Histological differences between colposcopic-directed biopsy and loop excision of the transformation zone (LETZ): a cause for concern

Colposcopy Accuracy and Diagnostic Performance: A Quality Control and Quality Assurance Survey in Italian Tertiary-Level Teaching and Academic Institutions-The Italian Society of Colposcopy and Cervico-Vaginal Pathology (SICPCV)

Quality Control (QC) and Quality Assurance (QA) principles are essential for effective cervical cancer prevention. Being a crucial diagnostic step, colposcopy's sensitivity and specificity improvements are strongly advocated worldwide since inter- and intra-observer differences are the main limiting factors. The objective of the present study was the evaluation of colposcopy accuracy through the results of a QC/QA assessment from a survey in Italian tertiary-level academic and teaching hospitals. A web-based, user-friendly platform based on 100 colposcopic digital images was forwarded to colposcopists with different levels of experience. Seventy-three participants were asked to identify colposcopic patterns, provide personal impressions, and indicate the correct clinical practice. The data were correlated with a panel of experts' evaluation and with the clinical/pathological data of the cases. Overall sensitivity and specificity with the threshold of CIN2+ accounted for 73.7% and 87.7%, respectively, with minor differences between senior and junior candidates. Identification and interpretation of colposcopic patterns showed full agreement with the experts' panel, ranging from 50% to 82%, in some instances with better results from junior colposcopists. Colposcopic impressions correlated with a 20% underestimation of CIN2+ lesions, with no differences linked to level of experience. Our results demonstrate the good diagnostic performance of colposcopy and the need for improving accuracy through QC assessments and adhesion to standard requirements and recommendations.

HPV High-risk Multiple Infection Is a Key Predictor of Cervical Dysplasia in Diagnostic LEEPs: a Retrospective Cohort Analysis

Objective This study aimed to identify predictors for the presence of cervical dysplasia in diagnostic LEEPs (Loop Electrical Excision Procedure) of the cervix. Materials/Methods The study was designed as a retrospective single-institution cohort analysis of all patients who underwent LEEP without prior proof of high-grade intraepithelial lesion (diagnostic LEEP) between 2015 and 2020 in the Department of Obstetrics and Gynecology of University Hospital Aachen. In order to identify the most meaningful predictive variables for CIN status (CIN2+ or non-CIN2+), multivariate logistic regression was performed and a machine-learning method was used. Results A total of 849 patients with an indication for loop excision of the cervix were assessed for eligibility. Finally, 125 patients without prior proof of CIN2+ were included into the study. Based on the final multivariate logistic regression model, multiple high-risk HPV infections (p = 0.001), the presence of a T2 transformation zone (p = 0.003) and major lesion changes (p = 0.015) as a result of the colposcopy examination were found to be statistically significant for CIN status based on the diagnostic LEEP. Subsequent ROC analysis showed a high predictive value for the model of 88.35% (AUC). The machine-learning technique (recursive partitioning) identified similar variables as important for CIN status with an accuracy of 75%. Conclusion For clinical decision-making, the result of the colposcopy examination (T2, major change) as well as the results of HPV testing (multiple high-risk HPV infections) are stronger indicators for clinicians to perform diagnostic excisional procedures of the cervix than the presence of high-grade cytological abnormalities.

Optimizing the Detection of Occult Cervical Cancer: A Prospective Multicentre Study in China

Purpose

Early-stage cervical cancer is usually diagnosed by colposcopy-directed biopsy (CDB) and/or endocervical curettage (ECC), but some neglected lesions must be detected by conization because they are occult. This study aimed to explore the optimal method for detecting these "occult" cervical cancers.

Patients and Methods

A total of 1299 patients who were high-risk for early-stage cervical cancer from five centres in China were prospectively included. We evaluated the diagnostic performance of cytology, HPV testing, colposcopy and CDB&ECC for detecting "occult" cervical cancer and discussed the diagnostic importance of transformation zone (TZ) type, conization length and the proportion of cervical cone excision.

Results

The diagnostic agreement between colposcopy impression and conization was 64.5% and 72.4% between CDB&ECC and conization. Forty-two patients were finally diagnosed with pathologic cancer, and the sensitivities of cytology, colposcopy, CDB&ECC were 4.8%, 7.1%, and 47.4%, respectively. Twenty cases were neglected by CDB&ECC but further diagnosed as cancer by conization, considered to be occult cervical cancer, accounting for 1.6%. Cytologic high-grade squamous intraepithelial lesion (HSIL)+, positive HPV, biopsy HSIL+ and cervical TZ type 3 were considered risk factors for developing HSIL+, while colposcopy impression HSIL+ was not. There was a significant difference between cancerous and HSIL patients in the proportion of cervical cone excision (P<0.001), which was recognized as a risk factor (P<0.001) for detecting cancer, while the length of cervical cone excision was not. The average proportion was 0.62, and the minimal effective proportion was 0.56.

Conclusion

Since the incidence of occult cervical cancer neglected by CDB&ECC, colposcopy and cytology was far beyond expectations, conization is necessary, especially in patients with TZ type 3, high-grade cytology and biopsy results. As the cervical length varies in patients, the proportion of cervical cone excision might be a better indicator for detecting occult cervical cancer.

Underdiagnosis of early cervical cancer with an invisible cervical transformation zone in an elderly patient: A case report

The treatment of cervical intraepithelial neoplasia (CIN) can result in under- or overtreatment. The current report describes a case of undertreatment of a cervical tumor. A 72-year-old woman was preoperatively diagnosed with CIN3. Following surgery, the final diagnosis of the excised specimen was keratinizing squamous cell carcinoma that measured 2.5 cm in size. The exocervical margin and deep margin were negative. The patient received adjuvant therapy with concurrent chemoradiotherapy and never had disease recurrence. In elderly patients, making an accurate preoperative diagnosis based on specimens from cervical biopsies with or without colposcopy is difficult. MRI may be an accurate preoperative indicator of early cervical tumor, although some studies have demonstrated that MRI has a limitation with respect to its diagnostic ability. Other studies have reported that it is necessary to perform conization prior to hysterectomy. Physicians must reconsider the determined preoperative diagnosis of an early cervical tumor and establish standard guidelines for deciding when to use surgical treatment in elderly patients.

