Conization Using Electrosurgical Conization and Cold Coagulation for International Federation of Gynecology and Obstetrics Stage IA1 Squamous Cell Carcinomas of the Uterine Cervix

Post-Conization FIGO stage IA1 squamous cell cervical carcinoma; is hysterectomy necessary?

OBJECTIVE

To compare and evaluate the results and suitability of two different approaches to the treatment of post-conization International Federation of Gynaecology and Obstetrics (FIGO) stage IA1 cervical carcinoma: a more radical approach, directly scheduling a second surgery versus a more conservative one, which consists of performing a cotest (PAP plus HPV-test) in a follow-up visit and deciding whether to apply a second surgery on the basis of the results.

STUDY DESIGN

Retrospective descriptive study including 144 cases of stage IA1 cervical carcinoma diagnosed after a loop electrosurgical excisional procedure (conization), between 1987 and 2019 in the Mother-and-Child University Hospital of Gran Canaria (Spain). Selected patients were split into two groups for analysis: patients directly undergoing a second surgical intervention (hysterectomy or re-conization) after diagnosis and patients who were followed-up before making a decision whether to schedule a second surgery or continue to follow-up.

RESULTS

75% of women directly receiving a second surgical intervention (no post-conization follow-up) underwent hysterectomy, while 25% underwent re-conization. Histological outcomes from hysterectomized patients showed 65% negative results for intraepithelial lesions, 9% low-grade squamous intraepithelial lesions (LSIL), 16% high-grade squamous intraepithelial lesions (HSIL) and only 10.5% confirmed invasive lesions: hysterectomy complication rate was 7%. Histological studies from women subjected to re-conization showed 32% negative results, 37% LSIL, 5% HSIL and 26% malignancy. In the group of patients who were followed-up after diagnosis, 8.8% needed a second intervention; none of them showed negative histological results, while 100% hysterectomized and 25% patients with re-conization showed HSIL. No unnecessary hysterectomy procedures were conducted in this group. HPV-16 was the most common genotype in both groups.

CONCLUSION

Conization proved to be a suitable alternative to hysterectomy as a treatment for post-conization stage IA1 cervical cancer. Our results showed that 65% hysterectomy procedures conducted without previously monitoring for residual disease corresponded to negative results and were therefore, unnecessary. We conclude that confirmation of the presence of residual disease by using cotest is essential to make a decision on further treatment and that a conservative management is often possible and, in our opinion, preferable.

The oncological and obstetric outcomes of cervical squamous cell carcinoma at stage IA1 managed with the loop electrosurgical excision procedure

OBJECTIVE

To evaluate the efficacy and superiority of loop electrosurgical excision procedure (LEEP) in managing stage IA1 cervical microinvasive squamous cell carcinoma (MISCC) without lymph-vascular space invasion (LVSI).

MATERIALS AND METHODS

The oncological and reproductive outcomes of a series of patients affected by stage IA1 MISCC without LVSI, initially treated by LEEP between February 2006 and December 2017, were retrospectively reviewed.

RESULTS

Ultimately, 109 patients were included. The mean age at diagnosis was 35.4 years old, and 36 patients were nulliparous. Multifocal lesions were identified in 15 patients (13.8%). The mean cone depth was 17.4 mm. Resection margins were positive/unevaluable and negative in 26 (23.9%) and 83 (76.1%) cases, respectively. Among cases undergoing salvage treatments, the residual disease rate for patients with positive/unevaluable margins was significantly higher than those with negative margins (P = 0.003). During the follow-up period of 43.0 ± 28.9 months, no relapse was identified. Fifteen of 20 patients (75.0%) conceived successfully, with a full-term live birth rate of 93.3%.

CONCLUSIONS

For stage IA1 MISCC without LVSI unexpectedly found in a loop excision, initial LEEP with clear margin is efficient and adequate. For cases with multifocal MISCC, or for those young patients who wish to become pregnant in the future, LEEP is the optimal choice.

