Phase II clinical trials of cisplatin-then-paclitaxel and paclitaxel-then-cisplatin in patients with previously untreated advanced epithelial ovarian cancer

PURPOSE

To examine the activity and safety of two sequentially scheduled chemotherapy regimens comprising four cycles of paclitaxel (pctx) 200 mg/m2/3 hours then four cycles ofcisplatin (cisDDP) 100 mg/m2, and vice versa, in patients with previously untreated advanced ovarian cancer.

PATIENTS AND METHODS

Between January 1994 and February 1996, we recruited 30 patients to the pctx-then-cisDDP regimen and 29 to cisDDP-then-pctx, in parallel phase II trials.

RESULTS

Both regimens were predictably active with responses seen in 22 of 30 patients (OR 74%; CR 27%, PR 47%) treated with pctx-then-cisDDP, as against 13 of 21 patients (OR 62%; CR 38%, PR 24%) treated with cisDDP-then-pctx. The OR rate to four cycles of pctx (induction) was 43%, with 27% disease progression; the OR to four cycles of cisDDP (induction) was 57%, with 5% progression. However, progression rates across both induction and consolidation phases were 16% (pctx-then-cisDDP) and 29% (cisDDP-then-pctx). Both regimens were unacceptably neurotoxic. II patients suffering grade 3 sensory neurotoxicity (5 on pctx-then-cisDDP, 6 on cisDDP-then-pctx) and 20 having grade 3 deafness (9 on pctx- then-cisDDP, 11 on cisDDP-then-pctx).

CONCLUSION

The activity of these sequential regimens justifies their further development using the less neurotoxic platinum analogue carboplatin, perhaps combining paclitaxel with other platinum non-cross resistant drugs.

A randomised, prospective, phase III clinical trial of primary bleomycin, ifosfamide and cisplatin (BIP) chemotherapy followed by radiotherapy versus radiotherapy alone in inoperable cancer of the cervix

BACKGROUND

Phase II studies have shown primary (neo-adjuvant) chemotherapy with bleomycin, ifosfamide and cisplatin (BIP) is active against inoperable cervical cancer. We present here results of a randomised phase III multicentre trial comparing radical radiotherapy with neo-adjuvant BIP chemotherapy followed by radical radiotherapy in patients with inoperable cervical cancer, designed to discover whether this combination might improve survival.

PATIENTS AND METHODS

Patients with inoperable cervical carcinoma were randomised to pelvic radiotherapy alone [RT] or two to three cycles of bleomycin 30 units/24-hour infusion, ifosfamide 5 g/m2/24 hours, and cisplatin 50 mg/m2) chemotherapy followed by pelvic radiotherapy (BIP + RT). Randomisation was stratified by stage and radiotherapy centre.

RESULTS

One hundred seventy-two eligible women were randomised into this trial; eighty-six to RT and eighty-six to BIP + RT. A total of 190 cycles of chemotherapy were given. Median follow-up for the 47 patients still alive is 9 years with a minimum follow-up of 3 years. Complete or partial response occurred in 51 of 86 (59%) of those randomised to RT and 60 of 86 (69%) of those randomised to BIP + RT. The difference between response rates does not reach statistical significance (chi2 = 2.06, P = 0.15). Median survival is two years with an actuarial survival at five years of 32% (95% confidence interval (95% CI): 25%-39%). There is no significant difference between the treatment groups (chi2log-rank = 0.11, P = 0.74).

CONCLUSIONS

This study does not show any survival benefit from the use of neo-adjuvant BIP chemotherapy in advanced cervical cancer.

Management guidelines for women with normal colposcopy after low grade cervical abnormalities: population study

OBJECTIVES

To develop an evidence based protocol for the follow up of women with low grade cervical abnormalities for whom treatment is not immediately indicated.

DESIGN

Population outcome study.

SETTING

Colposcopy clinic of an inner city teaching hospital.

PARTICIPANTS

566 women with low grade cytological abnormalities who were not treated at a first visit to the colposcopy clinic, followed up for a total of 881 years.

MAIN OUTCOME MEASURES

Resolution of abnormalities, persistence of disease, and treated disease.

RESULTS

Abnormalities resolved in 306 (54.1%) women, whereas 138 (24.4%) had persistent disease and 122 (21.5%) were subsequently treated. Colposcopic opinion, smear test results, age, smoking history, and number of pregnancies were all significantly related to outcome. Logistic regression analysis produced a model that correctly identified 70% of women whose abnormalities resolved. Only 23 of 295 women (7.8%) with a normal cervix on colposcopy and a smear without dyskaryosis at a first visit were treated by the end of the observation period.