Loop Electrosurgical Excision Procedure in Managing Persistent Low-Grade Abnormality or Human Papillomavirus Positivity

OBJECTIVES

The aims of the study were to estimate the rate and to identify predictors of high-grade abnormalities among women with persistent low-grade abnormalities or high-risk human papillomavirus (hrHPV) positivity for at least 2 years stratified by presence (high risk) or absence (low risk) of previous high-grade results or HPV 16/18.

MATERIALS AND METHODS

A retrospective cohort study of patients who underwent a loop electrosurgical excision procedure (LEEP) for persistent low-grade or hrHPV positivity was performed. Patients were stratified based on whether they had a history of high-grade and/or HPV 16/18 positivity. Rates of high-grade or worse abnormalities on LEEP were compared using Fisher exact tests. Logistic regression was used to evaluate the associations between patient characteristics and high-grade results on the LEEP.

RESULTS

Three hundred eleven LEEPs were performed for persistent low-grade or hrHPV positivity. The rates of occult high grade were 12% and 22% among the low- and high-risk groups, respectively. Compared with those 45 years and older, the adjusted odds of high grade was 3.79 (95% CI = 1.19-12.1) for women aged 25-29 years. The odds of high grade was higher among current versus never smokers (6.40; 95% CI = 2.01-20.4) and those with a history of high-grade abnormality (2.23; 95% CI = 1.12-4.43). At 2 years, approximately half had an abnormal cytology and/or hrHPV positivity result independent of whether high grade was identified on their LEEP specimen.

CONCLUSIONS

Patients with persistent low-grade abnormalities or persistent hrHPV should be counseled on the risks and benefits of a LEEP given that 12%-22% have a risk of occult high grade, especially if they have a history of high-grade dysplasia.

Accuracy of colposcopic findings in detecting vaginal intraepithelial neoplasia: a retrospective study

PURPOSE

Malignancies of the vagina are rare, but colposcopy-directed biopsies play a major role in detecting vaginal intraepithelial lesions. Data of accuracy in detecting neoplasia of the vagina are very rare compared to accuracy in detecting cervical neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with clinical findings of the examiner.

METHODS

The accuracy of colposcopy-directed biopsy was compared with the clinical finding in relation to the patient's age and the examiner's level of training. This was done in combination with PAP-smear, HPV-test results, and the history of other malignancies of the lower genital tract. The data were collected between January 2014 and February 2018 at the certified Dysplasia Unit of the University Hospital Erlangen.

RESULTS

In total, 253 biopsies from 253 women from the vagina were obtained. The overall accuracy of biopsy in comparison with clinical finding was 52.17% for all entities-benign lesions, low-grade squamous intraepithelial lesions (LSILs), high-grade squamous intraepithelial lesions (HSILs), and vaginal carcinoma. The accuracy for detecting HSIL was 82.46% (47/57), with an underdiagnosis rate of 15.79% and an overdiagnosis rate of 1.79%.

CONCLUSION

With a sensitivity of over 80%, colposcopy-directed biopsy plays an important role in detecting vaginal-HSIL. A highly experienced practitioner is increasing the sensitivity in detecting vaginal-HSIL. Careful examination is required in women with a history of HSIL of the lower genital tract or with simultaneous neoplasia because they are of greater risk of developing vaginal malignancies. The combination of careful clinical work up, PAP-smear, HPV-testing, and colposcopy-guided biopsy is crucial in detecting vaginal-HSIL.

Pathologic discrepancies between colposcopy-directed biopsy and loop electrosurgical excision procedure of the uterine cervix in women with cytologic high-grade squamous intraepithelial lesions

Objective

To investigate pathologic discrepancies between colposcopy-directed biopsy (CDB) of the cervix and loop electrosurgical excision procedure (LEEP) in women with cytologic high-grade squamous intraepithelial lesions (HSILs).

Methods

We retrospectively identified 297 patients who underwent both CDB and LEEP for HSILs in cervical cytology between 2015 and 2018, and compared their pathologic results. Considering the LEEP to be the gold standard, we evaluated the diagnostic performance of CDB for identifying cervical intraepithelial neoplasia (CIN) grades 2 and 3, adenocarcinoma in situ, and cancer (HSIL+). We also performed age subgroup analyses.

Results

Among the study population, 90.9% (270/297) had pathologic HSIL+ using the LEEP. The diagnostic performance of CDB for identifying HSIL+ was as follows: sensitivity, 87.8%; specificity, 59.3%; balanced accuracy, 73.6%; positive predictive value, 95.6%; and negative predictive value, 32.7%. Thirty-three false negative cases of CDB included CIN2,3 (n=29) and cervical cancer (n=4). The pathologic HSIL+ rate in patients with HSIL− by CDB was 67.3% (33/49). CDB exhibited a significant difference in the diagnosis of HSIL+ compared to LEEP in all patients (p<0.001). In age subgroup analyses, age groups <35 years and 35–50 years showed good agreement with the entire data set (p=0.496 and p=0.406, respectively), while age group ≥50 years did not (p=0.036).

Conclusion

A significant pathologic discrepancy was observed between CDB and LEEP results in women with cytologic HSILs. The diagnostic inaccuracy of CDB increased in those ≥50 years of age.

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.

