The treatment of cervical intraepithelial neoplasia by laser vaporization

Investigation of the efficiency and stability of a novel visualized lattice CO2 laser-based gynecological therapeutic apparatus for the treatment of cervical diseases in rhesus monkeys

The fractional CO₂ laser is a type of ablative laser. In this study, a novel fractional CO₂ laser therapeutic apparatus was developed for cervical diseases. To compare the depth and diameter of penetration as well as the stability of a novel laser against a control laser emitting at the same wavelength, we tested this using a rhesus monkey model. The cervixes of rhesus monkeys were irradiated with the novel CO₂ laser. The effects of irradiation were assessed by measuring the depths and diameters of the holes created by the laser. In addition, the depths and diameters of the holes were compared between the novel CO₂ laser-based gynecological therapeutic apparatus and the conventional CO₂ laser-based therapeutic apparatus. When operated under the single spot mode and at the same energy level, the novel CO₂ laser-based gynecological therapeutic apparatus created holes that could reach the greater depth. In addition, the laser spot size of the new apparatus was more constant. Moreover, there were no significant differences in the side effects between the new apparatus and the conventional apparatus. The results indicate that the novel CO₂ laser-based gynecological therapeutic apparatus exhibits better stability in comparison to the conventional CO₂ laser-based therapeutic apparatus.

Prognostic outcomes and risk factors for recurrence after laser vaporization for cervical intraepithelial neoplasia: a single-center retrospective study

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is a precancerous lesion that may progress to invasive cervical cancer without intervention. We aim to examine the prognostic outcomes and risk factors for recurrence after laser vaporization for CIN 3, CIN 2 with high-risk human papillomavirus (HPV) infection, and CIN 1 persisting for more than 2 years.

METHODS

Between 2008 and 2016, a total of 1070 patients underwent cervical laser vaporization using a carbon dioxide laser. We performed a retrospective review of their medical records to assess their clinical characteristics, pathologic factors, and prognostic outcomes.

RESULTS

The mean patient age was 34 years (range 18-64 years). The preoperative diagnosis was CIN 1 in 27 patients, CIN 2 in 485 patients, and CIN 3 in 558 patients. Over a median follow-up period of 15 months, the 2-year recurrence rate was 18.9%, and the 5-year recurrence rate was 46.5%. The 2-year retreatment rate was 12.6%, and the 5-year retreatment rate was 30.5%. We diagnosed 9 patients with invasive cancer after treatment; all patients underwent combined multidisciplinary treatment, and there were no deaths during follow-up. The recurrence-free interval was correlated with patient age (hazard ratio [HR], 1.028; 95% CI 1.005-1.051; P = 0.0167), body mass index (HR, 1.052; 95% CI 1.008-1.098; P = 0.0191), and glandular involvement (HR, 1.962; 95% CI 1.353-2.846; P = 0.0004).

CONCLUSIONS

Cervical laser vaporization is effective and useful for patients with CIN who wish to preserve fertility. However, patients with glandular involvement, older age, and higher body weight require close follow-up for recurrence.

Laser technologies in treatment of cervical intraepithelial neoplasia (review)

This review article discusses the key aspects of the use of laser technologies, namely, laser vaporization (LV) and photodynamic therapy (PDT), in the treatment of patients with cervical intraepithelial neoplasia (CIN). The authors analyzed and systematized the foreign experience of these methods of treatment, their indications and contraindications, as well as the advantages over traditional approaches to the treatment of this pathology. The main advantages of the LV are the possibility of complete evaporation of the pathological focus, visual control over the depth of tissue destruction, the absence of prolonged edema and cicatricial deformities, which allows maintaining the integrity of the cervix and its reproductive function. Despite the low trauma and low frequency of adverse reactions, the data on the effectiveness of LV are quite contradictory and, according to various authors, vary from 50% to 98%. To date, there is a significant amount of accumulated experience in the use of PDT with various photosensitizing agents (5-aminolevulinic acid (5-ALA), hematoporphyrin and chlorin and their derivatives) in the treatment of patients with CIN. The main advantages of the PDT are minimal toxicity to the surrounding normal tissues due to the selective accumulation of photosensitizer in pathological tissues, a low risk of severe pain syndrome, the absence of mechanisms of primary and acquired resistance, the possibility of an outpatient treatment session, the possibility of combining with other methods of therapeutic action, the absence of limiting cumulative doses of photosensitizers and light exposure, the possibility of multiple repetitions of the session, good cosmetic results and the possibility of implementing an organ-preserving method of treatment. The obtained results indicate good tolerability of the method (no severe adverse reactions) and a fairly high efficiency of PDT: the frequency of complete regressions varies from 30% to 67% - for application forms of 5-ALA and from 90% to 98.1% - for hematoporifirin and chlorin photosensitizers. Thus, LV and PDT can be considered safe and effective treatment options for patients with CIN.

