Invasive Cancer Following Conservative Therapy for Previous Cervical Intraepithelial Neoplasia

The management of genital condylomas, intraepithelial neoplasia, and vulvodynia

The natural history of HPV-related disease still is poorly understood. Screening of apparently healthy populations suggests that most HPV exposure results only in latent infection; that is, there is no active HPV DNA replication, but the HPV copy number is held at a steady state because viral replication parallels cell division. Unfortunately, knowledge of the cell-virus interaction and the host-immune response has not yet provided an effective medical therapy or a preventive vaccine. Rather, the management of HPV-induced disease remains rooted to the strategy of repeated local destruction. The physician should work methodically through a series of strategic decisions before committing to a management plan.

Invasive carcinoma of the cervix following local destructive treatment for cervical intraepithelial neoplasia

OBJECTIVE

To investigate the occurrence of invasive carcinomas following local destructive treatment for cervical intraepithelial neoplasia (CIN) and to evaluate the factors responsible.

DESIGN

A multicentre retrospective study.

SUBJECTS

Forty-nine women registered with the British Society for Colposcopy and Cervical Pathology from 24 centres throughout Great Britain between 1985 and 1992, who had been treated by local destructive methods for CIN and who subsequently developed invasive carcinoma of the cervix.

RESULTS

Of the 49 women whose details were submitted, 42 had squamous cell carcinoma, six adenosquamous carcinoma and one adenocarcinoma. Eight had microinvasive carcinomas (Stage Ia) at the time of diagnosis, 24 had Stage Ib tumours and eight Stages II to IV. Thirteen women have died. Thirty-five women had been treated by laser vaporization, ten by cold coagulator, two by diathermy and two by cryosurgery. In 19 women (39%) the diagnosis of invasive carcinoma was made on the first follow up visit or within one year of treatment. Five patients did not present with invasive disease until more than five years after treatment.

CONCLUSIONS

The data presented suggest that many, but not all, of the invasive carcinomas presenting after local destructive treatment for CIN resulted from failure to recognise early invasive disease at the time of the initial assessment. The importance of thorough evaluation before undertaking these forms of treatment is emphasised. The use of excisional procedures should further reduce the small risk of invasive carcinoma developing after treatment for CIN.

Controversies in the management of low-grade cervical intraepithelial neoplasia

During the last 30 years, there have been major changes in the methods used to diagnose and manage cervical cancer precursors. Early detection of precursors through mass cytologic screening programs and the eradication of these precursors when detected are currently the cornerstone of policies aimed at reducing cervical cancer. These policies have been successful, resulting in a marked reduction in both the number of cases and deaths from cervical cancer in North America and Western Europe. Recently, however, significant controversy has arisen over several aspects of the diagnosis and management of cervical intraepithelial neoplasia (CIN). Two of the most important of these controversies are whether all patients with low-grade CIN lesions require therapy and what is the appropriate role for the newly introduced loop electrosurgical excision procedure in managing patients with CIN. In this article, these controversies are reviewed with emphasis placed on how these controversies affect the practicing gynecologist.

Effective destruction of cervical intraepithelial neoplasia (CIN) 3 at 100 degrees C using the Semm cold coagulator: 14 years experience

A total of 1628 women with CIN 3 treated with the Semm cold coagulator between 1975 and 1989 was followed primarily by cytology. The standard suitability criteria for ablation were adhered to except that patients were treated at their first visit when the colposcopist expected that the diagnosis would be no worse than CIN 3. Overall 97% of the women were treated at their first visit. In 30 women (2%) the histology was glandular or worse than expected, but 22 of these showed no persistent cervical disease subsequently. Follow-up was achieved for 87% at 10 years. In actuarial terms the primary success rate was 95% at 1 year and 92% at 5 years, it was similar for all age groups. Repeat cold-coagulation for persistent/recurrent CIN 3 was less successful and is not advised. The outcome for 226 pregnancies established after treatment is known. The rates for miscarriage, preterm or operative delivery were not increased. Cold-coagulation of CIN 3 at 100 degrees C as performed by us is as effective as any other treatment and calls into question the need for more expensive practices.