Diagnostic significance and sequelae of cone biopsy

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

OBJECTIVE

Our purpose was to study the feasibility of conservatively managing selected cases of dysplasia involving endocervical cone margins.

STUDY DESIGN

A retrospective review of patients conservatively managed after being found to have squamous cell dysplasia involving the endocervical margins of their cervical cone biopsy specimens. In phase I patients who had cold-knife conization with positive endocervical margins underwent repeat Papanicolaou smears and colposcopy, with biopsies and endocervical curettage as indicated. Those found free of disease were followed up with frequent Papanicolaou smears. In phase II patients with dysplasia to the endocervical resection edges on loop electrical excision procedure biopsy specimens were followed up with frequent cytologic studies.

RESULTS

In phase I, 31 patients with positive endocervical margins on cold-knife conization and no evidence of dysplasia on reevaluation were followed up for 1 to 18 years. Dysplasia was detected in one patient during cytologic surveillance. In phase II, 11 patients were followed up for 12 to 31 months; only one patient has dysplasia.

CONCLUSION

Selected patients with squamous cell dysplasia at endocervical cone biopsy margins may avoid additional surgery.

A randomized study comparing suture with non-suture cold-knife conization

OBJECTIVE

To compare the short-term outcome of cold-knife conization between suture and non-suture (with Monsel's solution pack) methods.

METHODS

Between February, 1990 and March, 1992, 142 patients underwent cold-knife conization were randomly allocated into 2 groups. The hemostasis was done by suture in one group and by Monsel's solution pack without suture in the other group. The patients' and cone specimens' characteristics as well as short-term outcome were recorded and compared using Chi-square test, Fisher exact test and t-test where appropriate.

RESULTS

The patients' characteristics, cone size, and histologic diagnosis of both groups were comparable. The non-suture group had shorter operative time (10.69 +/- 7.86 vs. 20.04 +/- 6.99 minutes) and lesser late hemorrhage (2.9 vs. 15.9%) than the suture group (p < 0.05). There was no statistical difference in the operative blood loss.

CONCLUSION

The non-suture method of conization should replace the traditional suture method.

The incomplete cone biopsy: a comparison of conservative and surgical management

OBJECTIVE

to determine the reliability of conservative management of cone biopsies showing apparently incomplete excision of cervical intraepithelial neoplasia (CIN) by comparing surgical and conservative management.

DESIGN

a retrospective study.

SUBJECTS

74 consecutive cone biopsies with a histology report of apparently incomplete excision of CIN 2 or CIN 3 from a series of 738 cone biopsies.

MAIN OUTCOME MEASURES

the presence of CIN at hysterectomy against the pick up rate in conservatively managed patients.

RESULTS

where excision appeared incomplete at the ectocervix this was confirmed in 1 of 6 (16.7%) of patients managed surgically and 2 of 17 (11.8%) of patients managed conservatively (P = 0.40). Where excision appeared incomplete at both endo- and ectocervix, 5 of 6 (83.3%) were confirmed to have incomplete excision in the surgical group, and 3 of 5 (60%) had further proven CIN in the conservative group (P = 0.34). Where excision appeared incomplete at the endocervix only, this was confirmed in 7 of 22 (32%) of cases managed surgically, but only 2 of 18 (11.1%) of cases managed conservatively had further proven CIN (P = 0.14). Combining all patients with incomplete excision at the endocervix irrespective of the ectocervix status revealed confirmation of residual CIN in 12 of 28 (42.9%) patients managed surgically and in 5 of 23 (21.7%) patients managed conservatively (P = 0.097).

CONCLUSIONS

management should depend on the site of the apparent incomplete excision. Where excision appears incomplete at the ectocervix only, cytological follow up should be employed. If the endocervix is involved, further excisional surgery may be more appropriate.

Reliability of colposcopy and directed punch biopsy

A group of 118 women underwent laser cone biopsy. Data were collected routinely on proforma case notes and entered into a computerized database. The histology of the cone biopsies was compared with that of previous, colposcopically directed punch biopsies, with the cytology of smears taken in the clinic and with the colposcopic diagnosis. The punch biopsy had a 54% false negative rate and neither of the two microinvasive carcinomas biopsied in this way were detected by the biopsy. Ten of 24 women with negative punch biopsies had CIN III in the cone. When the punch biopsy showed CIN II or worse, the cone biopsy confirmed the presence of CIN in 86%. There was some evidence of false negative cone biopsies. The data suggest that management should not be based solely upon the punch biopsy result but should include consideration of the cytology and colposcopy findings. Excisional methods of treatment are more likely to reveal early invasion and adenocarcinoma-in-situ.

Laser cylindrical excision to replace conization

This report describes the procedures and results of two techniques, which were developed by the senior author (V.C.W.), for eliminating cervical intraepithelial neoplasia involving, to some degree, the endocervical canal. These are excision by carbon dioxide laser of a tall cylinder of tissue for pure endocervical lesions and shallow excision of a similar specimen followed by peripheral vaporization. In 364 consecutive referred cases one of these two procedures was performed. A total of 15.9% of patients required attention for bleeding; most cases were managed in the clinic. Near-normal tissue mass and a squamocolumnar junction at the os were observed during 3 to 60 months of follow-up. In 95.9% of cases, over half of which were grade 3 cervical intraepithelial neoplasia, normal cytologic and colposcopic findings were demonstrated after one laser procedure. A repeat laser procedure was used to eliminate persistent disease identified at 3 or 6 months. Five hysterectomies were performed. These procedures appear to be therapeutically effective, appear to preserve organ function, and allow regeneration of cervical mass.

Carbon dioxide laser surgery for cervical intraepithelial neoplasia

During 1977-1983, 787 consecutive referred cases of CIN were treated by vaporization of a dome-shaped defect, by excision of a cylindrical specimen, or a combination of procedures where 48% were CIN III. Vaporization was used for 72% of CIN I, 76% of CIN II, and 64% of CIN III cases. Less than 15% of vaporization and all excision cases were done in hospital under anesthesia; 11% had delayed bleeding requiring attention (admission was required in 2%); 100% of CIN I, 96% of CIN II, and 96% of CIN III cases were cured. Persistent disease was diagnosed at the first (96%) or second (4%) visit. Subsequent treatment included laser and less than 1% hysterectomy. Overall cure for laser surgery was 99.5%. Sixty-eight patients subsequently became pregnant; outcomes were normally distributed. Treatment success is related to adequate volume of tissue removed.