Fertility-Sparing Surgery in Gynecologic Cancer: A Systematic Review

Fertility-sparing surgery (FSS) is increasingly being offered to women with a gynecological malignancy who wish to preserve fertility. In this systematic review, we evaluate the best evidence currently available on oncological and reproductive outcome after FSS for early stage cervical cancer, epithelial ovarian cancer, and endometrial cancer. An extensive literature search was conducted using the electronic databases Medline (OVID), Embase, and Cochrane Library to identify eligible studies published up to December 2020. In total, 153 studies were included with 7544, 3944, and 1229 patients who underwent FSS for cervical, ovarian, and endometrial cancer, respectively. We assessed the different FSS techniques that are available to preserve fertility, i.e., omitting removal of the uterine body and preserving at least one ovary. Overall, recurrence rates after FSS are reassuring and therefore, these conservative procedures seem oncologically safe in the current selection of patients with low-stage and low-grade disease. However, generalized conclusions should be made with caution due to the methodology of available studies, i.e., mostly retrospective cohort studies with a heterogeneous patient population, inducing selection bias. Moreover, about half of patients do not pursue pregnancy despite FSS and the reasons for these decisions have not yet been well studied. International collaboration will facilitate the collection of solid evidence on FSS and the related decision-making process to optimize patient selection and counseling.

Oncologic and obstetric outcomes after conization for adenocarcinoma in situ or stage IA1 cervical cancer

This study aims to reveal the risk factors associated with recurrence or new-onset high-grade squamous intraepithelial lesions (HSILs) or more severe lesions (HSILs +) and analyze obstetrical outcomes in patients with adenocarcinoma in situ (AIS) or stage IA1 cervical cancer patients after conization. A retrospective cohort study was developed from January 1, 2002, and July 1, 2018, in a single center, where all patients with AIS or stage IA1 cervical cancer who accepted conization for primary surgery were reviewed and followed up until July 1, 2019, for the pathological findings of HSILs + and obstetric outcomes. Two hundred and seventeen patients were identified, including 114 cases of AIS, 76 cases of stage IA1 squamous cell carcinoma (SCC) and 27 cases of stage IA1 adenocarcinoma (ADC). A total of 88 (40.6%) patients had an intact uterus without radiotherapy. Five patients experienced HSIL+ recurrence. The cumulative 3-, 5- and 10-year incidence rates of HSILs + were 1.0%, 1.5% and 2.0%, respectively. No significant risk factors, including primary disease, margin status and hysterectomy, were associated with recurrence. Twenty (66.7%) of 30 patients who attempted pregnancy had 23 successful pregnancies, which result in 7 miscarriages, 16 live births and 5 preterm births. Age at conization was the only independent risk factor associated with pregnancy, live births and preterm births. In conclusion, conization is safe for young women with AIS, stage IA1 SCC and ADC who desire future fertility, and the associated HSIL recurrence rate is low. Increased age significantly lowered the conception or live birth rate.

Loop electrosurgical excision procedure combined with cold coagulation for cervical intraepithelial neoplasia and adenocarcinoma in-situ: a feasible treatment with a low risk of residual/recurrent disease

Objective

This study was performed to evaluate the significance of positive resection margins (RMs) with the loop electrosurgical excision procedure combined with cold coagulation (LEEP with CC) as a definitive treatment for patients with cervical intraepithelial neoplasia (CIN) and adenocarcinoma in-situ.

Methods

We retrospectively reviewed 467 patients who underwent LEEP with CC. A right-angled triangular loop in a single pass followed by a CC (120 °C) to the cone bed for 10 to 20 s was used. Pathology reports and clinical data were obtained and evaluated.

Results

Histopathology evaluation of LEEP tissue samples revealed the presence of CIN 1 in 69, CIN 2/3 in 366, AIS in 5 and invasive carcinoma in 16 (microinvasive squamous cell carcinoma (SCC) and invasive SCC, 13 and 3) patients. Margins were positive in 66 (14.5%) cases: 0 in CIN 1, 54 in CIN 2/3 (12.4%), 1 in AIS (20.0%) and 11 in microinvasive/invasive SCC (68.8%). Although 54 CIN2/3 patients with positive RMs did not undergo additional treatment, 1 of these (1.9%) was confirmed to have residual CIN3 at the first follow-up. Two of 8 (25.0%) microinvasive SCC patients with positive RMs were confirmed to have residual diseases (1 microinvasive SCC and 1 invasive SCC) after hysterectomy. Four out of 360 (1 positive RM, 3 negative RM) CIN cases recurred during the study period.

