Treatment of cervical intraepithelial neoplasia with the carbon dioxide laser beam. A preliminary report

See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions

In a see-and-treat protocol, patients referred for colposcopy because of an abnormal Pap smear in cervical-cancer screening can be treated by loop excision, without biopsy, during one visit to the clinic. However, overtreatment in the see-and-treat strategy has been reported to be 1.2-83.3% for low-grade squamous intraepithelial lesions (SIL) and to be 13.3-83.3% for high-grade SIL. Range of overtreatment narrowed to 4.0-23.5% for those with normal pathology and to 18.0-29.4% for those with normal or low-grade pathology when calculation of overtreatment was restricted to patients diagnosed with high-grade SIL on colposcopy and referral Pap smear. Most common treatment complications are bleeding and infection. Nonetheless, the strategy has become accepted internationally: low costs, decreased patient anxiety, and increased compliance make it appealing, especially in settings with limited health resources, and for patients at risk of not being treated in a timely manner or of not returning for a second appointment. Mathematical modelling may give information about the appropriateness and usefulness of this treatment while the results of long-term clinical trials are awaited.

Diagnostic value of conization of the uterine cervix in the management of cervical neoplasia: a review of 756 consecutive patients

A review of 584 consecutive cases of conizations performed over a 15-year period showed that 320 patients (54.8%) had conizations because of the presence of neoplastic cells in the endocervical curettings. Of these patients, 268 (83.4%) had cervical intraepithelial neoplasia of various grades on conization, and 12 (3.6%) had microinvasive cancer. The remaining 40 patients had normal cervical epithelium. One hundred seven (18.3%) patients had conization because of cytological smear and colposcopy discrepancy. Seventy-six (71.0%) patients in this category had cervical intraepithelial neoplasia. Two (2.0%) had superficially invasive cancer; the remaining 29 patients had normal cervical histology. Sixty-seven (11.5%) had conizations because of unsatisfactory colposcopic evaluations. This review indicates that although conization is less frequently performed, it is still a useful tool in the management of patients with abnormal cytology in whom colposcopy evaluation cannot rule out invasive cancer.

Human papillomavirus in paired normal and abnormal cervical biopsies--implications for treatment

A total of 143 consecutive patients with abnormal cervical cytology was examined at a large colposcopy clinic in Glasgow. Each patient had paired biopsies from normal and abnormal cervical epithelium examined both histologically and by immunoperoxidase staining for human papillomavirus (HPV) infection. More than 71% of the abnormal biopsies and 39% of the normal paired biopsies had histological evidence of HPV infection. Cytological evidence of HPV infection was seen in 38.5% of cervical smears. Immunocytochemistry revealed HPV antigen in 22% of the abnormal biopsies and in 4.2% of the 'normal' biopsies. The presence of HPV infection in colposcopically normal cervical tissue both inside and outside the transformation zone may help to explain why current methods for treatment of cervical HPV infection are often unsuccessful.

A randomized trial of the use of cocaine spray to provide pain relief during laser vaporization of the cervix

In a double-blind trial, 50 patients undergoing laser vaporization of the cervix for cervical intraepithelial neoplasia were randomly allocated to one of two groups. One group had the cervix sprayed with 3-4 ml of a solution containing 10% cocaine, the other a placebo solution during the laser treatment. Women in the cocaine group had significantly less pain as assessed by a visual analogue scale (P less than 0.001) and by a verbal rating scale (P = 0.002). The cocaine group also had less blood loss (P = 0.001) as assessed subjectively by the operator.

Residual cervical intraepithelial neoplasia after laser ablation

Some patients with histologically proven residual cervical intraepithelial neoplasia after laser ablation have false negative cytology. The explanation for this is not known, but there was no evidence of buried lesions. Follow-up of all patients treated by selective ablation is necessary. Cytology alone is inadequate and careful, accurate pre- and posttherapy colposcopy is essential.

Carbon dioxide laser vaporization of cervical subclinical papillomaviral infection and intraepithelial neoplasia: short-term effectiveness

134 patients with biopsy-proved cervical subclinical papillomaviral infection (SPI) (the so-called 'flat condylomas'), or with associated intraepithelial neoplasia (also called 'atypical condyloma' or 'CIN with features of condyloma'), or with isolated, apparently 'non-warty' intraepithelial neoplasia were treated by means of the carbon dioxide laser between July, 1982, and January, 1985, following a planned approach and on an outpatient clinic basis, without the use of anesthesia or analgesia. The complication rate was extremely low. The overall cure rate was 91.0%. This confirms that laser surgery, combined with colposcopic expertise, can offer acceptable treatment effectiveness, comparable to other techniques of local destruction. Moreover, rapid tissue healing allows early identification of persistent disease. Converging cytological, histopathological, immunochemical and serological evidence has established human papillomavirus - belonging as a subgroup to the papovavirus family - as an important etiologic factor in female genital tract carcinogenesis. The marked increase in prevalence of these mainly sexually transmitted cervical SPI lesions creates a growing problem of their management and/or follow-up.

