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

Comparison of Punch Biopsy and Loop Biopsy for the Management of Severe Cervical Intraepithelial Neoplasia (CIN)

Objective

The study was undertaken for comparing the colposcopy directed punch versus loop excision biopsy technique in order to get the most précised sample for study as well as comparing the complications associated with them.

Materials and Methods

The prospective clinical study was conducted on 50 women of age group 20-80 years. Women who were found to have a Reid colposcopic index of high grade disease, low grade disease or invasive disease recognized as the patients needed biopsy. They were randomly divided into either the punch biopsy forceps group (PB group) or the round loop electrode group (LE group).

Result

The quality of tissue of the LE group was found significantly better than the tissue quality of PB group based on the size, site and tissue damaged measures. Both the groups were found to have the same cytology report as well as colposcopic diagnosis and histology reports. Mild degree of bleeding has been reported as a frequent complication in LEEP and punch biopsy. The VAS pain score associated in each procedure was found to be 2.4 and 2.8, respectively, in both groups with no significant difference.

Conclusion

The present study has concluded that the quality of tissue from the LEEP biopsy electrode was better than the punch biopsy forceps with no difference in the pain score, and it could be suggested that use of the round loop electrode in CDB provides good quality tissue to evaluate the histology.

Accuracy of colposcopy-directed biopsy in detecting early cervical neoplasia: a retrospective study

PURPOSE

Colposcopy-directed biopsy is a cornerstone method for diagnosing cervical intraepithelial neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with definitive surgery.

METHODS

The accuracy of colposcopy-directed biopsy was compared with the final histology in relation to different types of transformation zone (TZ), the patient's age, and the examiner's level of training.

RESULTS

The overall accuracy of biopsy in comparison with definitive surgery was 71.9% for all entities-benign lesions, low-grade squamous intraepithelial lesions, high-grade squamous intraepithelial lesions (HSILs), and cervical carcinoma-with an underdiagnosis rate of 11.8% and an overdiagnosis rate of 16.5%. The accuracy for detecting HSIL was 88% (401/455), with an underdiagnosis rate of 10.5% and overdiagnosis rate of 1.3%. The accuracy rates for detecting HSIL in women with TZ 1, TZ 2, or TZ 3 were 92.2, 90.5, and 76.5%, respectively. The accuracy rates for detecting HSIL in the different age groups were 93.1% (age 0-34), 83.6% (age 34-55), and 80% (age 55 or older).

CONCLUSIONS

A combination of the colposcopic findings, cytology, human papillomavirus testing, and colposcopy-directed biopsy is necessary for the correct diagnosis of HSIL. The accuracy rate depends on the TZ and the patient's age. The examiner's level of training does not have any substantial influence on the accuracy.

Quality of tissue from punch biopsy forceps vs. round loop electrode in colposcopically directed biopsy: a randomized controlled trial

Objective

To compare the quality of tissue from punch biopsy forceps (PB group) with round loop electrode (LE group) in colposcopically directed biopsy along with the evaluation of pain associated with each procedure.

Methods

Patients with abnormal cervical cytologic results and abnormal colposcopic findings were enrolled into a randomized trial into either a PB group or LE group. The quality of tissue was evaluated in regards to the size of tissue, site of tissue, and tissue damage. Each quality had 1 to 3 points and the sum of each quality contributed to the total tissue score that ranged from 3 to 9. Pain associated with each procedure was assessed by a visual analog scale (VAS). This was a clinical trial study and was registered at www.clinicaltrials.in.th (Identifier: TCTR20160404001).

Results

Ninety-six women who met all eligibility requirements were enrolled in the study. Forty-eight patients were randomly assigned to the PB group and 48 patients were randomized into the LE group. The characteristics of the patients were similar between the 2 groups with the exception of the median age. The median total tissue score was 8 points in the LE group which was more than the median of 7 points in the PB group with a statistically significant difference (p=0.014). However, the median VAS pain score in both groups was 3.4 (p=0.82).

Conclusion

The quality of cervical tissues obtained from biopsy with a round loop electrode was better than the punch biopsy forceps with no difference in the level of pain.

Hysterectomy for Treatment of CIN

The objective of this investigation was to determine the percentage of microinvasive and invasive cancers found when CIN 3 was treated by hysterectomy. The postoperative histologic findings of all patients with CIN 3 treated by conization or hysterectomy were analyzed. In 295 patients treated by conization, 14 (4.75%) microinvasive and 11 (3.73%) invasive cancers were found. Histologic analysis of 106 hysterectomy specimens revealed microinvasive carcinoma in 11 (10.38%) and invasive carcinoma in 17 (16.04%) cases. The finding of unexpected invasive cervical cancer in hysterectomy specimens seems significantly higher compared with conization. One must be cautious to avoid hysterectomy as the primary mode of treatment for women with coincident uterine pathology, postmenopausal women, or those who do not desire further reproduction. Hysterectomy as a mode of treatment for CIN 3 should be performed only if the existence of invasive cancer was excluded with certainty.

