the uterus can be readily visualized and objectively assessed' with ultrasonic diagnosis, especially by vaginal sonography.
We present a series of 94 endocervical curettages (ECC) performed directly after cutting a cervical cone specimen. In 7 patients the ECC gave insufficient material for a histological diagnosis, but in 9 patients it contained CIN. The top of the cone contained CIN in 17 cases. The correlation between the histological results from the top of the cone and the ECC was poor. The presence of persistent disease after conization was studied in relation to both the status of the top of the cone and to the ECC. For the latter we found a sensitivity of 0.50 and a specificity of 0.95. The top of the cone showed a sensitivity of 0.80 and a specificity of 0.88. It is concluded that ECC is of little additional value in predicting persisting disease.
The reintroduction of colposcopy and the introduction of outpatient therapy have significantly altered the management of the woman with an abnormal Pap smear. Routine conization is no longer considered mandatory, particularly for the lower grades of CIN. We estimate that over 10,000 gynecologists in North America have received instruction in colposcopy. Virtually every teaching hospital and medical center has colposcopy available. It is a valuable evaluative tool, particularly with the increasing risk of CIN in young women and the fact that more women are delaying childbearing until the third and fourth decades of life. The technique does, however, require a rigorous period of training, significant experience, and strict adherence to an established evaluation protocol. In the hands of the neophyte, the consequences of in-appropriate evaluation of the woman with an abnormal Pap smear can be tragic.
This study describes 50 patients with abnormal cervical Papanicolaou smears who had colposcopically directed biopsies and then subsequent cervical conization. The objective was to test the accuracy of directed biopsies compared with that of standard method of diagnosis. A significant difference between the two methods occurred in 4% of patients. This figure is the same as that gained from a review of current literature (3.8%). There were no invasive carcinomas in this series.
The records and histologic specimens of 2,000 patients who underwent cold knife conization were reviewed with regard to the usefulness as a diagnostic and therapeutic procedure. In 81,4% further diagnostic procedures were not necessary. Intrapithelial neoplasia was demonstrated in 78% including 16,4% invasive carcinomas. The incidence of non-pathologic conditions was higher in cone specimens submitted from other hospitals or gynecologists. 85% of preinvasive and invasive epithelial neoplasia were detected by cytology.
A comparison is made of the histologic changes in the cervical epithelium and stroma following CO2 laser conization and office excisional biopsy of cervical tissue using the loop electrosurgical excision procedure. In both types of specimens, two zones of thermal injury were detected. The zone at the margin of resection measured approximately 50 microns in thickness and was characterized by extensive carbonization and charring. The other zone was much more variable in thickness and characterized by tissue coagulation, but lacked charring. No significant difference in the biocharacteristics or extent of thermal damage was detected between the methods. For 11 specimens obtained with the CO2 laser, the coagulated zone ranged from 130-750 microns in greatest thickness; the mean thickness was 411 microns. For 40 specimens obtained using the loop procedure, the range of thickness of the coagulated zone was 150-830 microns, and the mean thickness was 396 microns. The difference in the mean value of thermal injury (measured in microns) between the laser and loop procedures was not significant (Student t test; P = .79). Extensive areas of carbonization and epithelial distortion at the margins of excision were only occasionally present in specimens obtained by the electrosurgical excision procedure but almost invariably present in CO2 laser specimens. However, in all cases it was possible to evaluate the epithelium and the stroma both histologically and cytologically.
Fertility after conization appears to be normal if all the endocervical gland tissue has not been excised. The miscarriage and premature delivery rates do not appear to be affected either, and cerclage generally seems to be unnecessary.
The ideal cone biopsy should have its apex just above the transformation zone to ensure removal of all abnormal squamous and metaplastic epithelium in the endocervix, with only minimal normal glandular tissue included. The microhysteroscope has been shown to be useful in identifying the upper limit of the transformation zone within the canal, and this distance from the external os can be measured. However, this technique has not been evaluated to determine whether it can tailor cone length to this predetermined measurement. We report an observational analysis of 176 consecutive conizations in patients with colposcopically proved extension of abnormal epithelium high into the cervical canal. In 162 cases, the distance of the transformation zone from the external os could be measured with the microhysteroscope and its endocervicometer, permitting an attempt to tailor the cone length to this measurement plus a safety margin of 5 mm. There was good correlation between the intended cone length and the excised cone length, with 85% of the excised cones falling within 5 mm above or below the intended measurement. In 153 instances (94.4%), the excised cones had clear endocervical margins. Thus, tailoring of the cone length to the hysteroscopically determined measurement is feasible, thereby increasing the chances of complete excision while limiting cone size to the required minimum.
One hundred patients with histologically confirmed cervical intraepithelial neoplasia suitable for ablative therapy were randomly allocated to treatment by either laser vaporization or laser excision conization under local anesthesia in the outpatient colposcopy clinic. The two methods were compared with respect to the immediate surgical complications, ease of performance, and long-term complications. They were comparable in most respects, and both were well accepted by the patients. Laser excision had the added advantage of providing further material for histologic examination to confirm the absence of invasion and the completeness of excision of the lesion.