CONCLUSIONS

Women referred with low grade cytological abnormalities who have a normal cervix on colposcopy and a negative or borderline repeat smear test result may be discharged from the colposcopy clinic. We propose a follow up protocol that could safely avoid unnecessary visits to a clinic.

A study of the follow up patterns of women treated for CIN 2 and 3 before and after the introduction of the 1992 guidelines

OBJECTIVE

To analyse the five year cytology follow up data after discharge on women treated for histologically proven cervical intraepithelial neoplasia (CIN) 2 and 3. To assess whether the introduction of the 1992 Guidelines for Clinical Practice and Programme Management affected follow up patterns. To identify who was lost to follow up and for what reasons.

DESIGN

A retrospective cohort study of cervical cytological follow up data from 186 women treated for CIN 2 and 3.

SETTING

Primary care services, West Midlands, United Kingdom.

POPULATION

One hundred and eighty-six women with CIN 2 or 3 treated with large loop excision of the transformation zone at the City Hospital, Birmingham, in whom the first follow up smear at six months was normal. The women were divided into two groups: Group 1 consisted of women treated before the introduction of the Guidelines (1988-1990), and Group 2 consisted of women treated at the time of the introduction of the Guidelines in 1992.

INTERVENTION

Introduction of the 1992 Guidelines for Clinical Practice and Programme Management.

MAIN OUTCOME MEASURES

To determine the number of follow up smears each woman had over a five year period, to determine the number of women who had the recommended number of follow up smears, and to identify the number of women lost to follow up.

RESULTS

The median (interquartile range) number of smears in Group 1 was five (four to six) and in Group 2 was four (four to five). A similar proportion of women in both groups subsequently had abnormal smears (15% and 13.6%). Only one woman required further treatment. 22% of women in Group 1 and 10.2% of women in Group 2 had the correct number of smears to fulfil the 1992 Guidelines. There were 21 women (11.3%) who only had one smear following discharge from the clinic in the five year follow up period.

CONCLUSIONS

The data from both cohorts shows follow up to be poor, and the introduction of the 1992 Guidelines has yet to result in an improvement in follow up patterns. The absence of a national cervical cytology database means that surveys of cytology follow up data will continue to be difficult due to the problems of data collection from numerous health authorities and the mobility of women in this age group.

Response of vulvar lichen sclerosus and squamous cell hyperplasia to graduated topical steroids

OBJECTIVE

To determine whether symptomatic remission could be obtained equally effectively in patients with vulvar lichen sclerosus, squamous cell hyperplasia or mixed disease in response to a standardized course of graduated topical steroids.

STUDY DESIGN

A retrospective analysis of 137 patients with biopsy-proven lichen sclerosus (84), squamous cell hyperplasia (42) or mixed disease (11) treated between 1990 and 1997 with a standard, three-month regimen of graduated topical steroids was carried out. Presence or absence of symptoms and side effects of treatment were recorded three and six months following induction of the initial graduated topical steroid regimen.

RESULTS

On completion of the graduated topical steroid course, 59% of patients were asymptomatic (P = .035), and at six months, 58% were asymptomatic (P = .11). Remission of symptoms was more easily achieved in patients with lichen sclerosus as compared to patients with squamous cell hyperplasia and mixed disease at both three and six months (P = .09 at three and P = .035 at six). Four cases of local reactions to the steroids were recorded, as were two cases of vulvar malignancy.

CONCLUSION

Symptomatic remission was significantly easier to achieve in patients with vulvar lichen sclerosus as compared to those with squamous cell hyperplasia following treatment with graduated topical steroids.

Lichen sclerosus of the vulva. Long-term steroid maintenance therapy

OBJECTIVE

To assess the efficacy of graduated topical steroids for long-term maintenance therapy for vulvar lichen sclerosus.

STUDY DESIGN

A prospective observational study was performed in the Gynaecological Oncology Department, City Hospital, Birmingham, U.K. Fifty-four patients were recruited for the study. The diagnosis was confirmed with histopathologic examination. After confirmation of the diagnosis, patients were started on a diminishing regimen of topical steroid.

RESULTS

Of the 54 patients in the study, 51 responded to the steroid regimen, and three did not.