Characteristic findings of high-grade cervical intraepithelial neoplasia or more on magnifying endoscopy with narrow band imaging

BACKGROUND

Colposcopy, which is a standard modality for diagnosing cervical intraepithelial neoplasia (CIN), can have limited accuracy owing to poor visibility. Flexible magnifying endoscopy with narrow band imaging (ME-NBI) has excellent diagnostic accuracy for early gastrointestinal neoplasms and is expected to be highly useful for CIN diagnosis. This study aimed to determine the characteristic findings and evaluate the diagnostic ability of ME-NBI for lesions ≥ CIN 3.

METHODS

A well-designed prospective diagnostic case series conducted at multiple tertiary-care centers. A total of 24 patients who underwent cervical conization with a preoperative diagnosis of high-grade squamous cell intraepithelial lesions (HSILs) or lesions ≥ CIN 3 were enrolled. Prior to conization, still images and video of ME-NBI were captured to investigate the cervical lesions. The images were reviewed based on histological examination of the resected specimens.

RESULTS

The NBI-ME images revealed the following abnormal findings: (1) light white epithelium (l-WE), (2) heavy white epithelium (h-WE), and (3) atypical intra-epithelial papillary capillary loop (IPCL). Pathological examination of the resected specimens confirmed cervical lesions ≥ CIN 3 in 21 patients. The ME-NBI findings were classified into four groups: l-WE, l-WE with atypical IPCL, h-WE, and h-WE with atypical IPCL, at rates of 0, 23.8, 9.5, and 66.7%, respectively. Additionally, all 3 patients with micro-invasive carcinoma showed a strong irregularity of IPCLs.

CONCLUSION

The lesions ≥ CIN 3 demonstrated characteristic ME-NBI findings of h-WE alone, or l-/h-WE with atypical micro-vessels. This study indicates that ME-NBI may have novel value for CIN diagnosis.

A prospective randomized study on limits of colposcopy and histology: the skill of colposcopist and colposcopy-guided biopsy in diagnosis of cervical intraepithelial lesions

BACKGROUND

The main objective of our study was to evaluate the colposcopist ability to correctly identify the worst area of a cervical lesion where biopsy should be performed; the secondary objective was to investigate the influence of the colposcopist skill in grading cervical preneoplastic lesions.

METHODS

296 patients referred for colposcopy were enrolled in a prospective study. All patients were randomized in two groups: in the first group, "senior group", the colposcopy was performed by an experienced colposcopist; in the second group, "junior group", the colposcopy was performed by a less experienced colposcopist. A detailed colposcopic description, including a grading of the lesion, was completed for each case. During the colposcopic exam patients underwent two direct biopsies; each biopsy was labeled with letter A (suspicious area with most severe grade) or B (suspicious area with less severe grade) according to the judgment of the colposcopist. An experienced pathologist reanalyzed the histological slides, after routine diagnosis.

RESULTS

The senior group identify the worst area of the cervical lesion in statistical significant higher rates than junior group. Specimen A resulted representative of the higher-grade lesion (A > B) in 73.7 % (N = 28) in senior group and in 48.4 % (N = 15) in junior group; while in 26.3 % (N = 10) the higher-grade lesion corresponded to specimen B (A < B) in senior group and in 51.6 % (N = 16) in junior group (p < .05).

CONCLUSION

The ability of a colposcopist in grading cervical lesion depends on his experience.

Study of accuracy of colposcopy in VIA and HPV detection-based cervical cancer screening program

OBJECTIVE

This population-based study was conducted to evaluate the performance of colposcopy to assess women with positive visual inspection with acetic acid (VIA) and/or human papillomavirus (HPV) tests.

MATERIALS AND METHODS

A total of 30,773 women were screened by VIA and oncogenic HPV test. Hybrid capture 2 was used for oncogenic HPV detection. All VIA- and/or HPV-positive women and 8.7% test-negative women had the colposcopy. International Federation of Cervical Pathology & Colposcopy (IFCPC) 2011 nomenclature was used for colposcopic classification of abnormalities. All women with grade 1 or worse lesions had punch biopsies. Biopsies were also obtained from HPV-positive women with normal colposcopy.

RESULTS

Colposcopy and satisfactory biopsy reports were available for total 2466 women. The overall strength of agreement between colposcopy and histologic classification of cervical neoplasias was poor (kappa = 0.17). Agreement was better when colposcopy was performed on HPV-positive women compared to VIA-positive women. Sensitivity of colposcopy to detect high-grade squamous intraepithelial lesions (HSIL) at referral threshold of grade 1 abnormality was 84.8% after correction of verification bias. Colposcopy was most inaccurate in identifying non-neoplastic conditions often encountered in VIA- and/or HPV-positive women. In 68.8% women with normal histology, colposcopic impression was grade 1 and above. Overestimation of disease severity on colposcopy was more common in VIA-positive women. Colposcopy also underestimated severity of disease in 52.6% of women with HSIL diagnosis on biopsy.

CONCLUSIONS

Colposcopy performed well in the overall detection of cervical neoplasias, though its capability for accurate categorisation of degree of abnormality was poor.

Accuracy of Colposcopically Directed Biopsy: Results from an Online Quality Assurance Programme for Colposcopy in a Population-Based Cervical Screening Setting in Italy

PURPOSE

To report the accuracy of colposcopically directed biopsy in an internet-based colposcopy quality assurance programme in northern Italy.

METHODS

A web application was made accessible on the website of the regional Administration. Fifty-nine colposcopists out of the registered 65 logged in, viewed a posted set of 50 digital colpophotographs, classified them for colposcopic impression and need for biopsy, and indicated the most appropriate site for biopsy with a left-button mouse click on the image.

