The case for conservative management of "incomplete excision" of CIN after laser conization

Incomplete excision of cervical precancer as a predictor of treatment failure: a systematic review and meta-analysis

BACKGROUND

Incomplete excision of cervical precancer is associated with therapeutic failure and is therefore considered as a quality indicator of clinical practice. Conversely, the risk of preterm birth is reported to correlate with size of cervical excision and therefore balancing the risk of adequate treatment with iatrogenic harm is challenging. We reviewed the literature with an aim to reveal whether incomplete excision, reflected by presence of precancerous tissue at the section margins, or post-treatment HPV testing are accurate predictors of treatment failure.

METHODS

We did a systematic review and meta-analysis to assess the risk of therapeutic failure associated with the histological status of the margins of the tissue excised to treat cervical precancer. We estimated the accuracy of the margin status to predict occurrence of residual or recurrent high-grade cervical intraepithelial neoplasia of grade two or worse (CIN2+) and compared it with post-treatment high-risk human papillomavirus (HPV) testing. We searched for published systematic reviews and new references from PubMed-MEDLINE, Embase, and CENTRAL and did also a new search spanning the period Jan 1, 1975, until Feb 1, 2016. Studies were eligible if women underwent treatment by excision of a histologically confirmed CIN2+ lesion, with verification of presence or absence of CIN at the resection margins; were tested by cytology or HPV assay between 3 months and 9 months after treatment; and had subsequent follow-up of at least 18 months post-treatment including histological confirmation of the occurrence of CIN2+. Primary endpoints were the proportion of positive section margins and the occurrence of treatment failure associated with the marginal status, in which treatment failure was defined as occurrence of residual or recurrent CIN2+. Information about positive resection margins and subsequent treatment failure was pooled using procedures for meta-analysis of binomial data and analysed using random-effects models.

FINDINGS

97 studies were eligible for inclusion in the meta-analysis and included 44 446 women treated for cervical precancer. The proportion of positive margins was 23·1% (95% CI 20·4-25·9) overall and varied by treatment procedure (ranging from 17·8% [12·9-23·2] for laser conisation to 25·9% [22·3-29·6] for large loop excision of the transformation zone) and increased by the severity of the treated lesion. The overall risk of residual or recurrent CIN2+ was 6·6% (95% CI 4·9-8·4) and was increased with positive compared with negative resection margins (relative risk 4·8, 95% CI 3·2-7·2). The pooled sensitivity and specificity to predict residual or recurrent CIN2+ was 55·8% (95% CI 45·8-65·5) and 84·4% (79·5-88·4), respectively, for the margin status, and 91·0% (82·3-95·5) and 83·8% (77·7-88·7), respectively, for high-risk HPV testing. A negative high-risk HPV test post treatment was associated with a risk of CIN2+ of 0·8%, whereas this risk was 3·7% when margins were free.

INTERPRETATION

The risk of residual or recurrent CIN2+ is significantly greater with involved margins on excisional treatment; however, high-risk HPV post-treatment predicts treatment failure more accurately than margin status.

FUNDING

European Federation for Colposcopy and Institut national du Cancer (INCA).

European guidelines for clinical management of abnormal cervical cytology, part 2

The current paper presents the second part of chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. The first part of the same chapter was published in a previous issue (Cytopathology 2008;19:342-54). This part provides guidance on how to manage and treat women with histologically confirmed cervical intraepithelial neoplasia. The paper describes the characteristics, indications and possible complications of excisional and ablative treatment methods. The three options to monitor the outcome after treatment (repeat cytology, HPV testing and colposcopy) are discussed. Specific recommendations for particular clinical situations are provided: pregnancy, immuno-suppression, HIV infection, post-menopause, adolescence and cyto-colpo-histological disparity. The paper ends with recommendations for quality assurance in patient management and some general advice on how to communicate screening, diagnosis and treatment results to the woman concerned. Finally, a data collection form is attached.

Cervical intraepithelial neoplasia II-III with endocervical cone margin involvement after cervical loop conization: Is there any predictor for residual disease?

AIM

To determine the clinicopathological predictors for residual disease in women who have had cervical intraepithelial neoplasia (CIN) II-III with endocervical cone margin involvement after loop electrosurgical excision procedure (LEEP).

