Large loop excision of the transformation zone (LLETZ). A new method of management for women with cervical intraepithelial neoplasia

Quality evaluation of cone biopsy specimens obtained by large loop excision of the transformation zone

Background

Large loop excision of the transformation zone (LLETZ) has been used for the diagnosis and treatment of precancerous cervical lesions, and it is the first choice of treatment in the majority of cervical pathology services. The aim of this study was to evaluate the presence of thermal artifacts, the need for serial sections, the percentage of clear and involved resection margins and the relationship between endocervical gland involvement and the severity of the lesion in samples resected using LLETZ.

Methods

A retrospective study was performed at Santa Casa de Misericordia School of Science (HSCMV), Vitoria, Espirito Santo, Brazil with a sample of 52 histopathology slides from patients submitted to conization because of abnormal cytology findings and a biopsy result of cervical intraepithelial neoplasia (CIN) 2, CIN 3 and adenocarcinoma in situ. Statistical analysis was performed using Student’s t-test.

Results

Serial sections were required to confirm diagnosis in four of 52 cases. Thermal artifacts were present in all cases, with grade I being the most common (94.2% of cases). Clear margins were found in 96.2% of cases. No association was found between glandular involvement and CIN 1 (P > 0.05); however, there was an association with CIN 2 and CIN 3 (P < 0.05).

Conclusion

The amount of excised tissue was sufficient, thermal artifacts were slight, resection margins were clear in most of cases, and a possible association was found between glandular involvement and the severity of the lesion.

Loop electrosurgical excision procedure and risk of miscarriage

OBJECTIVE

To evaluate the risk of miscarriage in the subsequent pregnancy after a loop electrosurgical excision procedure (LEEP), also considering time elapsed from LEEP to pregnancy.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Tertiary care university hospitals.

PATIENT(S)

Women who had undergone LEEP from January 2000 to December 2011. Women with histologic assessment of low-grade cervical dysplasia, not requiring subsequent surgical treatment, constituted the control group.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The first pregnancy after the procedure was evaluated, and only women with singleton spontaneous pregnancies were considered. Women with time intervals of <12 months and women with intervals of ≥12 months or more from LEEP to pregnancy were then compared, to identify adjusted odds ratios for miscarriage.

RESULT(S)

In women previously treated with LEEP, a total of 116 cases of miscarriage (18.1%) was reported. The mean time interval from LEEP to pregnancy for women with miscarriage compared with women without miscarriage was significantly shorter (25.1 ± 11.7 months vs. 30.1 ± 13.3 months). A higher rate of miscarriage in women with a LEEP-to-pregnancy interval of <12 months compared with controls emerged (28.2% vs. 13.4%; adjusted odds ratio 2.60, 95% confidence interval 1.57-4.3). No significant difference in the rate of miscarriage in women with a LEEP-to-pregnancy interval of ≥12 months compared with controls emerged.

CONCLUSION(S)

Women with a time interval from LEEP to pregnancy of <12 months are at increased risk for miscarriage.

Long-term outcomes of a loop electrosurgical excision procedure for cervical intraepithelial neoplasia in a high incidence country

AIM

To evaluate the operative, oncologic and obstetric outcomes of the loop electrosurgical excision procedure (LEEP) in cases with cervical neoplasia.

MATERIALS AND METHODS

A retrospective cohort study was conducted on patients who were suspected of cervical neoplasia and therefore undergoing LEEP at Siriraj Hospital, Mahidol University, Thailand, during 1995-2000. Outcome measures included operative complications in 407 LEEP patients and long-term outcomes in the 248 patients with cervical intraepithelial neoplasia (CIN) who were treated with only LEEP.

RESULTS

There were 407 patients undergoing LEEP; their mean age was 39.7±10.5 years. The histopathology of LEEP specimens revealed that 89 patients (21.9%) had lesions ≤CIN I, 295 patients (72.5%) had CIN II or III, and 23 patients (5.6%) had invasive lesions. Operative complications were found in 15 patients and included bleeding (n=9), and infection (n=7). After diagnostic LEEP, 133 patients underwent hysterectomy as the definite treatment for cervical neoplasia. Of 248 CIN patients who had LEEP only, seven (2.8%) had suffered recurrence after a median of 16 (range 6-93) months; one had CIN I, one had CIN II, and five had CIN III. All of these recurrent patients achieved remission on surgical treatment with re-LEEP (n=6) or simple hysterectomy (n=1). A significant factor affecting recurrent disease was the LEEP margin involved with the lesion (p=0.05). Kaplan-Meier analysis showed 5-year and 10-year disease-free survival (DFS) estimates of 99.9%. Twelve patients became pregnant a total of 14 times, resulting in 12 term deliveries and two miscarriages - one of which was due to an incompetent cervix.

CONCLUSIONS

LEEP for patients with cervical neoplasia delivers favorable surgical, oncologic and obstetric outcomes.