CONCLUSION

The graduated topical steroid regimen has a high response rate and takes a relatively short time to achieve, justifying the use of graduated topical steroids for this condition. Graduated dose reduction allows the majority of patients to remain in asymptomatic remission and minimize steroid exposure.

Vulvar vestibulitis treated by modified vestibulectomy

OBJECTIVE

A prospective study to evaluate the success of a modified vestibulectomy in treating vulvar vestibulitis.

METHODS

Fifty seven consecutive women with vulvar vestibulitis and suitable for surgery based on the criteria: superficial dyspareunia, erythematous vestibular region, positive Q-tip test, symptoms reduced with local anesthetic cream. A modified vestibulectomy with or without a modified Fentons procedure was performed. Response was based on return to normal coitus, 3 months after surgery.

RESULTS

Most women suffered from chronic conditions (median duration of symptoms = 18 months). The median age was 28 years (range 18-53). Any infections were treated prior to surgery. All but 4 (7%) had histological abnormalities, mainly non-specific inflammation. In 18% of women who had cervical cytology some abnormality was detected. Mean follow-up time was 12 months (range 2-42). Three women were not evaluable. Complete response to surgery was achieved in 33 (61.1%) of the women, partial response was achieved in 15 (27.8%). Six (11.1%) had persistent symptoms, four of whom has psychosexual problems.

CONCLUSION

Presently, surgery remains the most successful intervention for vulvar vestibulitis. Modified surgery which is less destructive seems to afford acceptable results. The completion of randomized studies are needed to recognise the optimum surgical procedure.

Histologic and immunologic associations of an HPV16 variant in LoSIL smears

BACKGROUND

Human papillomavirus type 16 variants have been described and may have different biologic activities: this has implications for the design of HPV vaccines.

OBJECTIVES

The aim of this study was to see if the HPV16 variant E-G 131 can be detected in women with preinvasive disease and to consider the histological and immunological implications of such infection.

DESIGN

A prospective observational cross-sectional study on a cohort of women with minor cervical cytological abnormalities was performed.

METHODS

Samples were tested for HPV DNA by polymerase chain reaction and restriction enzyme digestion. Blood samples were tested for antibodies to HPV16 virus-like particles (VLP) and to determine class I HLA types. Women found to have abnormal colposcopy were treated by large-loop excision of the transformation zone on a see-and-treat basis.

RESULTS

Two hundred forty-one women were included in the study. Infection with the variant was detected in 20. 9% of cases and was not associated with any specific HLA type. These cases were more likely to have high-grade CIN than those with wild-type HPV16 or no HPV16 (chi2 = 18.85, P < 0.001). There were significant differences in seropositivity to HPV16 virus-like particles between the three groups (chi2 = 32.43, P < 0.001).

CONCLUSIONS

The E-G 131 variant may have increased oncogenic potential by evading host immune responses, but its identification is only weakly predictive of high-grade disease in stepwise logistic regression. The lack of seropositivity to HPV16 VLP has implications for the design of prophylactic vaccines based on VLP to HPV16.

Serum and tissue antioxidant capacity in cervical intraepithelial neoplasia investigated using an enhanced chemiluminescent reaction

Depleted antioxidant defence has been implicated in the pathogenesis of cervical neoplasia. We determined the systemic and local antioxidant status of women with this condition. Thirty-four women with varying grades of cervical intraepithelial neoplasia, 25 patients who had been treated successfully with diathermy loop excision, and 56 women who had no evidence of cervical abnormality acted as controls. Total antioxidant capacity of serum and protein-free serum, and of neat and protein-free homogenized cervical punch biopsies were determined using enhanced chemiluminescence. Mean serum antioxidant capacity of patients with current neoplasia and treated patients was not significantly different from that of controls. However, mean antioxidant capacity of homogenized cervical tissue from women with neoplasia was significantly lower than control means (P < 0.005), while results for treated patients were intermediate between those from diseased and normal samples (P < 0.05). The enhanced chemiluminescence technique has potential as a suitable method for measuring total antioxidant capacity of cervical tissue, and warrants further investigations using other tissue types. Significant antioxidant depletion in cervical intra-epithelial neoplasia appears to be confined to the local cervical mucosa.

