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PubMed2005

Partial trachelectomy: a new treatment choice for persistent or recurrent high grade cervical intraepithelial neoplasia.

BACKGROUND AND OBJECTIVE: Some women with persistent or recurrent disease after repeated conization for high grade cervical intraepithelial neoplasia (CIN) may desire to preserve uterus if not fertility. In such case, a partial trachelectomy may become treatment of choice for them. We undertook this prospective study to determine the feasibility of partial trachelectomy as a treatment choice for persistent or recurrent high grade CIN. METHOD: Twenty premenopausal women with persistent or recurrent high grade CIN after initial LEEP and repeated conization refused hysterectomy thus elected to undergo excision of vaginal portion of uterine cervix under general anesthesia in a tertiary university-affiliated medical center. High risk human papillomavirus (HPV) detection was done before initial loop electrosurgical excisional procedure (LEEP) and 3 months after partial trachelectomy. Follow-up PAP smear and colposcopy were done every 3 months during the first 2 years. If both examinations were negative, they were changed to yearly follow-ups. RESULTS: The out-patient procedure is simple and takes only 6.5 min in average. High risk human papillomavirus (HPV) were eradicated after procedure in all cases. During an average follow-up of 48 months, no recurrent dysplasia was observed. CONCLUSIONS: Partial trachelectomy is a reasonable alternative treatment choice for those who suffer persistent or recurrent CIN and desire to preserve their uterine corpri.

Adult↗
PubMed2000

Needle excision of the transformation zone: A new method for treatment of cervical intraepithelial neoplasia.

OBJECTIVE: This study was undertaken to evaluate a new needle electrode for conization of the cervix that was developed in my department. STUDY DESIGN: This was a prospective study of 58 unselected women with histologically verified cervical intraepithelial neoplasia who underwent conization with the diathermy needle. The operations were performed with local anesthesia as outpatient procedures. Follow-up time was 5 years. RESULTS: All cones were removed in one piece and were of high histologic quality. Mean (+/-SD) operating time, including anesthesia, was 7.9 +/- 2.7 minutes. Mean depth of thermal damage was 0.29 +/- 0.21 mm, and mean blood loss was 12.5 +/- 9.4 mL. No late complications have been noted, and 94.8% of patients have required no further treatment. CONCLUSION: Needle excision of the transformation zone is a simple and effective outpatient procedure that yields a one-piece cone specimen of high quality and carries a success rate of 94.8%.

Adult↗
PubMed1996

Conservative management of options for patients with dysplasia involving endocervical margins of cervical cone biopsy specimens.

OBJECTIVE: Our purpose was to study the feasibility of conservatively managing selected cases of dysplasia involving endocervical cone margins. STUDY DESIGN: A retrospective review of patients conservatively managed after being found to have squamous cell dysplasia involving the endocervical margins of their cervical cone biopsy specimens. In phase I patients who had cold-knife conization with positive endocervical margins underwent repeat Papanicolaou smears and colposcopy, with biopsies and endocervical curettage as indicated. Those found free of disease were followed up with frequent Papanicolaou smears. In phase II patients with dysplasia to the endocervical resection edges on loop electrical excision procedure biopsy specimens were followed up with frequent cytologic studies. RESULTS: In phase I, 31 patients with positive endocervical margins on cold-knife conization and no evidence of dysplasia on reevaluation were followed up for 1 to 18 years. Dysplasia was detected in one patient during cytologic surveillance. In phase II, 11 patients were followed up for 12 to 31 months; only one patient has dysplasia. CONCLUSION: Selected patients with squamous cell dysplasia at endocervical cone biopsy margins may avoid additional surgery.

Conization↗
PubMed1999

Positive cone biopsy specimen margins in women infected with the human immunodeficiency virus.

OBJECTIVES: The purpose of this study was to compare the positive margin rate associated with cervical conization among women who are seropositive for human immunodeficiency virus with that among women who are seronegative. STUDY DESIGN: This was a cross-sectional study of 245 women who underwent cervical conization for the following indications: biopsy-proven cervical intraepithelial neoplasia grade 2 or 3, abnormal endocervical curettage specimen, cytologic-histologic examination discrepancy, persistent cervical intraepithelial neoplasia grade 1, or abnormal cytologic characteristics with inadequate colposcopic examination. RESULTS: Twenty-two (47.8%) of 46 women who were seropositive for human immunodeficiency virus and 65 (32.7%) of 199 women who were seronegative had positive cone biopsy specimen margins. In a multivariable logistic regression the human immunodeficiency virus-seropositive women had a 2-fold increased risk of having a positive cone biopsy margin (odds ratio, 2.25; 95% confidence interval, 1.07-4.76). CONCLUSION: If the presence of positive cone biopsy specimen margins represents the potential for disease progression, then our findings of a positive margin rate of nearly 50% in a human immunodeficiency virus-positive population may argue against the kind of conservative management of colposcopic follow-up that has been proposed for immunocompetent women.