Efficacy of 5-aminolevulinic acid and LED photodynamic therapy in cervical intraepithelial neoplasia: A clinical trial

BACKGROUND

5-Aminolaevulinic acid (5ALA) is a precursor of the strong sensitizer protoporphyrin IX (PpIX) in the heme synthesis pathway. We conducted aclinical trial designed to evaluate the efficacy and safety of 5ALA photodynamic therapy (PDT) using a light-emitting diode (LED) in patients with cervical intraepithelial neoplasia (CIN).

METHODS

Data for 51 CIN patients who underwent 5ALA-PDT between 2012 and 2017 were prospectively analysed. After a 20 % 5ALA jelly formulation was topically applied to the cervix, the region was irradiated with red light at approximately 633 nm to excite PpIX for treatment. We estimated outcomes by cytology, pathology, and human papilloma virus (HPV) testing after PDT.

RESULTS

Patients underwent two PDT sessions at one-week intervals during outpatient treatment and achieved favourable results without photosensitivity and severe adverse events. Over a long follow-up period, 96.1 % of all patients showed some positive effects, including approximately 70 % with a complete response (CR), 10 % with a partial response, and 15 % with downgrades. The HPV clearance rate in patients with CR was 79.4 %. Recurrence occurred in five patients who mostly remained HPV-positive after PDT.

CONCLUSIONS

Based on our study, topical 5ALA-PDT using an LED light source potentially represents a safe treatment for CIN on an outpatient basis.

Cervical laser vaporization for women with cervical intraepithelial neoplasia-3

OBJECTIVE

This study evaluated outcomes of laser vaporization of the cervix for women with cervical intraepithelial neoplasia (CIN)-3.

METHODS

We retrospectively reviewed 161 consecutive patients with CIN3 who were treated with cervical laser vaporization between January 2008 and December 2012. At each follow-up visit, histologically confirmed CIN2, CIN3 and invasive carcinoma were defined as treatment failures, as were high-grade squamous intraepithelial lesion (HSIL) or atypical squamous cells that cannot exclude HSIL with subsequent treatment or lost to follow-up. Primary endpoints included long-term follow-up (at least 5 years of regular hospital visits) and treatment failure rate. Treatment failure rates were estimated by the Kaplan-Meier method.

RESULTS

Patients' median age was 31 years old. Median follow-up period was 67 months (interquartile range: 52-74 months). Over 5 years, 70.8% continued their follow-up visits, but significantly more patients aged ≥35 years did so (86.4%) than did those aged ≤34 years (61.8%, P = 0.0009). Treatment failure was observed in 14 (8.7%) patients, 1 of whom progressed to invasive cancer (0.6%). Cumulative treatment failure rates were 1-year: 5.1%, 2-year: 6.4% and 5-year: 9.5%. Among patients who suffered treatment failures, 57.1% initial failures occurred within the first year and 71.4% within the first 2 years.

CONCLUSIONS

Long-term oncologic outcomes of cervical vaporization in CIN3 remain at a suboptimal level. The importance of a minimum of 5 years of regular hospital visits should be emphasized to patients with CIN3 who are candidates for cervical laser vaporization, especially those aged ≤34 years.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to November 2012). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to April 2009). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

Laser CO2 vaporization for high-grade cervical intraepithelial neoplasia: a long-term follow-up series

OBJECTIVE

The goal of this study was to evaluate the effectiveness of laser CO(2) vaporization for conservative treatment of ectocervical high-grade cervical intraepithelial neoplasia (CIN) particularly by the evaluation of the reappearance risk of disease in long-term follow-up.