An audit of standards and quality in a teaching hospital colposcopy clinic

The National Health Service Cervical Screening Programme has issued minimum standards for a colposcopy service that facilitates audit. We have looked at the performance of a teaching hospital colposcopy service by analysing the case notes of 639 women who underwent large loop excision of the transformation zone over a nine-month period in 1995. We found delays in patient assessment and communication of results. There was overtreatment, particularly at first visit, and an excessive number of treatments were performed under general anaesthesia. A worrying number of women failed to have a follow up smear performed, but in those that did we found a reassuring treatment success rate. Our findings led to changes in the structure and functioning of the colposcopy clinic that should improve the detection of significant disease and improve the timeliness of diagnosis and the speed with which we communicate results.

Urological problems and the treatment of gynaecological cancer

This article reviews the recent literature on urological complications in gynaecological oncology. In particular it focuses on the current controversies in the management of urinary fistulae and reconstruction or urinary diversion after pelvic exenteration.

A pilot study on early post-operative morbidity and technique of inguinal node dissection in vulval carcinoma

Inguinal lymphadenectomy is part of the management plan for most cases of vulval carcinoma. The surgical techniques have been modified over the years resulting in less destructive operations. Even so, inguinal lymphadenectomy continues to pose difficulties particularly relating to wound breakdown and lymphocyst formation. Many different methods are described, though none have undergone any comparative assessment regarding morbidity. This small study compares two methods performed on the same patients. The radical procedure included excision of the fascia lata and exposure of the femoral vessels and nerve. The anatomically-directed method was more conservative with surgery directed at removing the nodes as described in anatomical textbooks. Both methods resulted in equal lymph node retrieval, though the subjective short-term morbidity was reduced with the more conservative surgery. This approach did not result in any detrimental outcomes regarding relapse disease, though a randomised trial is required to corroborate these findings.

Observer variability among colposcopists from the West Midlands region

OBJECTIVE

To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy.

DESIGN

A two-part video questionnaire study.

PARTICIPANTS

Colposcopists from West Midlands Region.

METHODS

Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart.

RESULTS

Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (chi 2 = 19.45, P < 0.0001) but not where the histology was CIN 1 or less (chi 2 = 2.64, P = 0.10). Overall interobserver agreement improved slightly from kappa = 0.169 to kappa = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been overtreated.

CONCLUSION

There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy.

Sjögren's syndrome in women presenting with chronic dyspareunia

OBJECTIVE

To identify cases of Sjögren's syndrome among women with chronic dyspareunia who did not already have a diagnosed rheumatological disorder.

DESIGN

Prospective recruitment over 12 months.

SETTING

Tertiary referral service for the assessment of vulval disease.

PARTICIPANTS

Women with chronic dyspareunia who had musculoskeletal symptoms, Raynaud's phenomenon or symptoms of ocular or oral dryness.

METHODS

The women underwent a Schirmer tear test and a comprehensive auto-antibody screen including latex fixation test for rheumatoid factor, antinuclear, anti-Ro, anti-La and anti-salivary duct antibodies. A labial salivary gland biopsy and vaginal biopsy were taken for routine histological analysis.

MAIN OUTCOME MEASURES

Cases of definite and probable Sjögren's syndrome were identified using the European criteria.

RESULTS

Eleven women were assessed for features of Sjögren's syndrome. Four had definite primary Sjögren's syndrome, two had probable primary Sjögren's syndrome and one had probable secondary Sjögren's syndrome. Among these seven women the median duration of vaginal symptoms was seven years (range 0.25-20), of ocular symptoms was one year (range 0.25-2) and of oral symptoms was 1.5 years (range 0-6). In all but one woman dyspareunia presented before ocular or oral symptoms, often by many years.

CONCLUSIONS

Although well-recognised as a feature of established Sjögren's syndrome, this study emphasises that chronic dyspareunia can be a presenting feature in these women, antedating the emergence of ocular or oral symptoms by many years. Symptoms of ocular or oral dryness, Raynaud's phenomenon or musculoskeletal symptoms should be sought in women with chronic dyspareunia to identify those who merit further investigation.

Randomised trial of immediate versus deferred treatment strategies for the management of minor cervical cytological abnormalities

OBJECTIVE

To compare immediate and deferred treatment in women with cervical smears showing borderline nuclear abnormalities or mild dyskaryosis.

DESIGN

Prospective randomised trial.

SETTING

Colposcopy clinics at Birmingham and Midland Hospital for Women and the City Hospital NHS Trust, Dudley Road, Birmingham.