Cervical conisation and the risk of preterm delivery: a retrospective matched pair analysis of a German cohort

PURPOSE

Since the routine screening program for cervical dysplasia by Pap smear was established in the early 1970s, the rate of cervical cancer has continually dropped. Even if a high percentage of cervical dysplasia shows spontaneous restitution, the only effective therapy for persisting cervical dysplasia is local ablation or excision which might be associated with an increased risk of preterm delivery in subsequent pregnancies. However, data from German patients are missing, so the aim of this study was to evaluate the risk of preterm delivery and associated risks in a cohort of patients who had undergone cervical conisation previous to their pregnancies.

METHODS

A total of 144 patients with conisation and subsequent pregnancy were identified. They were compared regarding week of delivery and preterm birth, fetal birth weight, fetal outcome and birth procedure (spontaneous delivery, vacuum extraction, primary and secondary cesarean section) with their matched partners.

RESULTS

135 patients with singleton pregnancies and their matched partners were evaluated in the final analysis. The mean age was 33.5 years. Comparing the case and control group we reached significant different results for week of delivery, but not preterm birth defined as birth prior to 37 weeks of gestation.

CONCLUSIONS

Within this German cohort cervical conisation did not increase the risk for preterm birth, cesarean section or poor fetal outcome. We therefore conclude that cervical conisation is an appropriate method to treat women with cervical dysplasia also at childbearing age when prevention of cervical cancer is needed.

The role of the cervix in fertility: is it time for a reappraisal?

Knowledge regarding the role of the cervix in fertility has expanded considerably over the past 20 years and in this article, we propose that it is now time for its function to be reappraised. First, we review the anatomy of the cervix and the vaginal ecosystem that it inhabits. Then, we examine the physiology and the role of the cervical mucus. The ongoing mystery of the exact mechanism of the sperm-cervical mucus interaction is reviewed and the key players that may unlock this mystery in the future are discussed. The soluble and cellular biomarkers of the lower female genital tract which are slowly being defined by contemporary research are reviewed. Attempts to standardize these markers, in this milieu, are hindered by the changes that may be attributed to endogenous or exogenous factors such as: age, hormonal changes during the menstrual cycle, ectropion, infection, smoking and exposure to semen during sexual intercourse. We review what is known about the immunology of the cervix. With the widespread use of large loop excision of the transformation zone (LLETZ) for treatment of cervical intraepithelial neoplasia, the anatomy of the cervix is changing for many women. While LLETZ surgery has had very positive effects in the fight against cervical cancer, we debate the impact it could have on a woman's fertility.

A literature review of the current evidence for routine antibiotic prophylaxis after cervical tissue excisions

Consistent data are available on supporting the routine use of prophylactic antibiotics for several obstetrical and gynaecological procedures. According to the Surgical Wounds Classification scheme, operations involving the vagina are included in the clean-contaminated category of procedures, and guidelines recommend the routine use of prophylactic antibiotics. The objective of this paper is to review the current evidence regarding prophylactic antibiotics for cervical tissue excisions. We performed a systematic search of medical databases to March 2014 and we found three randomised controlled trials reporting on the role of prophylactic antibiotics in 683 patients who underwent cervical excisions. When compared with controls, the prophylactic antibiotics group was similar in terms of postoperative bleeding, vaginal discharge, pain, incidence of adverse events, requirement of antibiotics and readmission rate secondary to bleeding. This systematic review based on three randomised controlled trials suggests that current evidence does not support the routine prophylactic antibiotics for cervical tissue excisions.

Secondary prevention of cervical cancer part 3: evidence-based management of women with cervical intraepithelial neoplasia

The management of cervical intraepithelial neoplasia has evolved over the last 20 years. Observation has replaced aggressive therapy in many cases. Evidence based guidelines now guide therapy. This chapter presents an overview of various treatment options, as well as the most recent guidelines of therapy.

Colposcopy: a global perspective: introduction of the new IFCPC colposcopy terminology

This article describes the current nomenclature of colposcopic findings in the lower genital tract as defined by the International Federation for Cervical Pathology and Colposcopy (IFCPC) and agreed at their Triennial General Meeting in July 2012 in Rio de Janeiro. It builds on previous nomenclature published by the IFCPC over the last two decades and introduces for the first time the concept of transformation zone excision types. Vulval and vaginal colposcopic terminology is described.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to November 2012). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

Lidocaine spray compared with submucosal injection for reducing pain during loop electrosurgical excision procedure: a randomized controlled trial

OBJECTIVE

To examine the effectiveness of lidocaine spray compared with conventional lidocaine submucosal injection during a loop electrosurgical excision procedure (LEEP).