METHODS

All of the women who had CIN II-III on LEEP specimens with endocervical margin involvement, and underwent subsequent surgical treatment including repeat LEEP or hysterectomy at Chiang Mai University Hospital between May 2003 and June 2006 were reviewed.

RESULTS

During the study period, 85 women who matched the study inclusion were identified. The mean age was 48.6 years. Fifty-two women (61.2%) were postmenopausal. The most common Pap smear before LEEP was high-grade squamous intraepithelial lesion (HSIL) (65.9%), followed by squamous cell carcinoma (21.2%). Twenty-five women (29.4%) had concurrent ectocervical and endocervical cone margin involvement. Residual disease was noted in 44 women (51.8%, 95%CI = 40.7-62.7) of whom six had unrecognized invasive squamous cell carcinoma, while the remaining 38 had CIN II-III. Only extensive endocervical cone margin involvement (3-4 quadrants) was noted as the significantly independent predictor for residual disease (aOR = 14.2, 95% CI = 3.6-55.8; P < 0.001).

CONCLUSION

Extensive endocervical cone margin involvement after LEEP for CIN II-III is a strong predictor for residual disease. Therefore, the number of involved quadrants should be evaluated to plan further management.

Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions

OBJECTIVE

The aim of the study was to evaluate human papillomavirus (HPV) testing during the follow-up of patients after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesion.

METHODS

A prospective study was conducted on 205 patients who underwent conization for high-grade squamous intraepithelial lesion (CIN 2 or 3). Loop electrosurgical excision procedure (LEEP) was used in all cases. High-risk HPV testing was realized by the Hybrid Capture II system before and 3 months after conization.

RESULTS

Of the 205 patients, 193 (94.1%) were positive for the HPV test before conization. Seventy-one were HPV positive after conization (34.6%). The margins were positive in 36.1%. Residual disease was observed in 27 cases (13.2%). Four patients (2%) developed a recurrence after a mean follow-up of 18.1 months (+/-12). There was no correlation between pretreatment HPV testing and the residual disease or recurrence. Patients with positive margins were significantly more likely to have residual disease than those with negative margins (P < 0.0001). Residual disease was more likely to occur when the posttreatment HPV test was positive (P < 10(-7)). All recurrences were observed in patients with a positive posttreatment HPV test (P < 0.05). Residual disease and recurrence were correctly predicted with a sensitivity of 81 and 100%, respectively, and a negative predictive value of 96 and 100%.

CONCLUSION

Posttreatment HPV testing could be useful in the follow-up of patients after conization. In case of negative posttreatment HPV testing, the frequency of follow-up could be reduced, particularly in those patients with free margins.

Frozen section examination of the endocervical margin of cervical conization specimens

OBJECTIVE

We conducted this retrospective study to determine accuracy of frozen section examination of endocervical margin during cold knife conization.

METHODS

Between June 1993 and June 2001, 310 consecutive patients underwent cervical conization for squamous intraepithelial lesion or stage IA1 cervical cancer. Before 1997, the surgical specimens of 149 patients were processed following a standard pathological procedure (historical group). After 1997, a frozen section of the upper endocervical margin was processed during surgery for 161 patients. If the upper endocervical margin was involved with intraepithelial neoplasia, the surgeon performed a second resection if possible. Results of the frozen section examination were compared with the final diagnoses to determine sensitivity, specificity, and positive and negative predictive values. The usefulness of this procedure was evaluated by comparison of positive margin status rate with the one of the historical control group.

RESULTS

For the diagnosis of intraepithelial neoplasia involving the endocervical margin, the sensitivity, specificity, and positive and negative predictive values of frozen section were 91%, 100%, 100%, and 98%, respectively. Eleven patients had definitive positive endocervical margin in the frozen section group (three false negatives, six patients without additional resection, and two patients with intraepithelial neoplasia involving the upper margin of the additional resection) and 17 patients in the historical group (P =.16).

CONCLUSION

Frozen section examination of the endocervical margin of cervical specimen obtained during cold knife conization is highly accurate. Its clinical relevance has to be demonstrated in a multicenter study.

Detection of residual disease by cytology in patients with cervical intraepithelial neoplasia III post-large loop excision of the transformation zone

OBJECTIVE

To evaluate the diagnostic accuracy of cytology in detecting residual disease in patients with cervical intraepithelial neoplasia (CIN) III post-large loop excision of the transformation zone (LLETZ).

