Large Loop Diathermy of the Transformation Zone: Is ‘See and Treat’ An Acceptable Option for the Management of Women with Abnormal Cervical Smears?

See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions

In a see-and-treat protocol, patients referred for colposcopy because of an abnormal Pap smear in cervical-cancer screening can be treated by loop excision, without biopsy, during one visit to the clinic. However, overtreatment in the see-and-treat strategy has been reported to be 1.2-83.3% for low-grade squamous intraepithelial lesions (SIL) and to be 13.3-83.3% for high-grade SIL. Range of overtreatment narrowed to 4.0-23.5% for those with normal pathology and to 18.0-29.4% for those with normal or low-grade pathology when calculation of overtreatment was restricted to patients diagnosed with high-grade SIL on colposcopy and referral Pap smear. Most common treatment complications are bleeding and infection. Nonetheless, the strategy has become accepted internationally: low costs, decreased patient anxiety, and increased compliance make it appealing, especially in settings with limited health resources, and for patients at risk of not being treated in a timely manner or of not returning for a second appointment. Mathematical modelling may give information about the appropriateness and usefulness of this treatment while the results of long-term clinical trials are awaited.

One-step management of cervical lesions

OBJECTIVE

To test the value of diagnosing and treating cervical lesions at the first colposcopic visit using large loop excision of the transformation zone (LLETZ) based on abnormal colposcopic findings as compared with punch biopsies followed by subsequent therapy accordingly.

PATIENTS AND METHODS

Among 1255 patients with a clinically suspicious cervix, 119 patients with abnormal and satisfactory colposcopy were divided into two groups. In group A (53 patients) multiple cervical punch biopsies were taken. In group B (66 patients), LLETZ under local paracervical anesthesia was done.

RESULTS

Cervical intraepithelial neoplasia was diagnosed in 25 and 29 cases, condyloma acuminatum in seven and six cases, granulomatous cervicitis including tuberculous and bilharzial cervicitis was diagnosed in two and four cases in groups A and B, respectively. Endocervical adenocarcinoma was diagnosed in two cases in group B whereas microinvasive squamous cell carcinoma was diagnosed in one case in each group. Histopathologic assessment of the specimens obtained in group B revealed minimal coagulation artifact, adequate biopsies and free margins in all but three cases (4.5%) who needed further treatment by hysterectomy. In group B, only one case was complicated by a second hemorrhage and the overtreatment rate was 30.3%. On follow-up visits 20 patients (38%) and 59 patients (89%) were satisfied with the procedure in both groups, respectively. Further treatment was required in 29 cases in group A (55%) after initial assessment of punch biopsies and in three cases in group B (4.5%). Persistent abnormal colposcopic findings at follow-up visits 3 months after diathermy coagulation were seen in five patients (9.4%) in group A.

CONCLUSIONS

LLETZ at the first colposcopic visit is a practical and fast method of treating most cervical lesions with limited complications and has the advantage of eliminating a second session of treatment. These advantages, particularly in developing countries, may outweigh the high overtreatment rate of this procedure. Many cervical lesions can be properly treated using large loop excision of the transformation zone at the first colposcopic visit. This may help save time and resources, especially in developing countries.