METHODS

Women undergoing LEEP for any degrees of cervical intraepithelial neoplasia were invited to participate. The participants were randomly assigned into two groups. In group 1 (injection), the participants were anesthetized with 1.8 mL (36 mg) of 2% lidocaine with 1:100,000 epinephrine injected submucosally using a pressure syringe injector with a 27-gauge needle tip at 3, 6, 9, and 12 o'clock locations of the ectocervix. For group 2 (spray), the patients were locally anesthetized with four puffs (40 mg) of 10% lidocaine spray applied thoroughly to the ectocervix. The patients rated their pain according to a 10-cm visual analog scale at different points during the procedure including baseline, postanesthesia, excision, and 30 minutes postexcision. Primary outcomes were the excision pain score and its difference from the baseline.

RESULTS

One hundred one patients (51 in the injection group and 50 in the spray group) participated in the study. The baseline pain scores, the excision pain scores, the difference between the excision and the baseline pain scores, and the postexcision pain scores were comparable between the study groups. The median postanesthesia pain score and the median difference of the postanesthesia score from baseline were significantly higher in the injection group, 3.4 compared with 0.6 and 1.9 compared with 0.0, respectively (P<.01).

CONCLUSION

Lidocaine spray is an effective and practical alternative measure for reducing pain associated with electrical excision of the cervix during LEEP.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01505920.

LEVEL OF EVIDENCE

I.

LLETZ Specimen Fragmentation: Impact on Diagnosis, Outcome, and Implications for Training

PURPOSE

This study was designed to assess fragmentation of Large loop excision of the transformation zone (LLETZ) specimens, its influence on short-term cytological outcome, and the risk factors for specimen fragmentation, as we well as trainee performance on clinical outcome.

METHOD

This retrospective study was performed at a cancer center. Women who underwent LLETZ for suspected high-grade cervical intra-epithelial neoplasia (CIN) over a 5-year period were included. Patients were identified through a regional database. Data were obtained from hospital and regional databases. Fisher's exact test was used.

RESULTS

75 % of all specimens were obtained intact. When the LLETZ specimen was intact, 89 % of smear tests were reported as negative, against 86 % when the specimen was fragmented. Fragmentation was significantly associated with high-grade smear results at 6 months. Trainee status was significantly related to specimen fragmentation.

CONCLUSION

Fragmentation of LLETZ specimens is associated with an increased likelihood of obtaining a high-grade smear at 6 months post treatment. Enhancing the colposcopy training may help improve clinical outcome.

Pregnancy outcome after loop electrosurgical excision procedure for cervical intraepithelial neoplasia

OBJECTIVE

To determine pregnancy outcomes among women who underwent loop electrosurgical excision procedure (LEEP).

METHODS

In a case-control study in Italy, 475 pregnant women who underwent LEEP and 441 untreated pregnant women were enrolled between January 2003 and January 2007. Outcome measures were spontaneous abortion, preterm delivery, and at-term delivery rates. Continuous and discrete variables were analyzed via t, χ(2), and Fisher exact tests. Groups were compared by analysis of variance and Tukey HSD test.

RESULTS

The spontaneous abortion rate was 14.5% and 14.1% in the LEEP and untreated groups, respectively. The preterm delivery rate was 6.4% and 5.0% in the LEEP and untreated groups, respectively. The number of women with a cervical length of less than 30mm was higher in the LEEP group, but this did not influence preterm delivery rate (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.53-1.95). Among women with a cervical length of less than 15mm, those treated with a wider removal of cervical tissue showed increased risk of preterm delivery (OR, 5.31; 95% CI, 1.01-28.07).

CONCLUSION

The preterm delivery rate was not higher among women who underwent LEEP than among untreated women. Preterm delivery was associated with cone size and cervical length in the second trimester.

Endocervical glandular involvement, multicentricity, and extent of the disease are features of high-grade cervical intraepithelial neoplasia

This study aimed to evaluate the rate of endocervical glandular involvement, positive surgical margins, multicentricity, and disease extent between low-grade and high-grade cervical intraepithelial lesions after loop electrosurgical excision procedure (LEEP). Pathology medical records of patients who underwent LEEP were reviewed retrospectively. Patients with negative LEEP results were excluded. Loop electrosurgical excision procedure reports of patients with cervical intraepithelial neoplasia (CIN) 1, 2, and 3 were compared. There was no statistically significant difference between patients with CIN 1 (n=24), CIN 2 (n=27), and CIN 3 (n=64) when age and surgical margin positivity were considered. Endocervical glandular involvement, multicentricity, and disease extent were higher in patients with CIN 3 (P=.001, P=.002, and P=.001, respectively). In conclusion, we recommend that patients with endocervical glandular involvement, lesions involving more than two-thirds of the LEEP specimen, and multicentricity be followed up more closely.

