Frozen section examination of the endocervical margin of cervical conization specimens

Can we predict surgical margin positivity while performing cervical excisional procedures?

We designed this study to evaluate any factors associated with positive surgical margin in conisation specimens and to determine the optimal cone size. The medical records of patients who had undergone a loop electrosurgical excision procedure (LEEP), cold-knife conisation (CKC) and needle excision of the transformation zone (NETZ) procedure were reviewed retrospectively. Two hundred and sixty eight women fulfilled the inclusion criteria. Univariate analyses showed that 'postmenopause', 'HSIL on smear', 'previous colposcopic examination revealing HSIL in endocervical curettage (ECC) material and in two or more ectocervical quadrants' and 'managing with LEEP' were significant predictors of surgical margin positivity. Nulliparous patients showed significantly lower rate of surgical margin positivity. 'Postmenopause', 'previous colposcopic examination revealing HSIL in ECC material and in two or more ectocervical quadrants' and 'HSIL on smear' were identified as independent predictors of surgical margin positivity according to multivariate analyses.IMPACT STATEMENTWhat is already known on this subject? Previous studies demonstrated 'menopause', 'Age ≥50', 'managing with LEEP', 'disease involving >2/3 of cervix at visual inspection', 'training level of the surgeon', 'cytology squamous cell carcinoma' and 'mean cone height' as factors associated with positive surgical margin in conisation specimens.What do the results of this study add? In our study, univariate analyses showed that 'postmenopause', 'HSIL on smear', 'previous colposcopic examination revealing HSIL in endocervical curettage material and in two or more ectocervical quadrants' and 'managing with LEEP' were associated with surgical margin positivity. On the other hand, nulliparous women showed significantly lower rate of surgical margin positivity compared with parous women. Multivariate analyses showed that 'postmenopause', 'previous colposcopic examination revealing HSIL in endocervical curettage material and in two or more ectocervical quadrants' and 'HSIL on smear' were independent predictors of surgical margin positivity in conisation specimens.What are the implications of these findings for clinical practice and/or further research? We can predict high-risk patients with regard to surgical margin positivity. Prediction of high-risk patients and management with a tailored approach may help minimise surgical margin positivity rates.

Utility of conization with frozen section for intraoperative triage prior to definitive hysterectomy

OBJECTIVE

To review our experience with conization with intraoperative frozen section analysis and to compare results from our tertiary cancer center with those from 2 community hospitals.

METHODS

The records of all women who underwent conization with intraoperative frozen section analysis from January 1, 1997, through April 30, 2011, at The University of Texas MD Anderson Cancer Center and 2 community hospitals-The Woman's Hospital of Texas and St. Luke's Episcopal Hospital-were reviewed. Findings on pathologic analysis of frozen sections, permanent loop electrosurgical excisional procedure/conization specimens, and hysterectomy specimens were compared for each patient, and the results from the cancer center were compared to those from the community hospitals.

RESULTS

One hundred fifty-three patients met the inclusion criteria. Rates of accuracy of conization with frozen section analysis in predicting definitive pathologic findings were as follows: cervix with no residual disease after prior extirpative procedure, 96.5% (95% CI 86.9-100%); cervical squamous carcinoma in situ, 95.4% (95% CI 84.5-100%); cervical adenocarcinoma in situ, 98.7% (95% CI 92.7-100%); microinvasive carcinoma, 97.4% (95% CI 90.1-100%); and invasive carcinoma≥3 mm, 100%. Most importantly, conization with frozen section analysis was 100% accurate for triaging patients to simple or radical hysterectomy. Finally, this approach performed equally well in the cancer center with subspecialized pathologists and the 2 community hospitals with general pathologists.

CONCLUSION

Conization with frozen section analysis is an effective technique for intraoperative triage of patients to immediate simple or radical hysterectomy and can be accurately performed in both academic and community hospitals.

The value of frozen sectioning for the evaluation of resection margins in cases of conization

OBJECTIVES

To determine the role of frozen section examination (FSE) of the cone specimen in the evaluation of the resection margin status and to rule out invasion in patients with high-grade cervical intraepithelial neoplasia.

METHODS

Thirty patients with cervical intraepithelial neoplasia underwent conization followed by FSE and planned hysterectomy. The results of the definitive paraffin exam were compared with FSE.