Conclusions

These results suggest that CIN patients with positive RMs after LEEP with CC may be followed up without additional treatment.

The effects of different instruments and suture methods of conization for cervical lesions

This study is to compare the surgical outcomes of patients undergoing cold knife conization (CKC) versus electrosurgical conization (ESC). Among 10,086 patients in a single center admitted between January 2000 and January 2019, CKS or ESC was used for grade 3 cervical intraepithelial neoplasia (CIN3) or more severe lesions. Modified Sturmdorf or Figure-of-eight sutures were applied after conization. A regression model was used to determine the risk factors for margin involvement and short-term post-operative complications. In total, 7275 (72.1%) and 2811 (27.9%) patients underwent CKC and ESC, respectively. Women who underwent ESC were older and had a higher risk of margin involvement and endocervical glandular involvement than those who underwent CKC in univariate analysis. However, in the multivariate analysis, age (odds ratio [OR] 1.032, 95% confidence interval [95% CI] 1.025–1.038) and glandular involvement (OR 2.196, 95% CI 1.915–2.517) were the independent risk factors associated with margin involvement, but the incision methods used caused no significant difference. Modified Sturmdorf sutures and Figure-of-eight sutures were applied in 3520 (34.9%) and 6566 (65.1%) patients, respectively. The modified Sturmdorf sutures was the only risk factor associated with wound hemorrhage (OR 1.852, 95% CI 1.111–3.085) after adjusted with other epidemiological and surgical factors. Various incision or suture methods had similar risk of cervical stenosis. Therefore, ESC is an acceptable alternative to CKC for the diagnosis and treatment of cervical lesions regarding the pathologic accuracy and integrity, and short-term safety. Modified Sturmdorf sutures increased the risk of wound hemorrhage compared with Figure-of-eight sutures.

Worthy of further consideration: An updated meta-analysis to address the feasibility, acceptability, safety and efficacy of thermal ablation in the treatment of cervical cancer precursor lesions

Treatment of preinvasive lesions is critical to the success of secondary prevention of cervical cancer. In many settings, however, excision or ablation of preinvasive lesions can prove challenging. Thermal ablation (TA) is a form of treatment for cervical precancer that may present fewer logistical challenges in resource limited settings. In 2013, Dolman and colleagues wrote a meta-analysis of publications reporting cure rates from TA. This included only one article from a low or middle-income country (LMIC). We updated Dolman's meta-analysis to include more recent articles from LMICs. A formal review of the world literature was performed for the years 2014-2017. Article titles and abstracts were reviewed for relevance; full articles were assessed for quality. The primary endpoint was treatment outcome for cervical intraepithelial neoplasia grade 2 or higher (CIN2+). The I2 statistic was used to assess heterogeneity between studies. Studies were stratified by geographic region, decade that the study was published, World Bank economic classification of the country where the study was performed, and other factors. We reviewed 34 total reports and included 23 in our meta-analysis, including 10,995 and 6371 patients, respectively. A total of 7 studies were performed in LMICs, including 6 studies included in the meta-analysis. The overall response rate for TA treatment of biopsy proven CIN2+ was 93.8%. Consistent with the wide variety of settings and patient populations, there was significant heterogeneity between studies. TA appears to be an effective treatment for CIN2+ across a variety of settings, including in LMICs.

Oncologic and obstetrical outcomes with fertility-sparing treatment of cervical cancer: a systematic review and meta-analysis

OBJECTIVE

The objectives of this study were to evaluate the rates of recurrence, survival and pregnancy, and characterize pregnancy outcomes of early-stage cervical cancer(eCC) treated with fertility-sparing methods such as cervical conization (CON) and radical trachelectomy(RT) with or without pelvic lymphadenectomy.

STUDY DESIGN

This was a meta-analysis of observational studies analyzed by a random-effects model and a meta-regression to assess heterogeneity.