Laboratory management of cervical intraepithelial neoplasia: proposing a new paradigm

Since the discovery of human papillomavirus (HPV) type 16 in early 80s, the link between HPV and cervical cancer has been established with certainty, a function of the discovery and cloning of a range of HPV types associated with both cancer precursors (cervical intraepithelial neoplasia or CIN) and carcinomas and extensive epidemiologic, clinical, pathologic, and experimental data. These accumulated results have culminated in new paradigms of cancer prevention through screening and triage. Despite this, the management of women with CIN is still suboptimal and the overtreatment of these conditions still occurs, largely due to the lack of clarity regarding which precancerous lesions are most likely to progress in grade. Recently, a discrete population of cuboidal cells was discovered at the cervical squamocolumnar junction, the anatomic site where the large majority of HPV-related (pre)neoplastic lesions develop. These cells seem to be embryonic in nature and participate both in benign metaplasias and the initial phase of precancer development. This review summarizes the historical evolution of precursor management, assesses the potential role of this and other discoveries in segregating lower from higher-risk precursors, and examines their potential impact on the management of women with real or potential cervical cancer precursors.

Appropriate cone dimensions to achieve negative excision margins after large loop excision of transformation zone in the uterine cervix for cervical intraepithelial neoplasia

AIMS

To determine appropriate cone dimensions for predicting margin status after large loop excision of transformation zone (LLETZ) treatment.

METHODS

An observational study performed at the Colposcopy Unit of a university hospital setting involving patients who underwent LLETZ conisation within a 1-year period. Data concerning the characteristics, cone dimensions, lesion grade and excision margins of the patients were recorded.

RESULTS

The median age of the women (n = 61) was 38 years (18-53). LLETZ cone specimens had 36.1% of cervical intraepithelial neoplasia (CIN)2/3 lesion and 13.1% positive margins. Mean cone depth and volume were 10.9 mm and 2.3 cm(3), respectively. Multiple logistic regression for main predictors and after adjustment for age, parity and CIN severity showed that cone volume and length, cone base surface and proportion of excised volume had a significant effect on margin positivity. ROC analysis showed that optimal cut-off for cone volume was 2.1 cm(3) (87.5% sensitivity - 54.7% specificity) or 8.6% of initial cervical volume (75% sensitivity - 75.5% specificity), and for cone length it was 10 mm (100% sensitivity - 52.8% specificity). Optimal cut-off for cone base surface as percentage of ectocervical surface was 32.7% (75% sensitivity - 69.8% specificity).

CONCLUSIONS

These findings should be taken into consideration when planning the outer boundaries of excision and cervical tissue to be removed so as to achieve oncologically safe limits.

Negative loop electrosurgical cone biopsy finding following a biopsy diagnosis of high-grade squamous intraepithelial lesion: frequency and clinical significance

CONTEXT

Loop electrosurgical excision procedure (LEEP) is a therapeutic option following biopsy diagnosis of high-grade squamous intraepithelial lesion (HSIL). Most LEEPs will confirm the HSIL biopsy diagnosis but a number of them will not. Such negative findings suggest the possibility of an incorrect biopsy diagnosis, removal of the lesion by biopsy, or insufficient LEEP sampling.

OBJECTIVE

To determine the frequency of negative LEEP findings following HSIL biopsies and better understand the clinical significance of negative LEEP findings.

DESIGN

The Department of Pathology's records were searched for all patients undergoing LEEP excision who had prior cervical biopsies and subsequent clinical follow-up.

RESULTS

Three hundred seventy-eight women were found who had index biopsies, subsequent LEEPs, and clinical follow-up averaging 25.8 months. Three hundred six women had HSIL on biopsy with 223 (73%) showing HSIL on LEEP. Seventy-three (24%) LEEPs in women with HSIL index biopsy results yielded negative findings or disclosed low-grade squamous intraepithelial lesion (LSIL). Twenty-nine of 223 patients (13%) with an HSIL result both on biopsies and LEEPs had HSIL on biopsy and/or excisional clinical follow-up. Seven of 73 patients (10%) with positive (HSIL) biopsy results but negative LEEP findings or LSIL had HSIL on biopsy and/or excisional follow-up.

CONCLUSIONS

Twenty-four percent of patients with HSIL on biopsy had negative findings or LSIL on LEEP. There is no statistical difference in development of HSIL after LEEP for those with positive biopsy and positive LEEP results (13%) versus positive biopsy and negative LEEP results (10%). The occurrence of a negative LEEP finding following a positive biopsy finding was frequent (24%) and does not portend a different clinical follow-up from a positive biopsy and positive LEEP result.

Prospective Comparison of Loop Excision under Colposcopic Guidance versus Vitom Guidance