PARTICIPANTS

Four hundred and thirty-five women with minor cytological abnormality younger than 35 years of age, of whom 353 were randomised to immediate treatment or deferred treatment.

MAIN OUTCOME MEASURES

Comparison of histologies in the subsequent two years in the immediate and deferred treatment groups.

RESULTS

Thirty-six women (21%) defaulted from follow up. The percentage of high grade abnormalities (CIN II and III) in the deferred treatment arm at two years is similar to that in the immediate treated arm at first colposcopy (25% vs 24%). Cytology failed to pick up two cases of CIN III and there was one case of early invasive carcinoma at the six month follow up. If treatment is deferred, the proportion with CIN I is almost halved (25% vs 13%); the proportion with koilocytic atypia is slightly reduced (51% vs 42%) and the proportion with no abnormality is substantially increased (0.6% vs 20%).

CONCLUSION

Immediate referral and a select-and-treat management strategy of all women with any degree of dyskaryosis is recommended based on the case of invasive cervical cancer, high default rate and the failure of cytology to pick up two cases of CIN III.

Is loop excision adequate primary management of adenocarcinoma in situ of the cervix?

OBJECTIVE

To assess the efficacy of cervical loop excision as primary management of adenocarcinoma in situ.

DESIGN

A two-centre retrospective study.

SETTING

Birmingham and Midlands Hospital for Women and City Hospital NHS Trust.

POPULATION

Nineteen women with a histological diagnosis of adenocarcinoma in situ (high grade CIGN) of the cervix made on diathermy loop excision.

MAIN OUTCOME MEASURES

Presence or absence of adenocarcinoma in situ at loop specimen margins, results of cervical cytological examinations following loop excision, results of histopathological assessment of any surgical specimens taken after initial loop excision.

RESULTS

Of the 19 women with confirmed adenocarcinoma in situ on loop excision, the median age was 31, and 8 (42%) were nulliparous. The median follow up of these women was 19 months. Eleven women were treated by loop excision alone and have had normal follow up to 18 months. Five women have undergone further surgical procedures, four had a hysterectomy and one had a repeat loop excision. No residual disease was found in any of these surgical specimens, confirming that loop excision was adequate primary management of the disease. Three women have had abnormal endocervical follow up cytology suggestive of residual disease. One of these three women may represent a case of residual endocervical disease. Excision margins of the loop specimen were not involved by adenocarcinoma in situ in 11 women. However, excision margin status of the loop specimen did not appear to be predictive of residual disease.

CONCLUSIONS

Our small retrospective study suggests that diathermy loop excision of the cervix is adequate primary management of adenocarcinoma in situ of the cervix. Cytological and colposcopic follow up, including cytobrush endocervical cytological sampling and long term follow up, is recommended in these women.

Video colpography: a new technique for secondary cervical screening

OBJECTIVE

To assess the diagnostic accuracy of a new technique of cervical imaging and to consider its potential as a secondary cervical screening method.

DESIGN

A prospective cross-sectional study with each case acting as its own control, comparing video colpography with colposcopy.

SETTING

University of Birmingham colposcopy clinics, City Hospital and Birmingham Women's Hospital.

PARTICIPANTS

Fifty women referred for colposcopy.

INTERVENTIONS

The women had a video colpogram recording made prior to colposcopy.

MAIN OUTCOME MEASURES

The proportion of technically suitable colpograms obtained and the level of agreement between colposcopist and video screener.

RESULTS

The images were satisfactory or good in 94% cases, and there was a very high level of agreement between colposcopist and video screener (kappa = 0.79). If the technique had been used in a primary health care setting as a secondary screening method for women with low grade cervical smear abnormalities, 61% would have avoided referral for colposcopy.

CONCLUSIONS

Video colpography is an accurate, portable and quick method of cervical imaging. It combines the simplicity of a video camera with the versatility of computerised digital imaging and has great potential in the fields of teaching, audit and screening of low grade smear abnormalities.

Vulvar intraepithelial neoplasia: long term follow up of treated and untreated women

OBJECTIVE

To investigate the long term outcome of patients with vulvar intraepithelial neoplasia.

DESIGN

A retrospective study using information obtained from patient casenotes.

SAMPLE

One hundred and thirty-three women with a primary diagnosis of vulvar intraepithelial neoplasia (VIN), identified during a 15-year period.