METHODS

This prospective study was performed between February 1994 and August 1999 at the Department of Obstetrics and Gynecology, Ramathibodi Hospital, and involved 90 patients who underwent LLETZ and had histologic confirmation of CIN III. Simple hysterectomy was performed in all patients 2-3 months after LLETZ. Two Papanicolaou smears were taken using Ayre spatula on each patient 6 weeks after LLETZ and 1 day before hysterectomy. Histologic findings of hysterectomy specimens were used as the 'gold standard'.

RESULTS

Forty-six cases (51.1%) were found to have residual diseases: seven cases with CIN I, 11 cases with CIN II, 27 cases with CIN III and one case with invasive squamous cell carcinoma. Using the most severe diagnosis of two Papanicolaou smears performed on each patient as the cytologic diagnosis, the sensitivity, specificity, positive predictive value and negative predictive value were 28.3, 93.2, 81.3 and 55.4%, respectively. The accuracy rate was 60.0%. Residual diseases were found in 62.5 and 39.0% of cases with the presence and absence of CIN at the margin of the LLETZ specimen, respectively.

CONCLUSION

Cytology using the Ayre spatula has low accuracy in detecting residual disease in the cervix post-LLETZ.

Is high-risk human papillomavirus infection associated with cervical intraepithelial neoplasia eliminated after conization by large-loop excision of the transformation zone?

OBJECTIVE

To investigate whether high-risk HPV infection associated with cervical intraepithelial neoplasia (CIN) was successfully eliminated after electrosurgical conization by large-loop excision of the transformation zone (LLETZ).

STUDY DESIGN

142 women, who were admitted for conization of CIN 1-3 were recruited into a prospective follow-up study of HPV infection, including cervical sampling for HPV DNA before, and then 3, 6 and 12 months after surgery. We examined whether there were any differences in the rate of HPV DNA positivity after LLETZ between specific risk groups, such as patients with primary (i.e. before surgical treatment) high-risk HPV infection, CIN of different grades, and positive margins.

RESULTS

We did not detect statistically significant differences between specific risk groups. According to the assay used (hybrid capture II) at the last follow-up visit 94% of primarily infected patients were completely free from infection with high-risk HPV types, while 6% had persisting HPV infection.

CONCLUSIONS

With a detection limit of 5000 genomes/ml HPV DNA the hybrid capture II results revealed, that after electrosurgical removal of CIN in 94% of patients testing positive for high-risk HPV DNA prior to surgery were negative 12 months post-surgery.

A comparison of the therapeutic efficacies of large loop excision of the transformation zone and hysterectomy for the treatment of cervical intraepithelial neoplasia III

The technique of large loop excision of the transformation zone (LLETZ) came into vogue in the 1990s, and has been widely used in place of cold knife conization for diagnosis and treatment. Although its therapeutic efficacy for cervical intraepithelial neoplasia (CIN) has been confirmed and accepted in many countries, no direct comparison is available of the efficacies of LLETZ and hysterectomy for the treatment of CIN III, and unfortunately, hysterectomy is still widely used in many other countries. The aim of this analysis was to confirm the efficacy of LLETZ for the treatment of CIN III and to compare its results with those of hysterectomy. Between Jan. 1993 and Dec. 1997, 380 patients with CIN III were treated in the Seoul National University Hospital. We defined group I (n = 101) as those patients who underwent therapeutic LLETZ and follow-up only and group II (n = 279) as those patients who underwent hysterectomy following LLETZ. Three patients in groups I (3.0%) and II (1.1%) developed persistent/recurrent CIN or vaginal intraepithelial neoplasia (VAIN). This result was not statistically significant. Group II contained more patients with positive resection margins and glandular extensions than group I (P < 0.05), and these factors might have been confounding variables. However, when parameters influencing the rate of treatment failure were compared, no significant differences were found by logistic regression analysis (P > 0.05). The results obtained show that the LLETZ is almost identical in terms of its therapeutic efficacy to hysterectomy and that it should be accepted as a standard treatment for CIN III.

Predictive factors for residual disease in subsequent hysterectomy following conization for CIN III

OBJECTIVE

The aim of this study was to determine predictive factors for post-cone residual disease in subsequent hysterectomy for CIN III.

METHODS

From June 1994 to June 1999, 120 patients with CIN III who received hysterectomy within 6 months of conization regardless of marginal status were identified from 1450 conization cases. The demographic features and pathologic parameters were analyzed for the predictive rate of post-cone residual disease.