Background: Aim of the study was to compare the quality of loop excision using a colposcope with results using the VITOM system. Results compared included cervical volume removed, intra- and postoperative complications, and positive resection margins. Methods: A total of 200 patients with histologically confirmed high-grade cervical premalignant lesions, persistent atypical cytological results and/or suspicious colposcopic findings, and cytological and histological discrepancies were included in the study. In transformation zone type 1 (T1) only a superficial cone biopsy was done, in zones type 2 and 3 (T2 and T3) a superficial outside cone biopsy or a deeper inside cone biopsy were done respectively, followed by endocervical curettage. Volume of removed tissue, complications, and positive resection margins were compared for the colposcopy and the VITOM groups. Findings: Demographic and reproductive features were similar between groups. In the VITOM group 49 % of patients had zone T1, 30 % had zone T2, and 21 % had zone T3. In the group of patients managed by colposcopy, 48, 45, and 7 % of patients had zone T1, T2 and T3 zone, respectively (p < 0.01). A "top hat" procedure was done in 65 % of patients in the VITOM group and in 38 % of patients in the colposcopy group (p < 0.05). Mean volume of removed cervical tissue measured was similar, with 1.2 cm³ measured in the VITOM group and 1.14 cm³ in the colposcopy group (p > 0.05). There were no significant differences in the type of procedure or the mean volume of removed tissue. Results were similar for both groups with respect to positive resection margins and complications. Conclusion: VITOM is a safe and reliable system. Results using the VITOM system are comparable to those obtained with conventional colposcopy. The potential advantage of VITOM is the broader availability of endoscopic systems in the operating theatre.

Early human papillomavirus testing predicts residual/recurrent disease after LEEP

Objective

The purpose of this study was to determine the predictive factors for residual/recurrent disease and to analyze the timing for Pap smears and human papillomavirus (HPV) testing during follow-up after loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) 2 or worse.

Methods

We retrospectively analyzed 183 patients (mean age, 39.3 years) with CIN 2/3 who were treated with LEEP. Post-LEEP follow-up was performed by Pap smear and HPV hybrid capture2 (HC2) testing. The definition of persistent/recurrent disease was biopsy-proven CIN 2 or worse.

Results

Among 183 patients, punch biopsies were CIN 2 in 31 (16.9%) and CIN 3 in 152 (83.1%). HPV HC2 tests before LEEP were positive in 170 (95.5%) of 178 patients. During follow-up, 12 patients (6.6%) had residual/recurrent CIN 2+. LEEP margin status was a significant predictive factor for persistent/recurrent disease. Other factors such as age, HPV HC2 viral load (≥100 relative light units), and HPV typing (type 16/18 vs. other types) did not predict recurrence. Early HPV HC2 testing at 3 months after LEEP detected all cases of residual/recurrent disease. The sensitivity and negative predictive value of the HPV HC2 test for residual/recurrent disease were both 100% at 3 and 6 months.

Conclusion

Margin involvement in conization specimens was a significant factor predicting residual/recurrent disease after LEEP. HPV test results at 3 and 6 months after treatment were comparable. Early 3-month follow-up testing after LEEP can offer timely information about residual/recurrent disease and alleviate patient anxiety early about treatment failure.

Efficacy of fibrin sealant in reducing hemorrhage after a loop electrosurgical excision procedure

BACKGROUND/AIMS

We examined the association of fibrin sealant use with post-operative hemorrhage in patients who underwent a loop electrosurgical excision procedure (LEEP).

METHODS

We retrospectively collected clinicopathologic data of 344 patients who underwent LEEP at our institute between 2007 and 2009. We defined hemorrhage which occurred between 1 and 30 days after LEEP and required electrocautery to achieve hemostasis as severe secondary hemorrhage (SSH). We determined whether or not the use of fibrin sealant during LEEP was associated with a decreased occurrence of SSH. In addition, we examined the associations of other clinicopathologic variables with SSH and fibrin sealant use.

RESULTS

SSH occurred in 6 of 200 patients (3%) with fibrin sealant and in 12 of 144 patients (8%) without fibrin sealant. Based on univariate analysis, the use of fibrin sealant was associated with SSH (p = 0.028). However, age, surgeons and pathologic diagnosis were not associated with SSH. Based on multivariate analysis, the use of fibrin sealant was associated with less SSH (p = 0.033, OR = 0.328, 95% CI 0.117-0.917).

CONCLUSION

Fibrin sealant use reduces the incidence of severe post-operative hemorrhage after LEEP.

C-LETZ versus large loop excision of the transformation zone for the treatment of cervical intraepithelial neoplasia: a randomized controlled trial

OBJECTIVE

To compare large loop excision of the transformation zone (LLETZ) with contour-loop excision of the transformation zone (C-LETZ) in management of cervical intraepithelial neoplasia (CIN) with respect to number of specimens obtained, weight of specimen, surgical margin, treatment time, and morbidity associated with those procedures.

METHOD

Women were randomly allocated to receive LLETZ or C-LETZ. Inclusion criteria were the following circumstances: (1) presence of biopsy-proved CIN 2/3, (2) persistent biopsy-proved CIN 1, (3) discrepancy between cytology and histology, or 4) an endocervical curettage was positive.

RESULTS

Ninety-eight women were eligible for the study. Mean weight of specimens in C-LETZ group was significantly more than LLETZ group (4.35 ± 1.39 vs. 3.55 ± 1.48 g, p = 0.007). Duration of treatment were similar in both groups (p = 0.39). After multiple logistic regressions were analyzed, C-LETZ was more likely to result in a single pathologic specimen (76 vs. 29.16 %, p < 0.001; adjusted RR 8.33, CI 3.23-21.47). There was no statistical significant difference in the frequency of positive margins between the groups (40 vs. 39.5 %, p = 0.64; adjusted RR 1.27, CI 0.46-3.50). The morbidity associated with those procedures was not different between the two groups.