A comparison between laser excisional conization and laser vaporization for the treatment of cervical intraepithelial neoplasia

One hundred twenty patients with cervical intraepithelial neoplasia who were treated by laser excisional conization were compared with a group of 100 women who had similar diagnoses and were treated by laser vaporization. Every operation in the series was performed in the outpatient surgical unit or in the office. In two thirds of the cases the procedures were carried out with the patients under local anesthesia. The parameters studied included time required to perform the procedure, immediate and delayed bleeding, postlaser stenosis, healing time, patient discomfort, persistence or recurrence of disease, and risk of invasion. The results of this study revealed few disadvantages to performing a laser excisional procedure. Immediate and delayed complications were less frequent with laser excisional conization. The time required to perform an excisional conization was on the average only 4 minutes longer than that for a vaporization. Most significantly, the laser excisional cone provides a large and excellent specimen for the pathologist to review.

Healing of cervical epithelium after laser treatment of cervical intraepithelial neoplasia

The recognition that only a minority of cervical premalignant lesions progress to invasion, and the increasing incidence of these lesions in young women, has led to a more conservative approach in the treatment of cervical intraepithelial neoplasia. One such method uses the carbon dioxide laser but inadequate length of follow-up has prevented a prediction of risk of recurrence. Observations made in this study on the speed of healing, source of new epithelium, maturation of the epithelium and the absence of herpes nucleic acid suggest that this risk is low.

Healing of cervical epithelium after laser ablation of cervical intraepithelial neoplasia

Healing of cervical epithelium was studied in 30 patients after destruction of cervical intraepithelial neoplasia using a carbon dioxide laser. Repeated examinations, using photography and colposcopically directed punch biopsies, were made from the eighth to the 32nd day after treatment. The biopsy specimens were submitted to examination by light and transmission electron microscopy. There was complete epithelial cover of the laser induced craters in all patients by 28 days. The base of the crater and endocervical edge became covered by columnar epithelial cells originating in endocervical crypts, while the vaginal edge re- epithelialised by an ingrowth of the surrounding squamous epithelium. Squamous metaplasia of the new columnar epithelium was a common observation as early as eight days after treatment. There was no evidence for a stromal contribution to epithelial cover.

Women's recollection of pain during and after carbon dioxide laser treatment to the uterine cervix

By use of postal questionnaires women who had undergone laser treatment to the uterine cervix without analgesia or anaesthesia were asked to comment retrospectively on their recollections of the pain that this caused. One hundred (42%) of 239 who replied had found the pain 'moderate' or 'severe', 102 (43%) thought it 'very slight' or 'mild', and 37 (15%) said they felt no pain at all. No greater sensation of pain was reported with higher intensity treatment. A total of 58 (24%) suggested that they would wish for some form of anaesthesia if they needed to have the same treatment again.

CIN and preclinical cervical carcinoma. A study of morbidity trends over a 10-year period

Between 1971 and 1980 1312 cone biopsies were performed at the Department of Gynecology and Obstetrics, Kiel. Comparing the two intervals from 1971 to 1975 and 1976 to 1980 the number of cases with dysplasia and Carcinoma in situ significantly rose in the last 5 years in patients 16-30 years of age. Amongst other reasons for this increase, on the basis of our investigation, the regular gynecological examination in combination with the prescription of the ovulation inhibitors seems to be responsible. The average age of patients (36-44 years) undergoing cone biopsy for the first time decreased in the period between 1971 and 1980 (approx. 8 years). The excision of carcinoma in situ in women under 30 years of age mostly showed margins free of pathological epithelium. With increasing age the cases of not free margins increased to 70%. For the hemostasis of the conization crater up to 1977, the conventional suture technique was applied, since 1977 cone coagulation probe according to Semm was used. In this group (1977-1980) treated with coagulation after cone biopsy, 45% of the cases with carcinoma in situ not free margins had histologically normal epithelium of the extirpated uterus. In patients with the desire for a child or in pregnant women a secondary coagulation of the wound crater is achieved to preserve the uterus.

Assessment of failures of cryosurgical treatment in cervical intraepithelial neoplasia

The overall recurrence rate in 166 patients treated with cryosurgery is 10.8%. Recurrent cervical intraepithelial neoplasia is much more common in patients with severe dysplasia. Failures are commonly due to one of four factors. First, cryosurgery is to be used only after adequate colposcopic assessment and a negative endocervical curettage. Cryosurgery is a safe, effective treatment in selected patients, but consideration of surgical management should be given in the older patient who has completed childbearing, particularly those with severe dysplasia or carcinoma in situ. A full 7-minute freeze with optimum application of the cryoprobe to the full affected surface is essential. Careful follow-up of these patients is mandatory. The majority of failures occur within the first 12 months and probably represent persistent rather than recurrent diseases.