METHODS

One hundred fifty-nine patients were submitted to CO(2) laser vaporization for high-grade CIN and followed up for a minimum of 5 years. Selection of cases, depth of ablation, complications, and cure rate (percentage of treated patients in whom there was no recurrent/persistent high-grade CIN at the 5-year follow-up examination) were retrospectively evaluated.

RESULTS

Selected cases for colposcopy were submitted to a 6-mm mean depth of vaporization without intra- or postoperative complications. The cure rate for a single treatment was 97.5% and a satisfactory colposcopic follow-up was possible in 99.4% of treated patients. No case of invasive carcinoma occurred after a mean follow-up of 7.1 years. Four cases (2.5%) were high-grade CIN persistence observed after a mean time of 3.75 months, suggesting incomplete destruction of the deepest part of the lesion involving the glandular crypt base.

CONCLUSIONS

Long-term follow-up proves that laser CO(2) vaporization still has a place in the treatment of CIN. In selected cases it represents a safe alternative for conization in the treatment of high-grade CIN, but colposcopic expertise is essential for adequate preoperative selection of cases.

Surgery for cervical intraepithelial neoplasia

OBJECTIVES

Cervical intra-epithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the severity of the disease. The objective of this review was to assess the effects of alternative surgical treatments for cervical intra-epithelial neoplasia.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group trials register and MEDLINE up to July 1997.

SELECTION CRITERIA

Randomised and quasi-randomised trials of alternative surgical treatments in women with cervical intra-epithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and two reviewers abstracted data independently.

MAIN RESULTS

Twenty-three trials were included. Seven surgical techniques were tested in various comparisons. No significant difference in eradication of disease was shown, other than between laser ablation and loop excision. This was based on one trial where the quality of randomisation was doubtful. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology. Morbidity was lower than with laser conisation, although all five trials did not provide data for every outcome. There were not enough data to assess the effect on morbidity compared with laser ablation.

REVIEWER'S CONCLUSIONS

The evidence suggests that there is no obviously superior surgical technique for treating cervical intra-epithelial neoplasia.

Is involvement of the surgical margins of large loop excision of the cervical transformation zone specimens for cervical intraepithelial neoplasia III a risk factor for persistent cervical intraepithelial neoplasia?

We aimed to test the hypothesis that patients with cervical intraepithelial neoplasia (CIN) III treated by large loop excision of the cervical transformation zone (LLETZ) are more likely to suffer recurrence of cervical abnormalities if the CIN reaches the margins of the index specimen. Three hundred and forty-five women treated by LLETZ in 1991, and 1992, and in whom the histological diagnosis was CIN III, were studied. The reports were reviewed and the cases were categorised as completely excised, incompletely excised, or undetermined. Cytological follow-up, or in some cases histological follow-up in the same year and in each of the 5 following years was tabulated. Follow-up data were recorded from the same and also surrounding institutions. The chi-squared test was used to compare the differences in recurrence rates between the three groups at the various points in time. A small advantage was demonstrated for those cases where excision was complete. This was statistically significant in the third following year (P=0.022). The resection margin status of LLETZ specimens for CIN III has only a minor effect on the likelihood of recurrence. Nevertheless, recording the status may be important in case of unexpected invasion. The relative reassurance the information will provide when the lesion has been excised may also be seen as worthwhile.

Laser vaporization and excisional techniques in the treatment of cervical intraepithelial neoplasia

The CO2 laser proved to be a vital tool in the development of conservative therapy for the treatment of CIN in the 1980s. In conjunction with colposcopy, the laser has allowed many women to achieve the security of identified and treated CIN with the freedom to live their lives normally, including the achievement of pregnancies. The laser may be used either in the ablative (vaporization) or the cutting mode. This flexibility allows patients with unsatisfactory as well as satisfactory colposcopy to be managed. The results of treatment are universally excellent, with clearance rates of 96% being reported. Complications are rare both in the short and long term, most patients returning fully to normal activities within 4 weeks of therapy. Although the laser is being superceded to some extent by the advent of the loop diathermy technique, it will for years to come represent a valuable and useful tool in the treatment of CIN.