RESULTS

Sixty observational studies encompassing 2,854 patients were included; 17 of which evaluated CON and 43 RT. Three hundred and seventy-five patients were included in the CON group: 176(46.9%) stage IA1 and 167(44.5%) stage IB1. In the RT group, 2479 cases were included: 143(6.0%) stage IA1, 299(12.1%) stage IA2, 1987(79.9%) stage IB1. CON was performed in 347(92.5%) cases, resulting in a recurrence rate of 0.4%(95%CI: 0.0%-1.4%), a death rate of 0%(0%-0%), a pregnancy rate of 36.1%(26.4%-46.2%), a spontaneous abortion rate of 14.8%(9.3%-21.2%) and a preterm delivery rate of 6.8%(1.5%-15.5%). For the RT group, 2273(91.7%) underwent successful surgeries with a recurrence rate of 2.3%(1.3%-3.4%),a death rate of 0.7%(0.3%-1.1%), a pregnancy rate of 20.5%(16.8%-24.5%), a spontaneous abortion rate of 24.0%(18.8%-29.6%) and a preterm delivery rate of 26.6%(19.6%-34.2%). From a subgroup analysis, the recurrence rates for stage IA tumors treated with CON and RT were 0.4%(0.0%-1.9%) and 0.7%(0.0%-2.3%), respectively; and for stage IB were 0.6%(0.0%-2.7%) and 2.3%(0.9%-4.1%).

CONCLUSION

Fertility-sparing treatment including CON or RT for eCC is feasible and carefully selected women can preserve fertility and achieve pregnancy resulting in live births. CON seems to result in better pregnancy outcomes than RT with similar rates of recurrence and mortality.

Conservative treatment of coexisting microinvasive squamous and adenocarcinoma of the cervix: report of two cases and literature review

Coexistence of microinvasive squamous cell carcinoma (MISCC) and microinvasive adenocarcinoma (MIAC) of the cervix is a rare phenomenon with very few clinically significant cases described in the literature. While a conservative approach has been studied, and may be effective in MISCC, a lower number of studies that recommend conservative treatment are available for MIAC. We report two cases of synchronous cervix lesions in two separate foci, MISCC and MIAC, who underwent fertility-sparing treatment with long-term follow-up. We describe clinical, histological, and immunohistochemical features of the two cases. The first case is a 41-year-old female with a diagnosis of MIAC of endocervical type, grade 1 differentiation, with a stromal invasion, associated with a separate area of squamous cell carcinoma (International Federation of Gynecology and Obstetrics/TNM stage: pT1a1G1). The second case is a 45-year-old female with a diagnosis of plurifocal MISCC, associated with an MIAC of endocervical type with a stromal invasion (International Federation of Gynecology and Obstetrics/TNM stage: pT1a1G1). After multidisciplinary counseling, both patients accepted conization as definitive treatment. Eleven years after the conization, all tests (Papanicolaou smear, colposcopy, cervical curettage, and hybrid capture 2-human papillomavirus test) planned quarterly in the first year and every 6 months in the subsequent years were negative in both patients. In women affected by stage IA1 squamous cervical cancer coexisting with stage IA1 adenocarcinoma endocervical type, with clear margins, and without lymphovascular space invasion, cervical conization may be considered a fertility-preserving, safe, and definitive therapeutic option.

The effect of coexisting squamous cell lesions on prognosis in patients with cervical adenocarcinoma in situ

OBJECTIVE

The aim of this study was to assess the relative incidences of cervical adenocarcinoma in situ (AIS) and squamous cell carcinoma in situ (sCIS) and to determine the effect of coexisting squamous cell lesions on prognosis in patients with cervical AIS.

STUDY DESIGN

We performed a retrospective review of patients diagnosed with AIS or sCIS who underwent cervical conization at a University hospital between 2000 and 2011.

RESULTS

A total of 1184 patients with cervical carcinoma in situ were included. The ratio of sCIS to AIS was 16:1. Among 71 patients with AIS, AIS with coexisting squamous cell lesions and AIS alone were detected in 41 patients (58%) and 30 patients (42%), respectively. During the median follow-up of 57.1 months, 5 episodes of AIS recurrences and one episode of invasive recurrence occurred. The recurrence rate was significantly higher in patients with AIS alone than in patients with AIS and coexisting squamous cell lesions (17% versus 2%; P=0.043).