CONCLUSION

C-LETZ has a clear clinical benefit in term of a higher rate of a single pathologic specimen. It removes more cervical tissue than LLETZ. The incidence of incomplete excision and complication seem to be similar in both groups.

Endocervical margin involvement as an important risk factor for abnormal cytology after LLETZ

This study was designed to determine the risk factors for abnormal Papanicolaou (Pap) smear after large loop excision of the transformation zone (LLETZ). We retrospectively reviewed the medical records of 343 women who underwent LLETZ between 2006 and 2008. The associations between clinicopathologic characteristics including margin status and abnormal follow-up cytology were analyzed. Forty-two (12.2%) women were found to have abnormal Pap after LLETZ. Old age at the time of procedure (21.2% versus 10.1%, P=0.020) and endocervical resection margin involvement (33.3% versus 10.7%, P=0.004) were the risk factors for abnormal Pap after LLETZ. The histologic grades of LLETZ pathology were inversely correlated with abnormal follow-up cytology (P=0.018). Logistic regression analysis revealed that old age, endocervical margin involvement, and lower histologic grades of LLETZ pathology were independent risk factors for recurrence. Our findings show that a positive endocervical margin is an important risk factor for abnormal Pap after LLETZ, suggesting that women with positive exocervical or deep cervical margins could be followed up with reassurance.

Thermal artifact after three techniques of loop excision of the transformation zone: a comparative study

AIMS

To compare a surgical-margin thermal artifact in 3 techniques of loop excision of the transformation zone (LETZ).

METHODS

The histopathologic specimens from 140 patients who underwent 3 techniques of LETZ with different electrosurgical units (large loop used with a Valleylab, large loop used with an Ellman Surgitron, and contoured loop with a Utah Finesse) performed in Rajavithi Hospital between January 2003 and June 2007 were reevaluated by one pathologist with regard to degree and width of diathermy artifact.

RESULTS

All of the specimens exhibited thermal tissue artifacts but there were varying degrees of extent and severity. Overall, the mean thermal artifact zone was 0.85 ± 0.94, 0.57 ± 0.47, and 0.49 ± 0.51 mm for the endocervical margin, ectocervical margin, and stromal margin, respectively. However, the thermal artifact did not interfere with the histological diagnosis or the assessment of the margins in all cases. There were no statistical differences in the thermal artifact measurements in the 3 groups. The 3 LETZ techniques provided comparable thermal artifacts in terms of qualitative and quantitative measurement.

CONCLUSIONS

The thermal artifacts, both in severity and extent, are not significantly different in the 3 LETZ techniques. For routine LETZ in clinical practice, those techniques can be used with a comparable outcome.

The role of genital pathogens in morbidity following diathermy loop excision of the transformation zone of the uterine cervix

OBJECTIVE

To evaluate the role of genital pathogens in postoperative morbidity following diathermy loop excision of the transformation zone (LETZ) of the uterine cervix.

METHODS

Patients with cervical intraepithelial neoplasia (CIN) who underwent diathermy LETZ were included in a prospective study. Cervical swabs for genital pathogens were collected before the diathermy procedure. After surgery, women were followed-up regarding the occurrence and severity of postoperative pain, bleeding, and discharge.

RESULTS

Genital pathogens were present in 463 of 788 (58.8%) cases. The most frequently isolated groups of microorganisms were group B β-hemolytic Streptococcus, α-hemolytic Streptococcus, Enterococcus species, and coliforms. In patients with genital pathogens, postoperative pain was present in 298 (37.8%), discharge in 262 (33.2%), and bleeding in 236 (29.9%) cases. In patients without genital pathogens, 199 (25.3%) experienced pain, 181 (23.0%) discharge, and 143 (18.1%) bleeding. The differences between the 2 groups were not statistically significant (χ(2) for pain=0.675; χ(2) for discharge=0.031; χ(2) for bleeding=3.444; P>0.05).

CONCLUSION

Genital pathogens are very common among patients with CIN and do not affect the occurrence or severity of pain, discharge, or postoperative bleeding after diathermy LETZ.

Number of fragments, margin status and thermal artifacts of conized specimens from LLETZ surgery to treat cervical intraepithelial neoplasia

CONTEXT AND OBJECTIVE

Large loop excision of the transformation zone (LLETZ) is a nontraumatic cut and coagulation method with several advantages, but it induces thermal artifacts in the cut region. The aim here was to assess the correlations of age, number of fragments, lesion grade and degree of thermal artifacts with margin quality in conized specimens from LLETZ for cervical intraepithelial neoplasia (CIN).

DESIGN AND SETTING

Cross-sectional study at Universidade Federal de São Paulo (Unifesp).