RESULTS

Age >==50 years and parity >==5 were significant factors associated with residual disease. The incidence of residual disease was 56.5 and 29. 3% in patients >==50 and <50 years, respectively, and 61.8 and 36.0% in patients with parity >==5 and <5. Post-cone endocervical curettage (ECC) and multiple-quadrant disease were the only pathologic predictive factors identified. The incidence of residual disease was 64.6 and 29.2% in patients with positive ECC and negative ECC, respectively, and 48.4 and 25.9% in patient with multiple-quadrant disease and one- or two-quadrant disease. Other pathologic parameters, including endocervical margins, ectocervical margins, endocervical gland involvement, and depth of conization, were not predictive of residual disease. When ECC was combined individually with age, endocervical margins, or multiple-quadrant disease, there was no increase of positive predictive rate.

CONCLUSIONS

(1) Age 50 years or more and parity >==5 were two demographic features that predicted post-cone residual disease. (2) ECC and multiple-quadrant disease were the only pathologic parameters that predicted post-cone residual disease. (3) With the appropriate application of the predictive factors, post-cone hysterectomy may be further decreased.

Persistence of human papillomavirus infection after therapeutic conization for CIN 3: is it an alarm for disease recurrence?

OBJECTIVE

The aims of this study were (1) to examine whether HPV DNA is persistently detected in the cervix after therapeutic conization for CIN 3 and (2) to explore whether a patient with persistence of HPV infection is at risk of developing recurrent disease.

METHODS

Of 74 patients referred with CIN 3, 58 who were tested for HPV DNA in the pretreatment cervical lesions were enrolled in the study. After standard therapeutic conization, patients were followed prospectively at the outpatient clinic. Our follow-up protocol was to follow patients without therapeutic intervention as long as they developed no recurrence or recurrence of CIN 1 or 2, while patients who experienced recurrence of CIN 3 were recommended for reconization or hysterectomy. The polymerase chain reaction for detecting HPV DNA was performed using fresh cell samples from the cervix.

RESULTS

In 56 of 58 patients (96.6%), HPV DNAs were detected in their primary cervical lesions prior to conization. With regard to the distribution of HPV types, HPV type 16 family (types 16, 31, and 35) was identified in 28 cases (50.0%), type 18 family (types 18, 33 and 58) in 15 (26.8%), and type X in 18 (32.1%). Up to August 1999, all of the 58 patients have been followed with a mean follow-up period of 31.8 months (range: 12 to 73 months). After treatment, HPV DNA was persistently detected in 11 (19.6%) but negative in 45 (80.4%) of 56 HPV DNA-positive patients. HPV DNA was not detected in both HPV DNA-negative patients. Five of 11 persistently HPV DNA-positive patients (45.5%) developed CIN recurrence, while none of 45 persistently HPV DNA-negative patients did. Thus, there was a significant difference between the recurrence rates of these two groups (P < 0.0001). Both patients who were initially HPV DNA-negative developed no recurrence. Accordingly, the overall recurrence following conservative treatment for CIN 3 was 5 of 58 patients (8.6%).

CONCLUSIONS

Patients with persistent HPV infection after conization for CIN 3 should be especially closely followed because they are at increased risk of developing disease recurrence.

Margin status and excision of cervical intraepithelial neoplasia: a review

Excisional biopsy of the cervix for diagnosis and treatment of cervical neoplasia is common. Management of patients with involved margins of resection is unresolved. Data concerning use of thermal techniques show that this technique yields equivalent results in most cases. Important exceptions are microinvasive squamous disease and adenocarcinoma. Conservative management of involved squamous margins is possible. Techniques for follow-up include cytology, colposcopy, and endocervical curettage. Adenocarcinoma in situ (AIS) should be treated with cold-knife conization. The standard of care for AIS is hysterectomy except in certain specific indications. Data concerning technique, follow-up, use of endocervical curettage, and the need for reexcision will be presented.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to compare the efficacy of the various excisional procedures in the treatment of cervical dysplasia, list the indications for additional surgery after positive margins on cervical excisions, and describe the proper management of a patient with adenocarcinoma in situ.

Positive margins after conization and risk of persistent lesion

OBJECTIVE

The aim of this study was to investigate a method to reduce the frequency of uterine reoperation with no persistent lesion and to identify factors predictive of persistent or recurrent lesions.