Decision analysis for best management of mildly dyskaryotic smear

Should a woman with a mildly dyskaryotic cervical smear be referred for colposcopy or should the smear be repeated? One way to answer this question is to use decision analysis and compare the expected mortality and cost of each policy. Data for each component of the question were obtained from published work worldwide and were supplemented with an audit of mildly dyskaryotic smears in West Yorkshire, UK. 2 out of 1000 women with an initial mildly dyskaryotic smear will develop cancer if a conservative repeat smear policy is adopted in association with five-yearly cervical screening. This number can be reduced to 1.6 per 1000 if cervical screening is offered every three years. A policy of immediate referral for colposcopy is also associated with a subsequent cancer rate of 1.6 per 1000. Therefore, repeating the smear is almost as effective as an immediate referral to a colposcopy unit. Even if a five-yearly cervical screening programme is adopted, 2500 women with a mildly dyskaryotic smear will need to be referred for immediate colposcopy to save 1 additional cancer. A conservative policy is not financially cheaper: an average of six additional smears is required to save each colposcopy referral. Sensitivity analysis shows that the excess cost of the conservative policy increases exponentially as the risk of a subsequent cytological abnormality exceeds 60%. Local cytopathology laboratories should audit their recurrent dyskaryosis rate associated with borderline, mild, and moderate dyskaryosis before accepting the U-turn in the national recommendations.

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.

Abnormal cervical cytology following large loop excision of the transformation zone: a case controlled study

OBJECTIVES

To determine factors that may predict cytological outcome at 6 months following large loop excision of transformation zone (LLETZ) for cervical intra epithelial neoplasia (CIN) and to investigate the outcome in women with continuing cytological abnormality.

DESIGN

Case controlled retrospective study.

SETTING

Dudley Road Hospital, Birmingham and Midland Hospital for Women.

SUBJECTS

Fifty-eight women with abnormal follow up cytology and a control group of 116 women.

MAIN OUTCOME MEASURES

The relation between pretreatment and treatment factors and cytological outcome, and the relation between cytology and histology in women who had biopsies for persistent abnormal cytology.

RESULTS

Univariate and stepwise logistic regression analysis showed that the number of sectors of atypical transformation zone (lesion size) and the excision margin status of the large loop excision specimen are of prognostic importance for the prediction of cytological abnormality at the 6 month follow up visit. Sixteen women have undergone further cervical biopsy. Of the five cases of persistent CIN, four had cytological changes showing moderate or severe dyskaryosis. Of the 11 women with koilocytosis or normal histology, 10 had mild dyskaryosis or borderline changes on their follow up cytology.

CONCLUSION

Lesion size and excision margin status are important correlates of follow up cytology when treating patients for CIN with LLETZ. All women with abnormal cervical cytology at follow up should undergo colposcopic assessment. Excision biopsy is indicated if follow up cytology shows moderate or severe dyskaryosis, especially if still present 12 months after treatment.

Laser excision of the transformation zone as treatment of cervical intraepithelial neoplasia with satisfactory colposcopy

A series of 123 patients with histologically confirmed cervical intraepithelial neoplasia (CIN) with satisfactory colposcopy were treated with outpatient laser excision of the transformation zone. Punch biopsy and/or endocervical curettage proved CIN III in 111 patients (90%). Histology of the laser excision specimen showed microinvasive disease in 3 patients. Operative hemorrhage occurred in 2 patients. The follow-up ranged from 12 to 59 months (median, 30 months). Four patients were found to have residual/recurrent CIN during the observation period, resulting in a cure rate of 97%. All patients with recurrence are free of disease after a second laser treatment. Only 1 patient out of 26 with involved resection margins relapsed. Laser excision of the transformation zone is proposed as a suitable replacement for laser vaporization in patients with CIN with satisfactory colposcopy, offering the major advantage of providing a histological specimen without an increase in morbidity.

Survey of colposcopy service provided by genito-urinary medicine in England and Wales

OBJECTIVE

To investigate the expansion of colposcopy services within genito-urinary medicine (GUM) in England and Wales since 1985.