CONCLUSION

These results suggest that patients with cervical AIS and coexisting squamous cell lesions have a more favorable prognosis than patients with AIS alone.

Management of stage Ia1 squamous cervical cancer and the importance of excision margins: a retrospective study of long-term outcome after 25 years of follow-up

OBJECTIVE

The aim of this study was to assess the effect of the excision margin after cone for stage Ia1 cervical cancer on long-term outcomes.

STUDY DESIGN

Retrospective observational study. Patients were divided into 3 groups. Group A underwent immediate reflex hysterectomy; group B had cervical intraepithelial neoplasia (CIN) at the margins but were followed up; group C had clear margins.

RESULTS

We identified 111 women: 19 (17.1%) in group A; 29 (26.1%) in group B; and 63 (56.8%) in group C. Women in group A were older (median, 40 years vs 35 years; P = .0001) with higher rate of endocervical margin involvement (89.5 vs 48.1%, P = .007) than in group B. The women had been followed for a total of 960 woman-years with median follow-up of 398 weeks (quartiles: 258,612). Women with clear margins in the initial excision were more likely to remain free of disease than those with involved (P < .0001). Further surgery was required due to abnormal cytology in 9 (31.0%) women from group B and 7 (11.1%) from group C (P = .04). The cumulative rate of recurrent CIN2+ was 6.4% in group B and 2.7% in group C (P = .17). In group B, recurrences were more common in positive endocervical rather than ectocervical margins (66.6% vs 33.4%, P < .05); all had high-grade CIN at the margins.

CONCLUSION

The risk of posttreatment CIN2+ is substantially reduced when complete excision is achieved at first treatment. Conservative management is contraindicated in women with microinvasion at the margin. When CIN involves the margin, there is a greater risk of residual disease and of further treatment.

Safety of less aggressive surgery for stage IA1 squamous cell carcinoma of the cervix

AIM

To determine the risk of extracervical disease in patients with stage IA1 squamous cell carcinoma of the cervix.

METHODS

A retrospective analysis was performed of 169 patients who had stage IA1 cervical cancer after conization at Seoul National University Hospital between 1997 and 2007.

RESULTS

During the study period, 18 patients had conization as a definite treatment and 151 underwent subsequent surgery ranging from simple hysterectomy to radical hysterectomy with lymphadenectomy. Of the 151 patients who underwent subsequent surgery following conization, 35 (23.3%) patients underwent a simple hysterectomy, 20 (13.1%) a simple hysterectomy with pelvic lymphadenectomy and 96 (63.6%) radical surgery with lymphadenectomy. No parametrial involvement or lymph node metastasis was noted in any of the patients who underwent parametrial resection and/or lymphadenectomy. Of the 62 patients who had negative resection margins in conization specimens, only one presented with residual tumor in subsequent surgery. One recurrence of the disease was identified in the total sample (169 patients) with a median follow-up time of 99 months.

CONCLUSION

The risk of extracervical disease following conization is negligible, even for patients with positive resection margins in conization specimens. A more conservative and less aggressive approach may be possible for this patient subset.

Meta-analysis of the efficacy of cold coagulation as a treatment method for cervical intraepithelial neoplasia: a systematic review

BACKGROUND

Cold coagulation is an ablative method for treatment of cervical intraepithelial neoplasia (CIN). Despite reports of efficacy against all grades of CIN (CIN1-3), cold coagulation has been infrequently used since the 1980s, and was absent from the recent Cochrane review on CIN treatment.

OBJECTIVES

To provide a systematic review of cold coagulation efficacy and acceptability for CIN treatment through meta-analysis of clinical reports and a randomised control trial.

SEARCH STRATEGY

A literature search in PubMed, Web of Science, EMBASE, and regional databases yielded 388 papers. Title, abstract and/or reference list review identified 22 papers describing cold coagulation treatment of CIN, with 13 providing adequate data for inclusion in the meta-analysis.