MATERIALS AND METHODS

Of 505 conizations performed by the same surgeon, 71 had positive margins (average patient age = 35.7 +/- 7.7 years). The patients underwent either immediate reoperation or monitoring with a Pap smear and colposcopy.

RESULTS

Histologic assessment of the cervical cone after conization showed positive margins in 14.1% of cases [endocervical and exocervical margins affected in 50 of 505 (9.9%) and 21 of 505 (4.2%) cases, respectively]. Of 59 of these patients (83.1%) who underwent follow-up monitoring over an average of 35.2 months (range: 2.6-180. 8), 12 patients (average age: 40.8 +/- 6.4 years) underwent immediate hysterectomy and 47 (average age 34.0 +/- 7.4 years) benefited from monitoring first [secondary discovery of 19 persistent lesions within 6 months and 9 recurrences within 18 months on average (range: 8.8-48 months)]. Of the 9 patients with recurrent lesions, 7 underwent reintervention and 2 monitoring. Of the 19 patients with persistent lesions, 18 underwent reintervention and 1 monitoring. Normal histology was observed in 29.4% of patients undergoing secondary reoperation for an abnormal smear compared with 66.7% of patients undergoing immediate reoperation (P = 0.04). Severity of lesion and age of patients could not be used to predict the incidence of a persistent or recurring lesion. Seventy-nine percent of conizations had positive endocervical margins in patients with a recurring or persistent lesion compared with 48% in patients with normal follow-up (P = 0.03).

CONCLUSION

Cytology and colposcopy follow-up in cases of positive conization margins may help to establish justification for the choice of reoperation, thereby limiting morbidity following repeated surgery.

The efficacy of cervical conization in the treatment of cervical intraepithelial neoplasia in HIV-positive women

OBJECTIVE

The aim of this study was to evaluate the efficacy of cervical conization in the treatment of CIN in HIV-positive women.

MATERIALS AND METHODS

Sixty-six HIV-positive women treated with cervical conization for CIN were stratified into four groups based on surgical margin and endocervical curetting (ECC) status (group 1: -margin/-ECC, group 2: +margin/-ECC, group 3: +margin/+ECC, group 4: -margin/+ECC). The rate of histologically proven recurrent CIN was calculated for each group and compared using chi(2) analysis. The effect of +margins, +ECC, degree of dysplasia, and CD4 count on the risk of recurrence was determined by logistic regression.

RESULTS

Forty-nine percent of patients with negative margins and negative ECC experienced recurrence, most within 36 months. There was no significant difference in recurrence rate for patients with positive margins (69.2%, P = 0.19), positive ECC (50%, P = 0.97), or positive margins and ECC (66.7%, P = 0.41) when compared to patients with complete excision of dysplasia. No significant difference in the mean CD4 count of patients with and without recurrent dysplasia (316 vs. 390 cells/mm3, P = 0.37) was observed. Logistic regression showed only degree of dysplasia in the cone specimen to have a marginally significant linear relationship with recurrence.

CONCLUSION

Cervical conization is not an effective method for eradicating CIN in HIV-positive women. Most patients will recur despite complete excision of dysplasia. Surgical margin status, ECC status, and CD4 count appear to have no effect on recurrence rate. Although multiple procedures were necessary in some patients, cone biopsy was effective in preventing progression to invasive cervical cancer in all cases.

Decision-making in the colposcopy clinic--a critical analysis

OBJECTIVE

To consider the omission of several diagnostic steps from the management of patients with high-grade squamous intraepithelial lesion (SIL) by analyzing the role of each step on the choice of treatment.

STUDY DESIGN

Each diagnostic procedure was correlated to the treatment and outcome in 87 women with high-grade SIL. Treatments considered were large loop excision of the transformation zone (LLETZ) cold knife conization, and CO2 laser vaporization.

RESULTS

Unsatisfactory colposcopy (P< or =0.01) and positive endocervical curettage (ECC) specimen (P< or =0.01) were essential for choice of treatment. CIN2 diagnoses of the preoperative cervical biopsy were rediagnosed as CIN3 based on the surgical specimen in 57% of the cases. The margins of 33 and 23% of surgical specimens removed by LLETZ or knife conization, respectively, displayed CIN involvement. Forty and 47% of these patients, respectively, later developed recurrent CIN.