Is colposcopy needed following laser ablation for dysplasia?

AIMS

To evaluate the effectiveness of cytology and colposcopy in the follow up of women treated by laser CO(2) ablation for cervical intraepithelial neoplasia (CIN).

METHODS

A retrospective analysis of 1784 patients with CIN treated with laser CO(2) ablation from 1998 to 2003 at the Royal Women's Hospital, Melbourne. Data were collected prospectively in a computerised colposcopy database utilised in the Dysplasia Unit.

RESULTS

There was equal distribution in the study population treated for low-grade intraepithelial neoplasia (LSIL) and high-grade intraepithelial neoplasia (HSIL), with no significant age difference in both groups (mean 27.6 years). The success rate of treatment of LSIL (94%) was similar to that of HSIL (92%). Fifty-seven per cent of all failures occurred within the first year of treatment. Colposcopy was more sensitive in detecting intraepithelial neoplasia (SIL) than cytology, whereas cytology was more specific. No case of cancer was diagnosed on follow up.

CONCLUSIONS

CO(2) laser ablation was equally effective in treating different grades of CIN. There is a continuing incidence of recurrent CIN, even up to five years after initial treatment, which suggests that it is necessary for patients to adhere to long-term follow up. The combination of cytology and colposcopic assessment is essential for surveillance of SIL in the initial two years after treatment.

Loop conization for the treatment of microinvasive carcinoma of the cervix

The purpose of the study was to evaluate the specimen adequacy and diagnostic accuracy of loop conization in microinvasive carcinoma of the cervix. A retrospective study was conducted from 1997 to 2003 at the Colposcopic Clinic, Department of Gynecology and Obstetrics, Chang Gung Memorial Hospital, Taipei, Taiwan. Sixty-three consecutive patients with microinvasive carcinoma of the cervix receiving cold-knife conization (35 patients) or loop conization (28 patients) were included in the study. All patients underwent definitive hysterectomy. We reviewed the conization specimen together with the hysterectomied uterus to compare the two conization techniques with respect to the histopathologic interpretation and diagnostic accuracy. The mean depth of cone specimens was significantly less in the loop conization compared with cold-knife conization (1.65 versus 2.35 cm, P = 0.035). Regarding the application of conization, the loop conization was completed in a single slice in 27 patients (77.1%) and in multiple slices in 8 patients (22.9 %), in spite of encouragement to perform conization in a one-pass application when possible. However, the cold-knife specimens were invariably a single cone-shaped piece. As reviewed by microscopic examination, the rate of tissue transection was significantly higher in the loop group than in the cold-knife group (14.3% versus 0%, P = 0.04). Because of tissue transection and disorientation, pathologic evaluation of stromal status was inadequate in 11.4% (4/35) of the loop cones as opposed to none of the 28 cold-knife cones. After assessing the hysterectomy specimens, the clinical diagnoses in the loop group were downgraded in three patients compared with only one in the cold-knife group. Data from this investigation suggest that cervical cold-knife conization is superior to loop conization as a method to assess microinvasive cervical cancer.

Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia

Invasive cancer of the cervix after treatment for cervical intraepithelial neoplasia (CIN) is becoming more important, as screening reduces the incidence of invasive disease. The rate of invasive cervical or vaginal cancer following treatment for CIN in UK remains elevated for at least 8 years. The aim of our study was to determine from international data how long this rate remains elevated and whether the rate of invasive disease reflects the rate of posttreatment CIN. The aim was to determine why the rate of invasive disease does not fall. A search of Medline and a secondary search of cited references identified 1,848 articles referring to the success rate of the treatment of CIN. Only 26 cohorts from 25 articles met all the inclusion criteria. The policy in these was to perform at least annual smears. After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 woman years until at least 20 years after treatment. This rate is approximately 2.8 times greater than expected. In contrast, the risk of posttreatment CIN declined steadily with time to about 190 per 100,000 women in the 10th year. Although the posttreatment rate of CIN falls with time, the rate of invasive disease remains static. It seems likely that this is due to diminishing compliance with follow-up. Women should be encouraged to persevere with annual smears for at least 10 years after their treatment as this may offer them the best chance of detecting recurrence at a treatable stage.