RESULTS

In evaluation of the margins by FSE, 4 patients (13%) had positive cone margines and 26 (87%) had negative margins. The definitive of paraffin examination of margin status was concordant in all the cases. Intraoperative diagnosis of invasion was made in three cases such that all of them were invasive squamous cell carcinoma. Among the remaining 27 cases, we detected five CIN1, two CIN2 and three CIN3, so the diagnosis of the FSE was concordant with paraffin section in 26 out of 30 cases (87%). Also we detected four additional CIN (one CIN 1, two CIN2 and one CIN3) after paraffin study, whose frozen specimens were reported normal.

CONCLUSION

Frozen section examination can provide immediate and precise evaluation of the cone margin status in high-grade cervical intraepithelial neoplasia. It can identify frank invasion and permit adequate treatment in a one-stage procedure and reliably detect clear resection margins.

Conservative treatment of cervical intraepithelial neoplasia using a cold-knife section technique

OBJECTIVE

The purpose of this study was to evaluate a conservative cold-knife section technique for treatment of cervical intraepithelial neoplasia (CIN). This procedure can be adapted to patient age, preservation of childbearing potential and extent of dysplasia.

DESIGN

Prospective study.

SETTING

Gynecological Oncology Department in French Public Hospital.

POPULATION

A total of 460 women treated for CIN between 1985 and 1999 were included.

METHODS

A conservative cold-knife cervical section followed by blanket suture reconstruction was used in all cases.

MAIN OUTCOME MEASURES

Immediate operative results, recurrence and reproductive function were assessed.

RESULTS

The mean length of the cervical specimen was 11.4 mm (range, 4-22 mm). Mean specimen thickness was strongly correlated with age: 10.6 +/- 4.1 mm in women <40 years versus 12.1 in women >40 years; p < 0.001. Complete excision was achieved in 395 cases (85.8%). Post-operative bleeding was observed in 5 cases (1.1%). The mean duration of follow-up was 62 months (range, 12.3-156.5 months). Recurrences developed in 26 patients (6.6%) including CIN 1 in 9 cases, CIN 2 in 9 and CIN 3 in 8. No patient developed carcinoma. The actuarial risk of recurrence was 2.4% (+/- S.D., 0.9) at 24 months and 7.8% (+/-S.D., 1.9) at 60 months. A total of 52 pregnancies were observed in 39 patients. No case of de novo infertility was reported post-operatively. Amenorrhea was noted in 1 patient (0.1%) and dysmenorrhea in 1 patient (0.1%).

CONCLUSIONS

This conservative cold-knife section technique is effective for treatment of CIN with low morbidity and little adverse effect on childbearing potential. Exposure of the squamocolumnar junction (SCJ) greatly facilitates follow-up.

Laparoscopic modified radical hysterectomy: a strategy for a clinical dilemma

OBJECTIVE

To investigate the role of laparoscopic modified radical (type 2) hysterectomy when cervical cancer cannot be excluded or documented preoperatively.

METHODS

Between 1996 and 2004, 50 patients with cervical intraepithelial neoplasia (CIN III) or adenocarcinoma in situ (AIS) involvement of cone endocervical margins and/or endocervical curettings, who were not candidates for observation or repeat conization, underwent laparoscopy to perform a modified radical hysterectomy.

RESULTS

Forty-nine (98.0%) modified radical hysterectomies were completed laparoscopically and one (2.0%) patient required a laparotomy. Of the overall group, 35 (70.0%) had residual pathology; 26 (52.0%) were precancerous lesions, and 9 (18.0%) had invasive disease (5 adenocarcinomas, 3 squamous lesions, and 1 adenosquamous carcinoma). Of the nine with cancer, one had stage IA1 disease, three had stage IA2 disease, and five had stage IB1 disease. Five (55.6%) invasive lesions were diagnosed intraoperatively (frozen section), and a laparoscopic pelvic and lower aortic lymph node dissection was performed. The median operative time was 96 min (range 58-185), blood loss 100 ml (50-450), and postoperative hospital stay 2.5 days (range 1-14). There were no incidences of prolonged urinary retention fistulas, or other serious complications. All patients with cancer remain disease-free (median follow-up 44.2 months, range 1-88.7 months).

CONCLUSIONS

Laparoscopic modified radical hysterectomy is a treatment option for patients for whom cervical cancer cannot be definitively excluded, and can be completed with acceptable operative time, blood loss, and hospitalization.