In this case report an unusual chain of late complications with a fatal outcome following conization is presented. A scarred obliteration of the cervix resulted in the development of a hematohydrometra, which caused a calf vein thrombosis by compression of the vena iliaca externa with obstruction of venous outflow of crural vessels and a final massive pulmonary thrombo-embolism 11 years after the surgical procedure.
A series of 111 cervical conization specimens from patients with carcinoma in situ (CIS) have been examined by the authors in order to point out the real incidence of condylomatous lesions and their different aspects. The histological criteria of condyloma and cervical intra-epithelial neoplasia (dysplasia and CIS) are recalled, and relationships between them are discussed. Koïlocytes have been observed in 77.5% of CIS examined. Different localisations of condylomatous aspects as regards dysplastic and neoplastic lesions are described and discussed. The histological pattern defined as CIN III with incomplete signs of condylomatous lesion, is significantly associated to flat condyloma (72.7% of cases). Morphological and biological border between condyloma and CIN seems to be not clean; therefore the authors stress on the careful screening, treatment and follow-up of this patients.
At the Institute of Pathology and Applied Cytology, 619 cases of conization or hysterectomies for CIS had been reviewed, through the study of 6,439 slides: 263 cases from the years 1957-1968, 287 cases from the years 1981-1983, have been studied. In the 1957-1968 group, a condylomatous lesion was associated with CINIII/CIS in 60% and in 79% in the 1981-1983 group. The relationship between the condylomatous lesions and the CIS, the grade of these lesions and the mean age of the patients had been examined. In the both groups, the HPV signs had been more frequently discovered in the younger women. But a difference of 4 years was found between the patients with CINIII without any sign of HPV infection and those with a CINIII/CIS associated with a condyloma. These data support the hypothesis of a lessening and a later disappearance of the HPV signs when the neoplasias become more severe. In both groups, the relationship between the signs of HPV infection and the grade of the cervical epithelial atypias are exactly the same. These lesions, more often extended, with a transitional passage between CIN with HPV cytopathological effects and CIS, comfort the hypothesis of a straight relationship between HPV infection and carcinoma of the cervix.
A case of an unusual complication of cold knife conization and associated extensive retroperitoneal hematoma is presented. The contributing factors, prevention, and management of this complication are discussed.
The relationship between involvement of the cervical cone margins by cervical intraepithelial neoplasia (CIN) and the presence or absence of CIN as determined by subsequent hysterectomy or cytology follow-up was studied in 522 cervical cones. Hysterectomy was performed in 161 patients, 54% of which were done within six weeks after conization. The remaining patients were followed up with cytology. In 136 women, cone margins were involved by CIN. Twelve of these patients were lost to follow-up. Forty of the 73 (54.8%) patients who underwent hysterectomy had CIN in the uterus. One of 51 (1.9%) patients followed up with cytology developed cytologic evidence of CIN. In 60% of the patients with CIN III and involved margins, in whom hysterectomy was delayed for more than six weeks, there was at least one interval of cytology positive for CIN. All these patients had CIN at the time of hysterectomy. In contrast, CIN was not present in patients with negative follow-up cytology. None of the 107 patients with CIN III and free margins had CIN at hysterectomy or during follow-up. However, of the 249 women with CIN I to II and free margins, six had CIN at hysterectomy. In none of the cases was the residual disease worse than CIN. Although it is impossible to predict the presence or absence of residual CIN based on the appearance of the cone margins, it is important to report the status of the margins. Free margins indicate removal of the CIN in a majority of cases, or reassures that invasive cancer is not present.(ABSTRACT TRUNCATED AT 250 WORDS)
Sixty four patients with stage III intra-epithelial neoplasia were seen in colposcopic clinic during a two years period. All were followed up for a minimum of 1 year (ranging 1 to 3 years). 28 patients 43.8%) were treated using the carbon dioxide laser in an ambulatory setting. In 36 patients (56.2%) a cone biopsy was first performed for therapy. Following laser treatment the failure rate is 7%, the failure and recurrence rate 14%. The CO2 laser appears to be an acceptable procedure for C.I.N. III lesions in young women. Selection of lesions is of paramount importance and should be able to reduce the number of therapeutic conizations.
Conization was performed on 1,500 patients with carcinoma in situ of the uterine cervix. One hundred and seventy-five needed further treatment, 165 because of residual disease and 10 because of a recurrence. This finding indicates a recurrence frequency similar to the incidence of carcinoma in situ in a normal population.
One hundred eight patients with "satisfactory" colposcopy, a histologic diagnosis of cervical carcinoma in situ and a stated desire to maintain fertility were treated by therapeutic conization performed under colposcopic guidance in the operating room. One patient had a recurrence of carcinoma in situ at 8 months, and two patients had mild dysplasia at 18 and 24 months. Fifteen patients conceived.
First experience with the paracervical block as an anesthetic method for the conization and plastic surgery of the cerviä is presented. The analgesic effect was good, except for one patient where general anesthesia was necessary. The authors recommend the multilocular application of the anesthetic, because the parametrial tissue in non-pregnant women has not the same density, hence a different uptake of the local anesthetic.