Adult↗
PubMed2003

Human papilloma virus testing in patient follow-up post cone biopsy due to high-grade cervical intraepithelial neoplasia.

OBJECTIVE: We evaluated the contribution of the human papilloma virus (HPV) load in planning follow-up and management of women post cone biopsy for high-grade cervical intraepithelial neoplasia (CIN2-3). METHODS: Ninety-six suitable women were followed-up by Pap smears: two consecutive abnormal smears dictated referral for colposcopy-directed biopsy. Before colposcopy, HPV tests determined high-risk HPV DNA type and load (Hybrid Capture System type I). Patients histologically diagnosed with CIN1 or CIN2-3 underwent repeat conization or hysterectomy for residual disease. HPV load was compared to cytology for the detection of residual disease. RESULTS: At follow-up, 20/89 (22.4%) studied women had positive cytology reports of either low- (n = 11) or high-grade (n = 9) squamous intraepithelial lesion (SIL). Colposcopic biopsies diagnosed 9 CIN1 and 8 CIN2-3 cases. Residual disease was corroborated in 16/17 (94.1%) women and the status was readjusted based on cone biopsy/hysterectomy: CIN2-3 in 9 and CIN1 in 7. The positive prediction values for CIN2-3 residual disease with high-grade SIL, CIN2-3 on colposcopic punch biopsy, and high HPV load were 89, 100, and 100%, respectively. For CIN1 residual disease with low-grade SIL, CIN1 on colposcopic punch biopsy, and low and borderline HPV load, they were 54.5, 77.7, and 100%. The HPV load was a more accurate predictor for CIN1 or CIN2-3 on the cervical specimen in cases with low-grade SIL or CIN1 on colposcopic biopsy. CONCLUSIONS: Evaluating HPV loads after a positive cytology report may assist in triaging women post conization biopsy for CIN2-3 to appropriate treatment. Its high positive predictive value, specificity, and sensitivity for CIN1 and CIN2-3 and supplementary information could be especially pertinent for clinical management of low-grade SIL cases.

Adolescent↗
PubMed1996

[Electrosurgical loop excision of the transformation zone in treatment of cervix neoplasia].

100 patients with CIN on referral Pap and with a distinct cervical lesion on colposcopy were treated with the loop electrosurgical excisional procedure (LEEP). Compared with 60 women who underwent cold-knife conization, the number of lesions classified as CIN-3 or more did not differ between the two groups (53% vs 53.3%). Severe haemorrhage and cervical stenosis were only observed after conization. Involvement of resection margins was found in 18% of all LEEP and in 16.7% of all cone biopsies. 3-12 months after LEEP the rate of cytologically and biopsy proven neoplasia was 2.2%. LEEP is a safe and effective procedure and should be used as the treatment of choice for distinct cervical lesions.

Biopsy↗
PubMed1999

Artifact in cervical LLETZ specimens: correlation with follow-up.