METHODS

The records and histopathology findings of 118 women who underwent LLETZ between 1999 and 2007 were reviewed. Age, number of fragments, lesion grade, degree of thermal artifacts and margin quality were assessed.

RESULTS

The patients' mean age was 27.14 years; 63.6% had been diagnosed with CIN II and 36.4% with CIN III. The lesion was removed as a single fragment in 79.6% of the cases. The margins were free from intraepithelial neoplasia in 85.6% and compromised in the endocervical margin in 6.8%. Fragment damage due to artifacts occurred in 2.5%. Severe artifacts occurred in 22.8%. Women aged 30 years or over presented more cases of CIN III (P < 0.0004). Neoplastic compromising of surgical margins and severe artifacts occurred more often in cases in which two or more fragments were removed, and in patients aged 30 years or over.

CONCLUSION

CIN III in women aged 30 or over, when removed in two or more fragments during LLETZ, presented a greater number of compromised margins and greater severity of thermal artifacts.

Factors associated with colposcopy-histopathology confirmed cervical intraepithelial neoplasia among HIV-infected women from Rio De Janeiro, Brazil

Introduction

Despite the availability of preventive strategies (screening tests and vaccines), cervical cancer continues to impose a significant health burden in low- and medium-resourced countries. HIV-infected women are at increased risk for infection with human papillomavirus (HPV) and thus development of cervical squamous intraepithelial neoplasia (CIN).

Methods

Study participants included HIV-infected women enrolling the prospective open cohort of Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation (IPEC/FIOCRUZ). At cohort entry, women were subjected to conventional Papanicolaou test, HPV-DNA test and colposcopy; lesions suspicious for CIN were biopsied. Histopathology report was based on directed biopsy or on specimens obtained by excision of the transformation zone or cervical conization. Poisson regression modeling was used to assess factors associated with CIN2+ diagnosis.

Results

The median age of the 366 HIV-infected women included in the study was 34 years (interquartile range: 28–41 years). The prevalence of CIN1, CIN2 and CIN3 were 20.0%, 3.5%, and 2.2%, respectively. One woman was found to have cervical cancer. The prevalence of CIN2+ was 6.0%. Factors associated with CIN2+ diagnosis in the multivariate model were age < years compared to ≥35 years (aPR  =  3.22 95%CI 1.23–8.39), current tobacco use (aPR  =  3.69 95%CI 1.54–8.78), nadir CD4 T-cell count <350 cells/mm3 when compared to ≥ 350 cells/mm3 (aPR  =  6.03 95%CI 1.50–24.3) and concomitant diagnosis of vulvar and/or vaginal intraepithelial lesion (aPR  =  2.68 95%CI 0.99–7.24).

Discussion

Increased survival through wide-spread use of highly active antiretroviral therapy might allow for the development of cervical cancer. In Brazil, limited cytology screening and gynecological care adds further complexity to the HIV-HPV co-infection problem. Integrated HIV care and cervical cancer prevention programs are needed for the prevention of cervical cancer mortality in this group of women.

The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization

OBJECTIVE

To evaluate pregnancy outcomes after electrosurgical conization.

METHODS

We retrospectively analyzed the outcomes of 56 singleton pregnancies after electrosurgical conization of the uterine cervix. Of the 56 cases, 25 women underwent prophylactic cerclage with McDonald procedure (cerclage group), and 31 were managed expectantly (expectant group). Pregnancy outcomes including rate of preterm delivery were compared, and the effect of potential risk factors such as depth of cone, interval between conization and pregnancy, and cervical length on the risk of preterm delivery was assessed.

RESULTS

The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization than those without (32.1% vs. 15.2%, p<0.001). However, preterm delivery rate was not different between the two groups (expectant group vs. cerclage group; <28 week, 6.5% vs. 8.0%, p=1.000; <34 week, 19.4% vs. 20.0%, p=1.000; <37 week, 29.0% vs. 36.0%, p=0.579). All obstetric and neonatal outcomes were similar in the two groups. Even when we confined the study subjects to 19 women (19/56, 33.9%) with cervical length less than 25 mm, the preterm delivery rate also was not significantly different between the expectant (n=7) and cerclage group (n=12). Finally, the potential risk factors for preterm delivery were not associated with risk of preterm delivery in patients with a history of electrosurgical conization.

CONCLUSION

The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization before pregnancy. However, prophylactic cervical cerclage did not prevent preterm delivery in these patients.

Absence of dysplasia in the excised cervix by a loop electrosurgical excision procedure in the treatment of cervical intraepithelial neoplasia

OBJECTIVE

Absence of dysplasia in the excised specimen following loop electrosurgical excision procedure (LEEP) for treatment of cervical intraepithelial neoplasia (CIN) 2/3 is an occasional finding of uncertain clinical significance. We evaluated several factors including age, liquid-based Pap (LBP) test, human papillomavirus (HPV) load before treatment, and HPV typing as predictors for absence of dysplasia. Absence of dysplasia in LEEP specimens was analyzed in terms of factors for recurrent disease after LEEP conization

METHODS

In total, 192 women (mean age, 39.3+/-8.4 years; range, 24 to 70 years) with biopsy-proven CIN 2/3 were treated by LEEP conization. Age, LBP test, histological grade, HPV load, and HPV DNA typing were evaluated as possible predictors of the absence of residual dysplasia or recurrent disease.