Microinvasive squamous cell cervical carcinoma

Several histologic tumor-related features are the key factors for further treatment planning in microinvasive cervical cancer (MIC) after conization. To better define the indications for conservative treatment of MIC we conducted a literature review for prognostic factors for MIC and we carried out a prospective observational study evaluating most important pathologic factors and the relationships between tumor and edges of the cone and incidence of recurrences. In our experience seven recurrences were observed. Two distinct groups of patients were identified with a clearance lower or higher of 10 and 8 mm for apical and lateral margin respectively. Depth of infiltration and even lymph-vascular involvement have been confirmed as the most important histologic parameters to be evaluated. Apical and lateral clearance of the tumor are significantly correlated with the recurrence rate. If an adequate lateral border of healthy tissue is present on the specimen, conization may be considered as definitive treatment of MIC.

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.

2001 consensus guidelines for the management of women with cervical intraepithelial neoplasia

OBJECTIVE

The study was undertaken to provide consensus guidelines for the management of women with histologically confirmed cervical intraepithelial neoplasia (CIN) that can act as a precursor to invasive cervical cancer and represents one of the most common significant gynecologic diseases of women of reproductive age.

PARTICIPANTS

An independent panel of 121 experts in various aspects of the diagnosis and management of cervical cancer precursors, including representatives from 29 participating professional organizations, federal agencies, national and international health organizations, and others were invited by the American Society for Colposcopy and Cervical Pathology (ASCCP).

CONSENSUS PROCESS

Guidelines for the management of women with CIN were developed through a multistep process. Draft management guidelines were developed by working groups who performed formal literature reviews and obtained input from the professional community at large by way of an interactive internet-based bulletin board. At the ASCCP Consensus Conference, September 6 through 8, 2001, in Bethesda, Md, all guidelines were discussed, revised, and adopted by formal vote.

CONCLUSION

Evidence-based guidelines have been developed for the management of women with biopsy-confirmed CIN.

2001 Consensus Guidelines for the Management of Women with Cervical Intraepithelial Neoplasia

OBJECTIVE

To provide consensus guidelines for the management of women with histologically confirmed cervical intraepithelial neoplasia (CIN), which can act as a precursor to invasive cervical cancer and represents one of the most common significant gynecologic diseases of women of reproductive age.

PARTICIPANTS

An independent panel of 121 experts in various aspects of the diagnosis and management of cervical cancer precursors, including representatives from 29 participating professional organizations, federal agencies, national and international health organizations, and others invited by the American Society for Colposcopy and Cervical Pathology (ASCCP).

CONSENSUS PROCESS

Guidelines for the management of women with CIN were developed through a multistep process. Working groups, who performed formal literature reviews and obtained input from the professional community at large by way of an interactive Internet-based bulletin board, developed draft management guidelines. At the ASCCP Consensus Conference, September 6-8, 2001, in Bethesda, Maryland, all guidelines were discussed, revised, and adopted by formal vote.

CONCLUSIONS

Evidence-based guidelines have been developed for the management of women with biopsy-confirmed CIN.

Management of women with cervical cancer precursor lesions

An understanding of the natural history of HPV-induced precancer and cancer, and of the immune response to HPV and to these lesions, has significantly changed the management of lower genital tract neoplasia. New management guidelines incorporate this understanding, providing a more rational approach to diagnosis and treatment. Understanding that low-grade HPV-induced lesions are not true cervical cancer precursor has fostered expectant management of women with these lesions; however, management approaches are still hampered by the inability to better predict who is at risk for high-grade intraepithelial neoplasia and cancer and who is not; this is particularly problematic in the expectant management of CIN 1. In addition, the decision whether or not to treat these low-grade lesions may depend on a number of complex factors that take into account the woman's preferences and reliability for follow-up, as well as a host of issues related to costs and the reliability of the original diagnosis and the tests used for follow-up. Management options for high-grade cervical cancer precursor lesions are much more definitive, because the option of expectant management is given except in pregnancy and for adolescents with CIN 2. New markers that better predict which women with high-risk HPV are at highest risk for subsequent development of a true cervical cancer precursor lesion appear to be on the horizon and may make the management of low-grade lesions as clear as present guide lines for their high-grade cousins. Until that time, understanding all the issues involved in expectant and in active management of cervical HPV-induced lesions will help provide women with the best care possible.

Photodynamic treatment of pooled coumarin plasma for external quality assessment of the prothrombin time

AIMS

To determine the conditions of photodynamic inactivation of vesicular stomatitis virus (VSV) added to pooled coumarin plasma and the effects of the photodynamic treatment on the prothrombin times and international normalised ratio (INR) in a Netherlands national external quality assessment scheme.

METHODS

Pooled coumarin plasma samples were illuminated with visible light in the presence of 1 microM methylene blue. Inactivation conditions for VSV in pooled coumarin plasma were determined using an end point dilution assay. Plasma illuminated for 20 minutes was mixed with red blood cells and mailed to participants of the Netherlands external quality assessment (EQA) scheme. Prothrombin times and INRs were determined with various thromboplastin reagents.