The effect of cautery artifact on the ability to accurately diagnose dysplasia and predict abnormal follow-up in large loop excision specimens of the transformation zone (LLETZ) has not been adequately addressed in the pathology literature. One hundred consecutive conization specimens with cytologic and/or histologic follow-up were studied. Indications for the procedure were high-grade squamous intraepithelial lesion (on Pap smear and/or biopsy) in 64 cases, low-grade squamous intraepithelial lesion in 28, atypical squamous cells of unknown significance (ASCUS) in 3, atypical glandular cells of unknown significance in 2, adenocarcinoma in situ, squamous carcinoma in situ, and invasive squamous carcinoma in 1 each. Twenty-four specimens were cold-knife conizations (CKCs) and 76 LLETZs. All LLETZs had at least 1+ artifact, and in 46 cases (61%) it interfered with at least one aspect of evaluation. In 21 cases (28%), 1+ artifact interfered only with margin assessment. In 25 cases (33%), there was 2+ or 3+ artifact precluding not only margin assessment, but also diagnosis and grading of dysplasia. Of the 43 LLETZs received in more than one piece, 33 (77%) had interfering artifact, and in 21 (49%) it was 2+ or 3+, at least focally interfering with diagnosis and grading. In contrast, of 33 LLETZs received in a single piece, only 13 (39%) had interfering artifact, which was 2+ or 3+ in 4 (12%), (p < 0.05). Positive follow-up (including ASCUS, favor dysplasia, and ASCUS, not otherwise specified) was found in 6 of 7 CKCs with positive margins (86%), 10 of 16 LLETZs with positive margins (63%), and 4 of 7 LLETZs with unassessable margins (57%). In cases with negative cone margins, positive follow-up was found in 2 of 17 CKCs (12%), and 18 of 53 LLETZs (34%), p < 0.05; a higher frequency of interfering artifact (p < 0.05) was seen in these cases. LLETZ margin status and postprocedure endocervical curettage (ECC) specimens were not good predictors of residual disease, unlike margin status in CKC. Post-CKC ECC was a better predictor of subsequent abnormal follow-up than post-LLETZ ECC (p < 0.05). The presence of interfering artifact was only rarely mentioned in the original pathology report. In conclusion, the status of margins is a better predictor of abnormal follow-up in CKC than in LLETZ specimens. Fragmentation of the specimen is an additional factor, compounding the inevitable artifact. Postprocedure ECC is not a useful indicator of residual dysplasia. The pathologist should not hesitate to comment on specimen adequacy in surgical pathology reports.

Adult↗
PubMedDate not supplied

Prognostic factors in microinvasive cervical squamous cell cancer: long-term results.

We examined tumor-related pathologic factors and cone-related characteristics to identify parameters related to recurrence in microinvasive squamous cell carcinoma of the cervix treated with conization. This is a retrospective study on 67 consecutive cases of microinvasive carcinoma of the cervix [depth of invasion (DI) < 3 mm] treated with conization. The mean follow-up was 121 months (range 72-276 months). Four (6%) invasive recurrences were observed. Presence of lymphvascular space involvement (LVSI) was significantly related with recurrences (P < 0.05). The mean distance between tumor margin and apex of the cone (apical clearance) was 10.6 mm (range 5-22 mm), and the mean distance between lateral border of the cone and tumor margin (lateral clearance) was 6.5 mm (range 1.7-15 mm). We adopted cut-off values of 10 and 8 mm for apical and lateral clearances, respectively. We found a statistically significant difference between apical clearance and recurrence rate (P < 0.02). The LVSI was, other than DI, an important prognostic factor. Apical clearance was significantly correlated with recurrence. The cone-related characteristics, other than tumor-related pathologic factors, could help the decision concerning the definitive therapy for microinvasive carcinoma of the cervix.

Adult↗
PubMed1998

Conservative surgery for microinvasive carcinoma of the cervix.

OBJECTIVE: To evaluate the prognosis of patients with stage IA1 and IA2 microcarcinoma of the cervix according to the 1994 FIGO classification. METHODS: The histologic specimens of 494 patients who underwent conization for microcarcinoma of the cervix between 1958 and 1992 were reviewed and classified according to the 1994 FIGO system. RESULTS: After a mean follow-up of 14 years (range, 1-35) 2 patients with stage IA1 tumors and 2 patients with stage IA2 tumors died of disease. Patients with early stromal invasion only accounted for 70% of patients with stage IA1 lesions. If these patients are excluded from stage IAI, the mortality rates for stage IA1 and IA2 did not differ significantly. Surgical radicality declined markedly during the study period. CONCLUSION: Neither the 1985 nor the 1994 FIGO classification of microcarcinoma can be used as a guide to therapy. Conization only suffices for patients with early stromal invasion or a depth of invasion of 1-3 mm without lymph vascular space involvement. Additional pelvic lymphadenectomy can be considered for patients with stage IA1 lesions with lymph vascular space involvement. Removal of the tumor and pelvic lymphadenectomy is indicated for all patients with stage IA2 lesions, regardless of lymph vascular space involvement. Radical vaginal or radical abdominal hysterectomy represent overtreatment for patients with microcarcinomas because parametrial involvement in these patients has not been demonstrated.