RESULTS

Total biopsy failure rate, comprising both nonbiopsy and incorrect selection of biopsy site, was 0.20 in CIN1, 0.11 in CIN2, 0.09 in CIN3, and 0.02 in carcinoma. Errors in the selection of biopsy site were stable between 0.08 and 0.09 in the three grades of CIN while decreasing to 0.01 in carcinoma. In multivariate analysis, the risk of incorrect selection of biopsy site was 1.97 for CIN2, 2.52 for CIN3, and 0.29 for carcinoma versus CIN1.

CONCLUSIONS

Although total biopsy failure rate decreased regularly with increasing severity of histological diagnosis, the rate of incorrect selection of biopsy site was stable up to CIN3. In multivariate analysis, CIN2 and CIN3 had an independently increased risk of incorrect selection of biopsy site.

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.

Prospective Comparison of Loop Excision under Colposcopic Guidance versus Vitom Guidance

Background: Aim of the study was to compare the quality of loop excision using a colposcope with results using the VITOM system. Results compared included cervical volume removed, intra- and postoperative complications, and positive resection margins. Methods: A total of 200 patients with histologically confirmed high-grade cervical premalignant lesions, persistent atypical cytological results and/or suspicious colposcopic findings, and cytological and histological discrepancies were included in the study. In transformation zone type 1 (T1) only a superficial cone biopsy was done, in zones type 2 and 3 (T2 and T3) a superficial outside cone biopsy or a deeper inside cone biopsy were done respectively, followed by endocervical curettage. Volume of removed tissue, complications, and positive resection margins were compared for the colposcopy and the VITOM groups. Findings: Demographic and reproductive features were similar between groups. In the VITOM group 49 % of patients had zone T1, 30 % had zone T2, and 21 % had zone T3. In the group of patients managed by colposcopy, 48, 45, and 7 % of patients had zone T1, T2 and T3 zone, respectively (p < 0.01). A "top hat" procedure was done in 65 % of patients in the VITOM group and in 38 % of patients in the colposcopy group (p < 0.05). Mean volume of removed cervical tissue measured was similar, with 1.2 cm³ measured in the VITOM group and 1.14 cm³ in the colposcopy group (p > 0.05). There were no significant differences in the type of procedure or the mean volume of removed tissue. Results were similar for both groups with respect to positive resection margins and complications. Conclusion: VITOM is a safe and reliable system. Results using the VITOM system are comparable to those obtained with conventional colposcopy. The potential advantage of VITOM is the broader availability of endoscopic systems in the operating theatre.

Number of fragments, margin status and thermal artifacts of conized specimens from LLETZ surgery to treat cervical intraepithelial neoplasia

CONTEXT AND OBJECTIVE

Large loop excision of the transformation zone (LLETZ) is a nontraumatic cut and coagulation method with several advantages, but it induces thermal artifacts in the cut region. The aim here was to assess the correlations of age, number of fragments, lesion grade and degree of thermal artifacts with margin quality in conized specimens from LLETZ for cervical intraepithelial neoplasia (CIN).

DESIGN AND SETTING

Cross-sectional study at Universidade Federal de São Paulo (Unifesp).

METHODS

The records and histopathology findings of 118 women who underwent LLETZ between 1999 and 2007 were reviewed. Age, number of fragments, lesion grade, degree of thermal artifacts and margin quality were assessed.

RESULTS

The patients' mean age was 27.14 years; 63.6% had been diagnosed with CIN II and 36.4% with CIN III. The lesion was removed as a single fragment in 79.6% of the cases. The margins were free from intraepithelial neoplasia in 85.6% and compromised in the endocervical margin in 6.8%. Fragment damage due to artifacts occurred in 2.5%. Severe artifacts occurred in 22.8%. Women aged 30 years or over presented more cases of CIN III (P < 0.0004). Neoplastic compromising of surgical margins and severe artifacts occurred more often in cases in which two or more fragments were removed, and in patients aged 30 years or over.

CONCLUSION

CIN III in women aged 30 or over, when removed in two or more fragments during LLETZ, presented a greater number of compromised margins and greater severity of thermal artifacts.

Cervical cytology/histology discrepancy: a 4-year review of patient outcome

OBJECTIVE

To investigate the diagnosis, review and management of women identified as having a cytology/histology discrepancy.

METHODS

A review of all patients diagnosed with a discrepancy between referral smear and cervical histology was performed between January 2003 and December 2004. Cases were followed for a minimum of 4 years and patient management and outcome reviewed.

RESULTS

A significant discrepancy was identified in 79 cases, 0.1% of all smears (n = 80,926) analysed during the study period. A discrepancy between cytology and histology, obtained from large loop excision of the transformation zone (LLETZ), was confirmed by multidisciplinary review in 42 cases (53.2%). In 37 cases (46.8%) the cytological and/or histological diagnosis was revised; the cytology was significantly more likely than the histology to be amended (chi square P = 0.005), most often because cytology had been overcalled. Of the confirmed discrepancy cases, 33 (78.6%) were due to high-grade squamous cell or glandular abnormalities on cytology with a negative, inflammatory or human papillomavirus (HPV) infection on histology (HGC/NH). HGC/NH cases were managed by cytological follow-up in 29 (87.9%), of which 72.4% of the smears were negative when performed at least 6 months post-excision. During the 4-year follow-up period six women with a confirmed HGC/NH underwent a repeat cervical excision (hysterectomy or LLETZ), and of these, HPV effect was seen in two cases but no cervical intraepithelial neoplasia was detected in any of the histological specimens.

CONCLUSION

Cytology overcall was responsible for the majority of cytology/histology discrepancies. A confirmed discrepancy is not an indication for a further excisional biopsy but follow-up is essential because a small percentage of patients may have disease that has been missed.