CONCLUSIONS

Omission of colposcopy and ECC could have resulted in sub-optimal treatment in many cases. Excision by LLETZ or knife conization is recommended for cases of CIN2 and CIN3. Follow up is imperative for patients with involvement of the margins.

Thermal artefact after diathermy loop excision and laser excision cone biopsy

Whether or not thermal artefact precludes accurate histopathologic assessment of excision biopsies of the uterine cervix is currently controversial. Some authors state that margins cannot be assessed at all while others feel that the pathologist can 'see through' the artefact in the majority of cases. Over a 7-month period, 164 patients had loop excision and 84 patients had laser cone biopsy. The zone of coagulation at the specimen periphery was measured and the adequacy of excision assessed. The average width for this zone of coagulation in diathermy loop was 0.32 mm and for laser cone biopsies was 0.31 mm. In 12% of the loop specimens the line of excision was compromised by dysplasia or its assessment was rendered uncertain by thermal artefact. This was far more common in fragmented specimens (20%) compared to those removed as a single specimen (6%). In this study, 40% of patients had fragmented loop specimens. Thus, in attempting to replace cone biopsy with loop excision, we are asking pathologists to reassemble a pathologic jigsaw, then look through the thermal artefact for a decision on margins. We believe that this fragmentation should preclude the use of loop excision for lesions which would previously have been managed by cone biopsy.

Residual disease and presence of human papillomavirus after conization

The objective of this study was to evaluate the incidence of residual disease and the presence of human papillomavirus (HPV) after conization. Data on 53 patients with carcinoma in situ or microinvasive carcinoma who underwent hysterectomy less than 2 months after conization were examined. Seven of 53 patients (13%) had positive margins. In 4 of these 7 patients (57%), residual disease was found in the postconization hysterectomy specimen. Two of 46 patients (4%) with negative margins also had residual disease. HPV DNA was detected by PCR in 27 of 53 conization specimens and in 2 postconization hysterectomy specimens. Of 2 patients, 1 did not have residual disease. Residual disease could be present even with a negative conization margin, and HPV DNA may be found in a histologically normal cervix after conization.

The frequency of bacterial and yeast infection in women with different grades of cervical intraepithelial neoplasia (CIN)

OBJECTIVE

To determine bacterial and yeast infection of the uterine cervix in women with different grades of cervical intraepithelial neoplasia (CIN).

STUDY DESIGN

578 patients with CIN were included in this study. In order to determine the presence of bacterial and yeast infection, a cervical swab was obtained before conization of the uterine cervix. After surgery and the definitive histology report, the frequency of bacterial and yeast infection in different grades of CIN was calculated.

RESULTS

Among 578 patients with CIN, bacterial or yeast infection was present in 379 (65.6%) patients. In patients with CIN 1, infection was present in 20 (71.4%), in CIN 2 in 106 (69.7%) and in CIN 3 in 252 (63.3%) cases. The differences in the frequency of infection among all three groups are not significant.

CONCLUSION

In patients with CIN bacterial and yeast infection of the uterine cervix is very common. Its occurrence does not depend on the grade of CIN.

Laser surgery in gynecologic oncology

In the treatment of premalignant epithelial cancers of the female lower genital tract, the CO2 laser beam is used with precision through a surgical microscope for tissue ablation and excision. Intra-abdominal vaporization of abnormal tissues can be performed endoscopically through fiberoptics. Surgical lasers provide thermal scalpels for hemostatic excision of malignant lesions. Photodynamic therapy is applied in the treatment of isolated malignancies persistent after conservative treatment. Surgical laser systems are important tools in the treatment of gynecologic malignancies.

Laser vaporization and excisional techniques in the treatment of cervical intraepithelial neoplasia

The CO2 laser proved to be a vital tool in the development of conservative therapy for the treatment of CIN in the 1980s. In conjunction with colposcopy, the laser has allowed many women to achieve the security of identified and treated CIN with the freedom to live their lives normally, including the achievement of pregnancies. The laser may be used either in the ablative (vaporization) or the cutting mode. This flexibility allows patients with unsatisfactory as well as satisfactory colposcopy to be managed. The results of treatment are universally excellent, with clearance rates of 96% being reported. Complications are rare both in the short and long term, most patients returning fully to normal activities within 4 weeks of therapy. Although the laser is being superceded to some extent by the advent of the loop diathermy technique, it will for years to come represent a valuable and useful tool in the treatment of CIN.