DESIGN

Data collected by postal and verbal communication from 189 genito-urinary medicine clinics in England and Wales in January 1990.

SUBJECTS

Consultant and junior genito-urinary physicians practising colposcopy.

MAIN OUTCOME MEASURES

Number of clinics providing colposcopy service; indication for colposcopy, treatment facilities available, waiting lists and training opportunities, compared with that in 1985.

RESULTS

Of the 189 genito-urinary medicine clinics contacted, 60 provided a colposcopy service and 55 of these returned completed questionnaires. There has been a 67% increase in the number of colposcopies in use and over 50% of clinics have the facilities to treat cervical pathology. Waiting lists were minimal for both examination and treatment. Both men and women are examined with the colposcope for a variety of indications. At present, 52% of career grade GUM physicians practise colposcopy compared to 24% in 1985 and 94% of senior registrars compared with 42% in 1985 were in training or trained in colposcopy.

Colposcopically directed punch biopsy: a potentially misleading investigation

OBJECTIVE

To determine the relation between the histology of an initial colposcopically directed punch biopsy and a subsequent diathermy loop excision biopsy of the transformation zone, and the effect of lesion size on this relation.

DESIGN

Prospective observational study of loop diathermy excision biopsies of the cervical transformation zone.

SETTING

Academic unit colposcopy clinics at The Birmingham and Midland Hospital for Women and Dudley Road Hospital, Birmingham.

SUBJECTS

243 women managed by colposcopy and directed punch biopsy followed by loop diathermy excision.

OUTCOME MEASURES

The histology of the punch biopsy and the excised transformation zone and the size of the abnormal lesion.

RESULTS

In 132 (54%) of the 243 women the histology of the punch biopsy and loop excision specimen did not agree. In 62 (47%) of these 132 women a more severe lesion was found in the excised transformation zone, including three unsuspected adenocarcinoma in situ and one stage Ia1 cancer. In 39 (41%) of the 96 women in whom a lesion of CIN 3, or greater severity, was found in the loop excision specimen, the paired punch biopsy had suggested a lesion of lesser severity. In small area lesions, the punch biopsy was more likely to show more severe disease than the loop excision specimen (P = 0.0014).

CONCLUSIONS

The results suggest that directed punch biopsy is an inadequate endpoint by which to judge the severity of an epithelial lesion. The findings have important implications for patient management and the design of trials and cast doubt on the results of studies using punch biopsy as an endpoint.

Patient acceptability of laser and cold coagulation therapy for pre-malignant disease of the uterine cervix

OBJECTIVE

To determine patient acceptability of cold coagulation and laser treatment for cervical intraepithelial neoplasia (CIN).

DESIGN

A prospective study with alternate allocation.

SETTING

Teaching hospital in London.

SUBJECTS

155 women requiring treatment for CIN.

MAIN OUTCOME MEASURES

Time taken to complete the treatment; visual analogue scores for pain experienced, anxiety felt and acceptability of the procedure; post treatment bleeding and discharge, and follow-up smear.

RESULTS

Cold coagulation treatment was found to be quicker and less painful than laser treatment, there were no other significant differences between the two methods of treatment.

CONCLUSION

Cold coagulation is a more acceptable form of treatment for CIN than laser.

Invasive cervical cancer after laser vaporization for cervical intraepithelial neoplasia: a 10-year experience

The treatment of cervical intraepithelial neoplasia by laser vaporization has been in progress at the Birmingham and Midland Hospital for Women since September 1977. In this interval, 3182 patients have been treated. Seven women have developed invasive cancer at intervals 4-34 months postlaser. The lesions diagnosed were stage Ia (3), Ib (1), IIb (1), IIIa (1), and IV (1). These case histories are presented. On retrospective assessment, there were contraindications to local destructive treatment in six of seven cases. This series emphasizes the need for thorough evaluation of patients before embarking on local destructive treatments and emphasizes the need for careful follow-up of treated patients.

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.