Conization↗
PubMed1996

Adenocarcinoma in situ of the uterine cervix progressing to invasive adenocarcinoma.

This report documents a case of adenocarcinoma in situ (AIS) of the cervix progressing to invasive adenocarcinoma. The patient, who was 32-years-old at the time of diagnosis of AIS, was followed with negative smears for 7 years after conization when a smear showed malignant glandular cells. A repeat conization demonstrated well differentiated papillary adenocarcinoma. The patient remains well 8 years after radical hysterectomy and lymph node dissection. The clinicopathological features of this case and a brief review of the literature are presented.

Adenocarcinoma↗
PubMed2006

The recurrence of cervical intraepithelial neoplasia in HIV-positive women: a review of the literature.

The objective of this study was to assess the available evidence on the outcome of cervical intraepithelial neoplasia (CIN) in HIV-positive women after conization. We performed a literature search of Medline and Cochrane libraries to locate published articles reporting about the rate of recurrence of CIN after excisional treatment in patients with negative surgical margins. Out of 15 articles, five studies reported recurrence rate of CIN in margin negative patients. The recurrence rate of CIN after conization in HIV-infected women ranges from 20% to 75%. No conclusions can be drawn about the impact of CD4 cell counts on the recurrence rate. Available evidence suggests that standard excisional treatments for CIN are associated with high rates of recurrence in HIV-positive women. Despite the fact that the evidence is limited because of the few number of eligible studies, this issue should be considered in the management of HIV-positive patient with CIN.

Conization↗
PubMed2004

Efficacy of cone biopsy of the uterine cervix during frozen section for the evaluation of cervical intraepithelial neoplasia grade 3.

We retrospectively selected 22 cases in which patients with a biopsy-proven diagnosis of cervical intraepithelial neoplasia grade 3 underwent cervical conization for frozen section (FS) evaluation followed by hysterectomy at the University of California Irvine Medical Center, Orange, during the August 1995 to September 9, 2001. All slides from FS and permanent section (PS) and hysterectomy specimens were reviewed. FS diagnoses were compared with those of previous biopsies, PS, and hysterectomy specimens. The PS correlated with FS in all cases but 1. Appropriate surgery was performed for all patients based on FS diagnosis. The McNemar test was used to compare the results of FS and PS, with a 2-sided P value of 1.0 and a c coefficient of 0.7755 with a 95% confidence level, indicating that the 2 groups were not significantly different. FS evaluation of cervical conization is as efficacious and accurate as evaluation of regular specimens in providing information for the appropriateness of same-day surgery. We recommend that entire tissue be submitted for FS to avoid sampling errors and to increase diagnostic accuracy.

Adult↗
PubMed2001

Microinvasive carcinoma of the cervix. Analysis of prognostic factors.

INTRODUCTION: Superficially invasive neoplasias of the uterine cervix are a matter of controversy in terms of their definition, prognostic factors and selection of treatment to minimize the risk of recurrences. We reviewed our treatment to determine whether any factors affect this risk. PATIENTS AND METHODS: The present study was conducted on 59 patients seen at our service, 22 of them with early stromal invasion (IA1) and 37 with microinvasive carcinoma (IA2) according to FIGO criteria (1995). Ten patients were submitted to conization as definitive treatment, although for three of them treatment was complemented with Wertheim-Meigs surgery due to recurrence in the remaining cervix. The other 49 patients were submitted to total abdominal hysterectomy. RESULTS: Forty-four patients underwent diagnostic or therapeutic conization, and 14 of them presented involvement of the endocervical margin. Seven patients presented recurrence with involvement of the endocervical margin in five. The age of recurrence ranged from 40 to 70 years, with a mean of 52.3 years, as opposed to a general mean of 42.3 (p<0.05). Angiolymphatic invasion was positively correlated to recurrence and death (p<0.01) as well as depth of invasion. CONCLUSIONS: We conclude that the presence of a cone with an involved endocervical margin represents a high risk of recurrence and that this condition occurs in older patients who are prone to present more extensive lesions. Thus, age should be regarded as an important risk factor. Angiolymphatic invasion and depth of invasion have a poor prognosis in terms of recurrence and death.

Adult↗
PubMed2003

[Pelviperitonitis and intestinal occlusion: two unusual cold-knife conisation complications].