Diagnostic accuracy of guided cervical biopsies: a prospective multicenter study comparing the histopathology of simultaneous biopsy and cone specimen

OBJECTIVE

We sought to determine the validity of colposcopically directed cervical biopsies as a diagnostic test to define the degree of cervical intraepithelial neoplasia (CIN).

STUDY DESIGN

In a prospective multicenter trial, patients undergoing excisional procedures of the transformation zone additionally had colposcopy and up to 3 guided cervical biopsies in a single procedure. Cervical biopsies were regarded as a diagnostic test to detect high-grade lesions (CIN 2,3), with the cone specimen as reference standard.

RESULTS

In all, 488 biopsies were performed in 244 cases, with 2 biopsies done in 192 cases. Cervical biopsies underestimated the severity of lesions in 46.7% of cases. Sensitivity, specificity, and positive and negative predictive values were 66.2% (95% confidence interval [CI], 59.4-72.3), 95.0% (95% CI, 83.5-98.6), 98.5% (95% CI, 94.8-99.6), and 35.5% (95% CI, 27.1-44.9), respectively.

CONCLUSION

Our data suggest that cytologically suspected high-grade lesions (CIN 2,3) can be confirmed by biopsy in many cases, but they cannot be excluded.

The impact of a multidisciplinary conference in the management of cervical cytological and histological abnormalities: a university hospital experience

OBJECTIVE

This study evaluates the impact of a cytology-colposcopy correlation conference (CCCC) on the management of preinvasive cervical lesions in a university hospital.

METHODS

This is a retrospective analysis of 130 consecutive cases from the colposcopy clinic at our University Health Center that were presented in the CCCC during a period of 1 year (November 2006 to October 2007). Variables examined to assess the usefulness of CCCC included the actual number of times there was a recorded change in the diagnosis or management recommendation secondary to presentation in the conference. The algorithms from the 2001 American Society of Colposcopy and Cervical Pathology consensus guidelines for the management of cytologic and histologic abnormalities were used to identify the patients in whom the conference recommendations were a deviation from the standard society recommendations.

RESULTS

The diagnosis was changed on review of the original cytology or biopsy 24 times (13%), downgraded 13 times (7%), and upgraded 11 times (6%). The conference recommendations were a modification of the standard 2001 American Society of Colposcopy and Cervical Pathology guidelines 38 times (21%) in 34 patients. The most common triage change was the recommendation for observation of unexplained high-grade cytology with negative or lower-grade biopsy (73%), followed by observation of high-grade lesion on biopsy (27%). This recommendation, while an option in the 2006 guidelines, was not given as a choice in the 2001 guidelines.

CONCLUSIONS

The CCCC at our institution provided significant input into the management of patients with preinvasive cervical lesions, anticipating some of the changes made in the 2006 guidelines.

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.

Subsequent risk and presentation of cervical intraepithelial neoplasia (CIN) 3 or cancer after a colposcopic diagnosis of CIN 1 or less

OBJECTIVE

The purpose of this study was to determine the risk and presentation of cervical intraepithelial neoplasia (CIN) 3 or cancer after colposcopic diagnosis of CIN 1 or less.

STUDY DESIGN

After colposcopy for an abnormal cytology, women with CIN 1 or less had annual cytology evaluations and high-risk human papillomavirus (HPV) tests (Hybrid Capture II). Colposcopy was repeated if the cytology result was ASC-H, or worse, ASC-US/high-risk HPV test positive, or every 2 years if the cytology was normal/high-risk HPV test positive. Differences in rates of CIN 3 or cancer were compared by log rank Kaplan-Meier survival analysis.

RESULTS

With median follow-up periods of 26.3 months, 47 of 2490 women (1.9%) with CIN 1 or less subsequently had CIN 3 or cancer. Subsequent CIN 3 or cancer was more likely if the high-risk HPV test was initially positive (45/1960 women [2.3%]) compared with negative (2/530 women [0.4%]; P = .0002) and if women were older (age > or = 30 years, 28/1021 women [2.7%]; age 20-29 years, 17/1017 women [1.7%]; age < 20 years, 2/452 women [0.4%]; P = .045). When CIN 3 or cancer was diagnosed, 45 of 46 women (97.8%) had positive high-risk HPV test and 42/46 women (91.3%) had an abnormal cervical cytology. The yield of CIN 3 or cancer per colposcopy for women (4/205 women [2.0%]) who had normal cervical cytology/positive high-risk HPV tests was lower than for women (41/541 women [7.6%]) who had abnormal cervical cytology/positive high-risk HPV tests (chi-square test, 8.3; P < .005), and it did not increase with increasing length of follow-up.

CONCLUSION

Annual cytology and high-risk HPV tests with colposcopy for high-risk HPV test positive/abnormal cytology and at least every 2 years for high-risk HPV test positive/normal cytology is advised after a colposcopic diagnosis of CIN 1 or less.

Does microcolposcopy protect patients with CIN and unsatisfactory colposcopy from the risk of incomplete excision of disease at the time of conization?

OBJECTIVE

To evaluate the effectiveness of microcolposcopy in preventing incomplete electrosurgical excision at the endocervical cone margin in patients with CIN and unsatisfactory colposcopy.

MATERIALS AND METHODS

Four-hundred and twenty-one patients were studied. Complete excision of disease at the endocervical margin was evaluated using multiple logistic regression analysis.

RESULTS

One-hundred and eighty-three patients underwent microcolposcopy. In 160 patients, the cone depth exceeded the endocervical extension of the squamocolumnar junction as predicted by microcolposcopy. In 23 patients, the opposite was observed. Microcolposcopy was not performed in 238 patients. For the three groups, the frequency of endocervical cone margin involvement was 22%, 22%, and 13%, respectively. Multiple logistic regression analysis showed that patients with a cone depth exceeding the endocervical margin of the squamocolumnar junction as predicted by microcolposcopy had no reduction in the risk of incomplete conization.