SELECTION CRITERIA

Publications or conference abstracts describing original data (number of women treated, followed up and cured, provider type, cure definition) were retained. No language or publication date limitations were imposed.

DATA COLLECTION AND ANALYSIS

Data extracted from 13 studies were pooled, and statistical analyses of proportion cured were conducted with data stratified by lesion grade and study region.

MAIN RESULTS

Among 4569 CIN patients treated with cold coagulation, summary proportion cured of 96% [95% confidence interval (CI) 92-99%] and 95% (92-98%) were obtained for CIN1 and CIN2-3 disease, respectively. Side-effects and adverse effects were infrequent, and fertility was not impaired.

CONCLUSIONS

Cold coagulation CIN cure rates were comparable to those of other excisional and ablative methods. Cold coagulation is indicated for all grades of CIN, is safe, quick and acceptable, and may be of particular relevance for use in resource-limited settings.

The role of prophylactic cerclage in preventing preterm delivery after electrosurgical conization

OBJECTIVE

To evaluate pregnancy outcomes after electrosurgical conization.

METHODS

We retrospectively analyzed the outcomes of 56 singleton pregnancies after electrosurgical conization of the uterine cervix. Of the 56 cases, 25 women underwent prophylactic cerclage with McDonald procedure (cerclage group), and 31 were managed expectantly (expectant group). Pregnancy outcomes including rate of preterm delivery were compared, and the effect of potential risk factors such as depth of cone, interval between conization and pregnancy, and cervical length on the risk of preterm delivery was assessed.

RESULTS

The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization than those without (32.1% vs. 15.2%, p<0.001). However, preterm delivery rate was not different between the two groups (expectant group vs. cerclage group; <28 week, 6.5% vs. 8.0%, p=1.000; <34 week, 19.4% vs. 20.0%, p=1.000; <37 week, 29.0% vs. 36.0%, p=0.579). All obstetric and neonatal outcomes were similar in the two groups. Even when we confined the study subjects to 19 women (19/56, 33.9%) with cervical length less than 25 mm, the preterm delivery rate also was not significantly different between the expectant (n=7) and cerclage group (n=12). Finally, the potential risk factors for preterm delivery were not associated with risk of preterm delivery in patients with a history of electrosurgical conization.

CONCLUSION

The rate of preterm delivery was significantly higher in women with a history of electrosurgical conization before pregnancy. However, prophylactic cervical cerclage did not prevent preterm delivery in these patients.

Fertility-conserving surgery for young women with stage IA1 cervical cancer: safety and access

OBJECTIVE

To estimate the safety of fertility-conserving surgery for stage IA1 cervical cancer and to analyze predictors of access to conization.

METHODS

We analyzed women with stage IA1 cervical cancer aged 40 years or younger who were diagnosed between 1988 and 2005 and recorded in the Surveillance, Epidemiology, and End Results database. The outcomes of hysterectomy were compared with fertility-conserving conization. Clinical and demographic characteristics were compared using chi2. Multivariable logistic regression models were constructed to examine predictors of conization. Survival was examined using multivariable Cox proportional hazards models and the Kaplan-Meier method.

RESULTS

A total of 1,409 patients were identified, including 841 (60%) who underwent hysterectomy and 568 (40%) who underwent conization. In a multivariable logistic regression of factors associated with conization, Asian patients, single women, those diagnosed in the later years of the study, and those residing in the eastern United States were more likely to have fertility-conserving surgery. Compared with women younger than 30 years, those older than 35 years were 78% (odds ratio 0.22, 95% confidence interval [CI] 0.16-0.30) less likely to undergo conization. In a Cox proportional hazards model accounting for other prognostic variables, there was no difference in survival (hazard ratio 0.65, 95% CI 0.23-1.47) between conization and hysterectomy. Five-year survival for women who underwent conization was 98% (95% CI 96-99%), compared with 99% (95% CI 97-99%) for those treated with hysterectomy.

CONCLUSION

Fertility-conserving surgery is safe for young women with stage IA1 squamous cell carcinoma of the cervix. Young women with microinvasive cervical tumors should weigh the risks and benefits of conization in the context of individual preferences and tumor characteristics.