Complications associated with cold-knife conization are mainly hemorrhage, genital and urinary infections. We presented two cases of accidental posterior colpotomy with Douglas pouch wound initially unnoticed at the time of the cold-knife conization, and secondary complicated by a pelviperitonitis for the first case and by an incarceration of the bowel loop in the vaginal wound for the second case.

Adult↗
PubMed2003

Postconization surveillance of cervical adenocarcinoma in situ. A prospective trial.

OBJECTIVE: To conduct a surveillance trial after conization to prospectively determine the outcome of conservative management of adenocarcinoma in situ (AIS). STUDY DESIGN: Women diagnosed with AIS were prospectively enrolled from September 2000 to September 2001. Eligibility criteria included patient age younger than 40 years, prior conization with negative margins and the desire to preserve fertility. Each cone biopsy specimen was secondarily reviewed. Postconization surveillance consisted of a liquid-based Pap test and endocervical curettage (ECC) every 4 months. Follow-up ended in September 2002. RESULTS: Ten women with a median age of 32 years (range, 26-37) were enrolled. Six were nulliparous and 2 primiparous. Seven patients were clinically free of disease after a median of 21 months (range, 5-24), 2 were lost to follow-up, and 1 was excluded when AIS could not be confirmed on the original specimen. Twenty-eight Pap smears and 18 ECCs were performed, but no additional surgical procedures were required due to abnormal cytopathology. CONCLUSION: This prospective trial on postconization surveillance demonstrated the safety of conservative management for AIS patients desiring to preserve fertility.

Adenocarcinoma↗
PubMed2006

Efficiency of three surgical procedures in eliminating high-risk human papillomavirus infection in women with precancerous cervical lesions.

PURPOSE OF INVESTIGATION: To establish the efficiency of laser vaporization (LV), large loop excision of the transformation zone (LLETZ) and cold knife conization, done for precancerous cervical lesions, in eliminating high-risk human papillomavirus (HPV) infection. Additionally, we determined whether the same HPV genotype persisted after surgery. METHODS: A total of 214 women were tested for HPV infection by the Hybrid Capture II (HCII) test prior to surgery. HPV-positive women were followed by HCII test ten months after surgery. In persistently HPV-positive women, HPV genotypes were determined by PCR - PGMY09/PGMY11. RESULTS: The HCII test showed elimination of HPV infection after LV, LLETZ and cold knife conization in 67.6%, 86.3%, and 100% (p < 0.05) of women, respectively. In seven (38.9%) women a different HPV genotype was found to be present after surgery, the corrected efficiency thus being 79.4%, 92.7% and 100% (p = NS), respectively. CONCLUSIONS: The three analyzed surgical procedures are effective in eliminating high-risk HPV infection. HPV testing is useful at follow-up, since it can identify a small proportion of women requiring close surveillance and potential treatment.

Adult↗
PubMed1996

[Diagnostic and morphologic criteria in cervix intraepithelial neoplasia (CIN) and squamous intraepithelial lesion (SIL) and differentiated therapy].

The action of CIN eg SIL has, in recent years, altered. The reasons behind this are varied: In particular conization was previously assessed differently and furthermore there are now new methods of treatment available eg laser and loop. Pretherapeutic assessment methods such as Cytology. Colposcopy and biopsy now enable an experienced practitioner to make an accurate diagnosis. Accordingly one can then choose, depending on the individual patient, the optimal therapy required. In less serious cases observation would be sufficient and in more serious cases and with younger women local therapy would be recommended. In the cases of women of more advanced years a hysterectomy should be considered. With all other patients conization would be applicable. The graduation and individual action shown is lacking in complications and considered very patient friendly.

Adult↗
PubMed1996

[Laser use in the uterine cervix. CO2 or KTP laser].

86 patients with cervical neoplasia were treated by conization. The KTP/532-laser was used in 52 cases (group 1) and the conization was performed with a carbon dioxide laser in 34 other cases (group 2). The operation took approximately 30.5 min in the KTP group and 13.5 min in the carbon dioxide group. Complications occurred in 2 cases of the KTP-laser treated patients. In group 2 no complication were observed. The time of hospitalisation was 5 days. The thermal damage of the cut-edge came up to 1 mm (group 1) and 0.1 mm (group 2), respectively. In 4 cases the histological examination was negatively effected by the heat of the KTP laser. In group 2 no affects were observed. The advantage of the KTP-laser is its styptic effect whereas the CO2-laser is better for an histological examination.

Adult↗