RESULTS

Of the LEEP specimens, 34 (17.7%) showed no dysplasia in preoperative biopsies from patients with proven CIN 2/3. Low HPV load (<100 relative light units [RLU]) was significantly related to the absence of dysplasia in LEEP specimens, using logistic regression. Margin involvement and high HPV load (>/=400 RLU) were significant factors for recurrence.

CONCLUSION

Absence of dysplasia in LEEP specimens occurred in 17.7% of our specimens. Prediction of the absence of dysplasia in LEEP specimens was associated with low HPV load. Residual/recurrent disease after LEEP was associated with a positive resection margin and high viral load, and was not associated with absence of dysplasia in LEEP specimens. Even if there is no dysplasia in conization specimens, close follow-up for residual/recurrent disease is needed.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to April 2009). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

Are treatments for cervical precancerous lesions in less-developed countries safe enough to promote scaling-up of cervical screening programs? A systematic review

Background

Since the mid-1990s, there have been growing efforts to prevent cervical cancer in less-developed countries through the development of innovative screening approaches such as visual inspection of the cervix associated with same day management of cervical lesions with cryotherapy or loop electrosurgical excision procedure (LEEP). In the past, promising cancer screening interventions have been widely promoted despite incomplete evidence, only to become the subject of intense controversies about ensuing net health benefit. Because the efficacy and effectiveness of the new protocols for global cervical cancer screening have not been well characterized yet, and as a contribution to the evaluation of the balance between the benefits and risks of these protocols, we reviewed the literature on the safety of cryotherapy and LEEP for cervical intraepithelial neoplasia (CIN) in low- and middle-income countries.

Methods

We searched 12 databases (Medline, Google Scholar, Scopus, Cochrane Library, Web of Science, OCLC, PAIS International Database, WHO Global Health Library, CINAHL, Science.gov, NYAM Grey Literature Report, and POPLINE) for original research published between January 1995 and April 2009. Both peer-reviewed publications and items of "grey" literature were retrieved; no language restriction was applied. We calculated the median (minimum, maximum) reported rate for each harm considered. Because of limitations and heterogeneity in the data, no formal meta-analysis was performed.

Results

The search identified 32 articles that reported safety data from 24 cryotherapy and LEEP studies. The combined sample consisted of 6,902 women treated by cryotherapy and 4,524 women treated by LEEP. Most studies were conducted in reference or research settings in Asia and Africa. Short-term harms of cryotherapy and LEEP appeared to be similar to those described in the literature from high-income countries. Information was sparse on HIV-related harms and long-term reproductive outcomes of treatment.

Conclusions

When performed in resource-limited settings by qualified providers, cryotherapy and LEEP are not associated with excess harm. However, available data are insufficient to propose fully evidence-based protocols for routine screening of HIV-infected women and women of reproductive age.

A pilot study comparing efficacy of a cervical intraepithelial neoplasia Excisor with loop electrosurgical excision procedure

OBJECTIVE

To determine whether the proportion of incomplete resection of cervical intraepithelial neoplasia (CIN 1-3) may be reduced by CIN Excisor compared with loop excision of the transformation zone (LLETZ).

STUDY DESIGN

A prospective trial during a 2-year period at a district general hospital in London, United Kingdom, including 420 women scheduled for treatment due to CIN, after colposcopy guided biopsy results. This study was expected to demonstrate a statistically significant difference (p<0.05) in the proportion of women with clear histopathological resection margins after treatment with CIN Excisor compared with LLETZ. Chi-square or Fisher's exact test were used to compare histopathological resection margins in the CIN Excisor and LLETZ groups.

RESULTS

Overall, there is strong evidence of a difference in the proportion of histopathological specimens with clear resection margins for the CIN Excisor group, compared with the LLETZ group (201/210, 95.7% versus 180/210, 85.7%: p<0.001). Sub-analysis within the two groups, of the proportion of histopathological specimens with clear resection margins in relation to CIN grades, revealed a statistically significant difference in favour of the CIN Excisor group for CIN 1 (99/103, 96.1% versus 82/95, 86.3%: p=0.01), and CIN 2 (73/77, 94.8% versus 68/80, 85%: p=0.04). There is a numerical difference in the proportion of clear resection margins in favour of the CIN Excisor for CIN 3 (29/30, 96.7% versus 30/35, 85.7%), but this difference was not statistically significant (p=0.21). Perioperative complications were similar between the two groups.

CONCLUSION

CIN Excisor achieved better results than LLETZ for treatment of CIN 1-3 with respect to clear histopathological resection margins. However, further studies including a larger number of women treated for CIN 3 are needed before firm conclusions are drawn.