Cervical intraepithelial neoplasia III treatments by carbon dioxide laser

162 women underwent one or more carbon dioxide laser conservative treatments for lesions of severe dysplasia and cervical intraepithelial neoplasia (CIN III) between 1982 and 1987. Therapy involved destruction of lesions by vaporisation in 45% of cases and excisional conisation in 55% (32% performed with a hand-held apparatus and 23% colposcopically guided). Rates of cure were, respectively, 93, 96.1 and 94.4%, with an overall rate of 2.5% for dropouts. Recurrences (rates, respectively, of 8.5, 5.8 and 5.5%) were associated with human papilloma virus in 92% of cases. The increasing numbers of very young women affected, as well as the spread of intraepithelial and condylomatous neoplastic lesions along the endocervical canal, are major reasons for the use of colposcopically guided carbon dioxide laser treatment.

Loop diathermy excision of the cervical transformation zone in patients with abnormal cervical smears

OBJECTIVE

To determine the efficacy and morbidity of fine loop diathermy excision of the cervical transformation zone as applied to the management of outpatients with abnormal cervical smears.

DESIGN

Prospective programme trial with six month follow up.

SETTING

Two hospital based colposcopy clinics.

PATIENTS

616 Patients aged 16-60 with abnormal cervical smears.

INTERVENTIONS

After colposcopic and cytological assessment excision of the cervical transformation zone by fine loop diathermy under local anaesthesia in the outpatient department.

MAIN OUTCOME MEASURES

Time to complete the treatment, immediate morbidity in terms of discomfort and bleeding, and cytological and colposcopic findings at six months.

RESULTS

Treatment was completed in a mean of 3.47 minutes (SD 1.99). Immediate morbidity was minimal, and histological specimens were adequate in over 90% of cases. Almost two thirds of patients were treated at their first visit to the clinic. 58 Patients (9.4%) failed to attend for follow up at six months and one had had a hysterectomy. Of the 557 patients who attended for colposcopic and cytological follow up at six months, 506 (91%) were normal cytologically and 19 (3.4%) had histologically confirmed persistence of cervical intraepithelial neoplasia. The overall confirmed failure rate of the technique was 4.4%.

CONCLUSION

Loop diathermy excision is an effective treatment with low morbidity and is an appropriate modality for patients with abnormal cervical smears.

Is routine colposcopic assessment necessary following laser ablation of cervical intraepithelial neoplasia?

The colposcopic and cytological findings at follow-up of 1000 women treated by laser ablation for cervical intraepithelial neoplasia or human papillomavirus infection at the Regional Department of Gynaecological Oncology, Gateshead, were reviewed. Colposcopy detected six of 27 patients with residual disease compared with cytology which was abnormal in 26 of the 27 and detected 21 as abnormal on the first visit after laser treatment. In our unit invasive disease after laser treatment was never detected solely on initial colposcopic review.

Diagnostic and treatment procedures induced by cervical cancer screening

The amount of diagnostic and treatment procedures induced by cervical cancer screening has been assessed prospectively and related to mortality reduction. Assumptions are based on data from Dutch screening programmes and on a scenario for future developments. With 5 invitations for screening, between ages 37-70 every eight years, 13 deaths are avoided per million women per screening year. Each death avoided is balanced by 2800 preventive smears, 9 women referred to a gynaecology department and 4 minor treatment procedures (conserving treatment or exconisation). 25 invitations in a life-time avoids 27 deaths per million women per screening year but with 7300 preventive smears, 22 referrals and 8 small treatment procedures. Thus intensifying screening will not only result in diminishing returns of extra screening efforts, but also in increasing risk for women to undergo unnecessary (no invasive disease or death avoided) diagnostic and treatment procedures. The balance between beneficial and adverse effects deteriorates strongly when hysterectomies play an important part in the management of cervical intraepithelial neoplasia.

The management of cervical intraepithelial neoplasia by coagulation electrodiathermy

Of 140 women with cervical intraepithelial neoplasia treated with a single application of coagulation electrodiathermy, 123 (88%) remain cytologically free of disease after a median follow-up of 3 years. The new squamocolumnar junction was colposcopically visible in 70% of the 130 patients assessed after treatment. In 15 of 17 women requiring further treatment, residual disease was suspected at the time of the first postoperative assessment. The incidence of significant morbidity following this procedure was 4%. In selected patients coagulation electrodiathermy is an effective method of treating pre-invasive disease of the cervix.