CONCLUSION

The use of microcolposcopy awaits validation for assessment of the transformation zone to predict negative conization margins.

Evidence Supporting the Current Management Guidelines for High-Grade Squamous Intraepithelial Lesion Cytology

OBJECTIVE

The study was undertaken to provide consensus guidelines for the management of women with a cytologic interpretation of high-grade squamous intraepithelial lesion (HSIL) on cytologic examination. This review article presents relevant literature supporting the proposed guidelines.

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.

CONSENSUS PROCESS

Guidelines for the management of women with HSIL cytologic results were developed through a multistep process. Draft management guidelines were developed by the HSIL working group after formal literature reviews and obtained input from the professional community at large by way of an interactive internet-based bulletin board. At the American Society for Colposcopy and Cervical Pathology Consensus Conference, September 6 through 8, 2001, in Bethesda, Maryland, the guidelines were discussed, revised, and adopted by formal vote.

CONCLUSIONS

Evidence-based guidelines have been developed for the management of women with HSIL cytologic results.

Independent determinants of inaccuracy of colposcopically directed punch biopsy of the cervix

OBJECTIVE

The goal of this study was to determine the clinical factors independently associated with inaccuracy of colposcopically directed punch biopsy in defining extent and severity of epithelial lesions of the cervix.

METHODS

The study was conducted in a colposcopy clinic devoted to the management of patients with abnormal Pap smear and/or histology diagnosis of cervical intraepithelial neoplasia (CIN) on punch biopsy or endocervical curettage. Seven hundred and thirty-nine patients (median age, 33 years; range, 18-83 years) referred with a punch biopsy diagnosis of CIN2-3 and treated with electrosurgical conization were evaluated. Cone histology diagnosis was assumed to supply the correct diagnosis. Two types of deviation of biopsy diagnosis were considered: (1). unconfirmed high-grade CIN diagnosis, defined as a cone diagnosis of CIN1 and reactive/reparative changes, and (2). nondiagnosis of carcinoma, defined as a cone diagnosis of microinvasive and invasive squamous carcinoma. Multinomial logistic regression analysis was used to assess the determinants of the probability of each type of deviation.

RESULTS

The probability of unconfirmed high-grade CIN diagnosis (n = 190, 25.7%) was inversely related to number of quadrants involved, severity of referral Pap smear, and grade of biopsy. The probability of nondiagnosis of carcinoma (n = 43, 5.8%) was positively related to patient age, invisibility of the squamocolumnar junction, number of quadrants involved, and cone width. Endo-ectocervical location, cone depth, and time period had no effect whatsoever.

CONCLUSIONS

The study confirmed previous observations regarding the positive association of patient age and invisibility of squamocolumnar junction with the probability of nondiagnosis of carcinoma. The concomitant positive effects of number of quadrants involved and cone width were suggested to mirror the effect of circumferential development and, respectively, surface area of CIN. Severity of referral Pap smear and grade of biopsy were shown to be inversely related to the probability of a cone diagnosis of CIN1 and benign changes.

Confirmation of cervical neoplasia using a hand-held, lighted magnification device

OBJECTIVES

The objective of this study was to estimate the sensitivity and specificity of visual inspection with acetic acid and magnification (VIAM) using the AviScope device to confirm high-grade cervical intraepithelial neoplasia or carcinoma.

METHODS

VIAM was performed on 142 women aged 18-50 years referred to three colposcopy clinics because of abnormal cervical cytology. Each woman then had a colposcopic examination with cervical biopsy when indicated.

RESULTS

The AviScope device identified 24 of the 40 women who had CIN 2, 3, or carcinoma, yielding a sensitivity of 60.0% (95% CI 43.4, 74.7). The AviScope correctly identified 60 of 87 women negative for dysplasia or cancer, yielding a specificity of 69.0% (95% CI 58.0, 78.2) compared with colposcopy and cervical histology.

CONCLUSION

VIAM using the AviScope device was moderately sensitive and specific for the confirmation of high-grade cervical lesions in women referred with abnormal cervical cytology.

Human papillomavirus testing for triage of women referred because of abnormal smears. a decision analysis considering outcomes and costs

The objective of this article was to evaluate the utility of high-risk human papillomavirus (HR-HPV) testing for triage of women referred for colposcopy because of abnormal smears. We considered women with persistent mild or moderate dyskaryosis and women with severe dyskaryosis who were referred for colposcopy. For both patient groups we evaluated three alternative management policies: (1) conventional management based on histological assessment; (2) HR-HPV-triage with direct treatment without prior histologic assessment for HR-HPV-positive women and conventional management for HR-HPV-negative women; and (3) direct treatment without histologic assessment for all referred women. For each policy the average number of medical procedures, doctor visits, and the costs per referred woman were calculated. Based on a literature review, the results were tested and translated to other patient groups. Per woman with persistent mild or moderate dyskaryosis and compared with conventional policy, HR-HPV-triage will avoid 0.51 colposcopically directed biopsies, but adds 0.05 local treatments of the cervix (i.e., loop excision of the transformation zone) and 0.09 outpatient visits, and will cost $134 US dollars extra. HPV triage is less efficient in women with borderline or mildly dyskaryotic cytology. In women with severe dyskaryosis, direct treatment is more efficient as conventional management or HPV triage. The decision to introduce HPV testing or direct treatment in women with persistent mild or moderate dyskaryosis strongly depends on the relative burden attributed to a colposcopically directed biopsy and an outpatient visit compared to loop excision of the transformation zone treatment of the cervix. For women with severe dyskaryosis, direct treatment should be seriously considered.