RESULTS

The diagnosis of vulvar intraepithelial neoplasia increased throughout the study period. Human papilloma virus changes were noted in 104 patients (78%); these women were significantly younger than those without (P < or = 0.001). Nineteen (14%) were managed by observation or medical treatment and the remainder by surgical methods. Histological or symptomatic recurrence after surgical treatment occurred in 55 (48%). When disease recurred, it usually did so within four years of treatment. Recurrence was more common following laser vapourisation than after local excision (75% vs 40%; P < or = 0.01). Progression to invasive disease occurred in nine patients (7%), none of whom were in the group being observed. Four deaths occurred in this group, three from gynaecological malignancies of the lower genital tract.

CONCLUSION

Patients with vulvar intraepithelial neoplasia require long term follow up, and the risk of invasion may be higher than previously thought. Surgical treatment when required should be by excisional rather than ablative methods in most instances. In selected cases it is also possible to safely manage patients by more conservative methods.

Vulvar intraepithelial neoplasia with superficially invasive carcinoma of the vulva

OBJECTIVE

To investigate the long-term outcome of patients presenting with vulvar intraepithelial neoplasia (VIN) with superficially invasive carcinoma of the vulva (SICa).

DESIGN

A retrospective study using information obtained from patient case notes.

SAMPLE

Twenty-six women found at presentation to have VIN in association with superficially invasive carcinoma were identified during a 15-year period.

RESULTS

Pruritus vulvae was the most frequent presenting symptom in 18 patients (69%). Sixteen women (61.5%) had multiple symptoms. Features noted at vulvar examination were variable and none were pathognomonic of either VIN or of superficial invasion. All patients had VIN 3 in association with a superficially invasive carcinoma. Histological changes associated with human papillomavirus were found in 19 (73%) women. Half had a co-existent or previous abnormality of the lower genital tract. Local excision was the most frequent initial treatment (n = 9 [35%]). Mean follow up time was 65 months (range 12-174). Disease persisted after primary treatment in five women (19%). Both histological recurrence (of either VIN or SICa) or symptomatic recurrence occurred in 10 patients (38%). All patients who experienced recurrence did so within 36 months of treatment. Overall, 12 patients (46%) relapsed (histological or symptomatic recurrence); the mean time was 18 months. Fourteen patients (54%) were managed satisfactorily by their initial treatment. One patient died of recurrent cervical cancer. Three progressed to frankly invasive disease: two (aged 31 and 39 years) with carcinoma of the vulva and one aged 34 years with carcinoma of the perianal margin. All are alive and well after treatment. One patient had recurrence of superficially invasive carcinoma treated by local excision with no further problems. No episode of metastasis via lymphatic or vascular channels has been seen.

CONCLUSIONS

Patients with superficially invasive carcinoma of the vulva may be safely treated by local excisional methods without recourse to lymphadenectomy. Relapse after primary treatment is common, and there appears to be a significant risk of progression to frankly invasive carcinoma.

The effect of directed biopsy on the atypical cervical transformation zone: assessed by digital imaging colposcopy

OBJECTIVE

To determine the effect of directed punch biopsy trauma on the natural history of atypical cervical transformation zones.

DESIGN

A prospective randomised clinical trial.

SETTING

Academic Unit colposcopy clinics in Birmingham.

PARTICIPANTS

One hundred and eighty women attending the colposcopy clinics were recruited over an 18 month period, of which 161 were eligible for analysis.

METHODS

Three-way randomisation of patients into 1. no biopsy, 2. central biopsy and 3. peripheral biopsy groups. Quantitative assessment of the change in surface area and severity of cervical intra-epithelial neoplasia (CIN) lesions in each group measured six weeks apart using digital imaging colposcopy.

RESULTS

No significant difference in change in lesion size (P = 0.40) was noted in the three treatment groups. Results suggest that the severity of the lesion was underestimated by the peripheral biopsy.

CONCLUSIONS

The results of this study suggest that directed punch biopsy trauma does not have a significant effect on the immediate natural history of CIN. No statistically significant differences were found in lesion size whether biopsy was employed or not. In addition, the site of biopsy had no influence on the outcome. It appears, therefore, that tissue trauma from punch biopsy and the subsequent inflammatory and wound healing processes do not modify the course of CIN. The regressive changes observed after punch biopsy in previous natural history studies are probably not a result of the initial inflammatory response to biopsy trauma and subsequent re-epithelialisation with normal cells, but may result from processes that continue long after tissue repair is completed.