The abnormal Pap smear--what to do next?

The patient with an abnormal Papanicolaou smear must have proper and adequate diagnostic evaluation to determine the degree of cervical abnormality. Gross clinical evaluation alone is inadequate for definitive diagnosis because cytologic screening identifies patients with preclinical disease. Outpatient diagnostic evaluation must include colposcopy, colposcopic-directed biopsies, endocervical curettage, and pelvic examination. Conization of the cervix is required whenever these techniques are unsatisfactory or are unable to rule out invasive cancer. When outpatient diagnostic procedures including cytologic analysis rule out invasive disease, one may elect cryosurgery, electrocautery, or laser in treating cervical intraepithelial neoplasia. Nevertheless, conization or hysterectomy may be inpatient treatments for selected patients.

Cryosurgery and the CO2 laser

Over the past decade, the management of intraepithelial lesions of the visible portion of the female genital tract has substantially changed with the introduction of cryosurgery and the carbon dioxide laser. Although cryosurgery and the carbon dioxide laser are very effective in eradicating preinvasive disease, the selection of patients by colposcopy and appropriate biopsies is more important than the treatment techniques. Failure to properly evaluate women with genital tract neoplasia can result in disastrous consequences for the patient. The CO2 laser shows considerable promise in managing dysplasia and carcinoma in situ of the vagina and vulva. The laser combines the accuracy of the operating microscope and the precision and control of the photon beam. Posttreatment sequelae are minimal, and scarring is absent.

The conservative management of cervical intraepithelial neoplasia: the use of cryosurgery and the carbon dioxide laser

This study comprises 336 consecutive patients of whom 283 were candidates for conservative therapy involving either cryosurgery or the carbon dioxide laser for the management of cervical intraepithelial neoplasia (CIN). A total of 152 patients were treated first in the series with cryosurgery followed by 131 patients in the laser group. Distribution of disease classification within CIN groups was similar. The overall persistent disease after one treatment was higher in the cryo group (14.5 per cent) as compared to the laser group (3.1 per cent). Of particular significance is the high percentage of failures in the cryo treated group (25.0 per cent) with CIN III disease as compared to the CIN III laser treated group (7.7 per cent). The high persistent disease rate observed in the CIN III lesions treated by cryosurgery suggests that this modality be employed with caution in this disease classification.

The carbon dioxide laser in cervical intraepithelial neoplasia: a five-year experience in treating 230 patients

Two hundred and thirty patients with cervical intraepithelial neoplasia were treated over a 5-year period with the carbon dioxide laser at the University of Kansas. Analysis of cytologic findings, biopsy results, location of the lesion, treatment factors, and recurrence rates are reported. Ninety percent of the patients were cytologically free of intraepithelial neoplasia at the end of the study.

Vaginal intraepithelial neoplasia: Biologic aspects and treatment with topical 5-fluorouracil and the carbon dioxide laser

A review of 41 evaluable patients was made in order to study vaginal intraepithelial neoplasia (VAIN) and to investigate new methods of treatment. Colposcopic examination of the vagina revealed white epithelium alone in 20 patients and white epithelium associated with vascular punctation in 15. No lesion had a vascular mosaic pattern. Most patients had multifocal disease located in the vaginal apex. Iodine staining was positive in six patients with negative colposcopic examinations. Twenty-four patients had severe dysplasia or carcinoma in situ, and 17 had minimal or moderate dyplasia. Associated genital disease occurred in 17 patients with antecedent cervical or vulvar squamous neoplasia, and six additional patients had coexistent lesions. The chronology of vaginal disease that appeared after treatment of cervical neoplasia suggests a persistent but decreasing likelihood of the development of VAIN with the passage of time. In patients followed without therapy, six had spontaneous remission of disease. Treatment was successful in 12 of 15 patients with topical 5-fluorouracil and in nine of 10 patients with the carbon dioxide laser. The advantage of these methods of treatment for patients with VAIN relative to surgical procedures and radiation therapy are considered.

High-power--density carbon dioxide laser therapy for early cervical neoplasia

A total of 115 women with various grades of CIN were treated with high-power--density, continuous time mode CO2 laser beams. During the 2-year follow-up period, residual tumor was noted in 4.34% of the treated cases. Detailed observations of the rapid healing of tissues after laser exposure were carried out in 50 women who were colposcoped every other day for 4 weeks. The CO2 laser is an acceptable instrument for use in treating early gynecologic malignancy, with its principal advantage being the precision with which it destroys tissue.