Baseline inaccuracy rates for the comparison of cervical biopsy to loop electrosurgical excision histopathologic diagnoses

OBJECTIVE

The purpose of this study was to quantify the baseline inaccuracies in histopathologic diagnosis between colposcopically directed cervical biopsies and loop electrosurgical excision procedure specimens.

STUDY DESIGN

A retrospective review was made of cervical biopsies and loop electrosurgical excision procedure pairs (n = 448) that were performed at the University of Arizona between 1992 and 2000. Agreement was assessed by kappa statistics and Spearman rho coefficients. Subgroup analysis was performed (n = 139) to assess pairs with significant inaccuracy between biopsy and loop electrosurgical excision procedure, when these were performed within 28 days of each other.

RESULTS

Eighty-one percent agreement was found between cervical biopsy and loop electrosurgical excision procedure histopathologic diagnoses, when compared to within 1 degree (kappa, 0.73; P <.0001). A discrepancy that would be attributed to regression or progression was found: mild biopsy (regression, none by definition; progression, 4%), moderate biopsy (regression, 9%; progression, 0%), and severe biopsy (regression, 26%; progression, 0%).

CONCLUSION

Even when colposcopically directed cervical biopsy correlates strongly with loop electrosurgical excision procedure histopathologic diagnosis, there is a definable percentage of patients for whom there is a discrepancy between these 2 diagnoses. This discrepancy represents an inherent inaccuracy of the diagnostic testing modality and should not be interpreted as progression or regression of disease.

Disease persistence in patients with cervical intraepithelial neoplasia undergoing electrosurgical conization

OBJECTIVE

Cone margin status has been reported to be the most important predictor of residual disease in patients with cervical intraepithelial neoplasia (CIN) undergoing electrosurgical excisional treatment. The primary aim of this study of patients treated with electrosurgical conization was to evaluate the association of cone margin status and other clinical and pathologic factors with the probability of residual disease.

METHODS

The study population comprised 699 patients with at least one follow-up visit within 12 months of conization. Residual disease was defined as a histology diagnosis of CIN within 3 years of conization. Multivariate associations were evaluated with multiple logistic regression analysis.

RESULTS

Attendance to follow-up was 97% for the second visit and 34% for the third visit. Residual disease was detected in a total of 38 patients (5.4%). The detection rate was 3.3% at the first visit, 2.1% at the second visit, and 0.4% at the third visit. An increased probability of residual disease was associated with a referral Pap smear reported as high-grade squamous intraepithelial neoplasia and carcinoma (odds ratio, 2.9; reference category, low-grade squamous intraepithelial neoplasia). A decreased probability was associated with a squamocolumnar junction entirely visible at the first follow-up visit (odds ratio, 0.2; reference category, squamocolumnar junction not visible). Patient age, time period, lesion size, lesion site, grade of CIN, cone width, cone depth, and margin status had no influence.

CONCLUSIONS

The determinants of residual disease in this study differed from those generally reported so far. Factors associated with effectiveness of electrosurgical treatment of CIN need further research.

The correlation between colposcopically directed cervical biopsy and loop electrosurgical excision procedure pathology and the effect of time on that agreement

OBJECTIVE

The goal of this study was to evaluate whether colposcopically directed cervical biopsy accurately predicts histopathology found on loop electrosurgical excision procedure specimen and to assess whether this correlation was affected by a delay in treatment of greater than 12 weeks.

METHODS

A retrospective review was performed of all cervical biopsy and loop electrosurgical excision procedure pairs performed at University of Arizona Medical Center between March 1992 and March 2000. Agreement was assessed by kappa statistics and Spearman rho coefficients. A subgroup analysis was performed to assess the effect of a delay greater than 12 weeks between cervical biopsy and loop excision on the histopathologic correlation.

RESULTS

An 84% agreement was found between cervical biopsy histopathology and loop electrosurgical excision procedure histopathology when compared to within 1 degree (kappa = 0.78, P < 0.0001; Spearman rho = 0.40, P < 0.0001). This agreement remained strong (87%) even when loop electrosurgical excision procedure was delayed greater than 12 weeks (kappa = 0.81, P = 0.01).

CONCLUSION

Colposcopically directed cervical biopsy correlated strongly with loop specimen histopathology. A delay in loop electrosurgical excision procedure greater than 12 weeks does not negatively affect this correlation. This delay of 12 weeks may be used safely in the future to test chemotherapeutic dysplasia treatments.

Recurrence of dysplasia after loop electrosurgical excision procedures with long-term follow-up

OBJECTIVE

The aim of this study was to determine the rates of recurrent dysplasia with longer follow-up durations and to determine whether margin status and other variables were associated with recurrence.

STUDY DESIGN

A retrospective chart review was performed for all women who underwent a loop electrosurgical excision procedure at Wilford Hall Medical Center, Lackland Air Force Base, Texas, between January 1993 and December 1994. Extracted information included age, parity, indication for the loop electrosurgical excision procedure, histologic classification of the loop electrosurgical excision procedure specimen, margin status, and whether a "deep" (endocervical) pass had been performed. Follow-up data included findings of repeated cytologic examination, colposcopy, and biopsy if performed.

RESULTS

The mean duration of follow-up for all women was 24 months. Margins were positive in 28%, with 73% of these being endocervical. The overall recurrent dysplasia rate was 31%, with a mean time to recurrence of 11.9 months. Participants with any positive margins had a higher recurrence rate than did those with negative margins (47% vs 26%; P = .009). High-grade lesions at the margin were more commonly associated with recurrence than were low-grade lesions relative to those with clear margins (high-grade lesion vs negative margins, 55% vs 26%; P = .003; low-grade lesion vs negative margins, 36% vs 26%; P = .34). Recurrence was not associated either with the performance of an endocervical pass or with the histologic diagnosis of the loop electrosurgical excision procedure specimen.