RESULTS

Photodynamic treatment using 1 microM methylene blue and 700 W/m2 caused 4.7 log inactivation of VSV in pooled coumarin plasma. Fibrinogen and coagulation factors II, V, VII, and X were decreased slightly by the treatment. These conditions caused prolongation of the prothrombin time in EQA surveys. The magnitude of the effect was different for various thromboplastin reagents. The increase of the INR was negligible when measured with the Thrombotest reagent. With other reagents, an approximately 5-16% increase of the INR was observed. Interlaboratory variation of the INR was not affected by photodynamic treatment.

CONCLUSIONS

Photodynamic treatment of pooled coumarin plasma is very effective for the inactivation of some enveloped viruses such as VSV, but has only a limited effect on the prothrombin time and INR. Photodynamic treatment can be used to improve the viral safety of coumarin plasma for EQA of the prothrombin time and INR.

Needle excision of the transformation zone: A new method for treatment of cervical intraepithelial neoplasia

OBJECTIVE

This study was undertaken to evaluate a new needle electrode for conization of the cervix that was developed in my department.

STUDY DESIGN

This was a prospective study of 58 unselected women with histologically verified cervical intraepithelial neoplasia who underwent conization with the diathermy needle. The operations were performed with local anesthesia as outpatient procedures. Follow-up time was 5 years.

RESULTS

All cones were removed in one piece and were of high histologic quality. Mean (+/-SD) operating time, including anesthesia, was 7.9 +/- 2.7 minutes. Mean depth of thermal damage was 0.29 +/- 0.21 mm, and mean blood loss was 12.5 +/- 9.4 mL. No late complications have been noted, and 94.8% of patients have required no further treatment.

CONCLUSION

Needle excision of the transformation zone is a simple and effective outpatient procedure that yields a one-piece cone specimen of high quality and carries a success rate of 94.8%.

Completeness of excision and follow up cytology in patients treated with loop excision biopsy

AIMS

To assess the relation between the grade and the status of follow up cytology, the completeness of loop excision biopsies with cervical intraepithelial neoplasia (CIN), and the findings at follow up cytology, as well as the differences between complete and incomplete exclusion, using the odds ratio. Treatment failure was assessed.

METHODS

1600 women with CIN (290 CIN1, 304 CIN2, 1006 CIN3) were followed for a minimum of six months and a maximum of 10 years. A database was created and comparisons performed. The mean age of the patients was 37 years.

RESULTS

Excision was complete in over 84% of loops. Residual disease and recurrence of high grade dyskaryosis was more common in women with CIN 3 than CIN 2 or 1. No high grade dyskaryosis was seen in the fifth follow up smear in patients with CIN 1 and CIN 2. Residual, recurrent, and persistent disease was most common in patients with incompletely excised CIN at ectocervical and endocervical margins and deep margins of resection than in patients with completely excised CIN. The odds ratios were significantly higher in the women who had incomplete excision of CIN at ectocervical, endocervical, both ecto- and endocervical, and deep margins of resection compared with those with apparent complete excision of CIN lesions. One patient developed invasive squamous cell carcinoma 44 months after loop excision which showed CIN 3 invading endocervical crypts and extending to both ectocervical and endocervical margins of resection.

CONCLUSIONS

At long term follow up, patients with CIN who have residual disease are at increased risk of persistent disease and should therefore be followed up regularly with cytology and colposcopy. The findings support national policy of returning women with treated CIN of any grade to normal recall after five years except for cases of CIN3 where excision was incomplete or equivocal. In these cases follow up with annual smear for 10 years is recommended.

Pattern of CIN recurrence following laser ablation treatment: long-term follow-up

Chew GK, Jandial L, Paraskevaidis E, Kitchener HC. Pattern of CIN recurrence following laser ablation treatment: Long-term follow-up. Our objective was to study the long-term patern of recurrence of cervical intraepithelial neoplasia (CIN) and development of cervical carcinoma in patients who had been treated with laser ablative treatment. The study design consisted of a retrospective analysis of the case records of 2130 patients who received laser ablation treatment for CIN lesions from 1980-1988, with the years 1980 and 1988 inclusive. All of the 2130 women in the cohort have had at least seven years of follow-up. Of the treated population, 79% remain under regular cytological follow-up at the regional laboratory. Nine percent required further treatment, 52% of this within the first year of treatment, 19% within the second year, 4% in the third, 5% in the fourth and fifth years, and 15% over the next five years. These lesions were detected up to ten years after the initial treatment. No recurrent lesions have yet been detected after ten years, and 0.2% of the cohort have developed cervical carcinoma. Long-term follow-up has demonstrated a continuing incidence of recurrent CIN up to ten years after initial treatment. This emphasizes the need for adherence to follow-up protocol if the incidence of cervical carcinoma post-treatment is to be reduced. The data suggest that annual follow-up for 10 years may be advisable to reduce the risk of post-treatment invasive disease.