CONCLUSION

With comprehensive long-term follow-up, positive margins on loop electrosurgical excision procedure specimens were shown to be a risk factor for recurrence of cervical dysplasia, particularly when high-grade lesions were seen at the margin. Recurrence was also considerable among women with negative margins. Women should be counseled regarding this risk, and the importance of follow-up should be emphasized.

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.

Diagnosis and treatment of cervical intraepithelial neoplasia in a single visit

We evaluated the diagnostic and therapeutic efficacy of large loop excision of the transformation zone (LLETZ) performed in the first visit (see and treat policy) as compared to LLETZ treatment performed as an interval procedure. Data of 248 patients were analyzed of which 206 patients had LLETZ. Two thirds of the procedures were performed at the first visit. Of all the women who had the 'see and treat policy' 94.9% were diagnosed to have cervical intraepithelial neoplasia (CIN) on histology compared to 90.8% in the interval treatment group. A total of 3 (1.4%) patients were detected to have microinvasive carcinoma. There was no difference in the immediate postoperative complication rate, overtreatment rate and need of repeat treatment in both the groups. Single visit colposcopy and loop treatment is a safe and effective option for treatment of cervical epithelial abnormalities. The experience of the colposcopist is very important.

Positive predictive rate of colposcopic examination of the cervix uteri: an overview of literature

Study of literature revealed that the positive predictive rate of the colposcopic impression is better as the cervical lesion is more severe. When directed biopsies are taken, the positive predictive rate of colposcopy increases considerably. For microinvasive disease, the positive predictive rate is quite poor, probably because of the absence of characteristic features. Large loop biopsies diagnosed all cases of microinvasive disease missed by directed biopsies, but this technique has the disadvantage of considerable "overtreatment" when integrated in the management of all patients with abnormal cytology. The restrictions of colposcopy are the invisibility of the squamocolumnar junction and observer variability in the assessment of the impression. The levels of agreement among experienced colposcopists are in the same range as those in cytological and histopathological diagnosis. It is concluded that colposcopy is an indispensable tool in the management of premalignant cervical disease, as long as the restrictions of the technique are kept in mind by the colposcopist.

Postprocedural Pap Smears: a LEEP of faith?

Loop electrosurgical excision procedure (LEEP) is gaining in popularity in the United States as an outpatient alternative to the diagnosis, and potentially the treatment, of cervical intraepithelial neoplasia (CIN). LEEP is fast, simple, performed under local anesthesia, readily learned, and without significant morbidity. As cytopathologists and cytotechnologists, immediate cytologic evaluation of cervico-vaginal smears following LEEP is not the routine; however, there are very specific artifacts, most of which are related to the transfer of thermal energy, which result from the procedure. It is important to recognize these cytomorphologic features for accurate interpretation. The indications and contraindications for LEEP are similar to those for other ablative or excisional procedures. There appears to sacrifice in the efficacy of diagnosing and treating CIN by this method. Factors predictive of disease clearance are as confounding as they are for any other cone procedure. At the University of Iowa Hospital and Clinics (UIHC), immediate post-LEEP endocervical brush (PLEB) is often performed as a method of assessing the endocervical canal for residual disease or skip lesions. The most common cytomorphologic features observed are: "taffy-pulled" nuclei in elongated endocervical cells; cell aggregates with coalesced cytoplasm; hockey stick nuclei; notched and enlarged nuclei; and, smudgy chromatin. The difficulties or most frequent diagnostic dilemmas in interpreting these smears initially include abundant blood and smudgy chromatin, often tempting an interpretation of "unsatisfactory". However, careful study reveals that these changes are related to the nature of the procedure and reproducible. Recognition and familiarization of these features enables more accurate interpretation of PLEB cytology. The significance of abnormal PLEB, with regard to disease clearance, is still uncertain.

Pseudoinvasion of vascular spaces: report of an artifact caused by cervical lidocaine injection prior to loop diathermy

Cervical loop diathermy is a relatively new procedure performed by gynecologists to diagnose and treat squamous intraepithelial lesions. We report a case of pseudoinvasion of vascular spaces noted in an excisional biopsy of a high-grade squamous intraepithelial lesion of the cervix. The neoplastic epithelium was forced into the cervical stroma by injection of local anesthetic through the lesion prior to loop diathermy. The identification of this pseudovascular space invasion as artifact had important prognostic and therapeutic value. With the increasing use of loop diathermy and local anesthesia this type of artifact may be seen more commonly.

Loop electrosurgical excision procedures for cervical dysplasia: experience in a community hospital

OBJECTIVE

The study was undertaken to evaluate the use of the loop electrosurgical excision procedure as an outpatient hospital or surgicenter procedure.

STUDY DESIGN

The records of 358 patients treated for cervical intraepithelial neoplasia at a large community hospital over a 1-year period were reviewed.

RESULTS

The specimens obtained by loop electrosurgical excision procedure and laser cone excision were comparable in size but smaller than those by means of cold-knife conization. Seventy-two percent of loop electrosurgical excision procedure specimens consisted of two to eight tissue fragments (mean 3.4). In addition, 48% of the loop electrosurgical excision procedure specimens and 38% of laser cones had moderate or severe thermal artifacts. Fragmentation and cautery damage precluded orientation of tissue and evaluation of margins in 19% of the cases.

CONCLUSIONS

The advent of the loop electrosurgical excision procedure has shifted the management of cervical intraepithelial neoplasia from the office to the outpatient surgery centers. This negates and, in fact, reverses the advantage of loop electrosurgical excision procedure over other methods in regard to cost and convenience through evaluating and treating a patient with cervical intraepithelial neoplasia in one office visit. Loop electrosurgical excision procedures provide specimens that are inferior compared with cold-knife cones; therefore the role of loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia outside the office appears limited.