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PubMed1997

Risk of residual invasive disease in women with microinvasive squamous cancer in a conization specimen.

OBJECTIVE: To quantify the risk of residual invasion when cervical conization reveals microinvasive squamous carcinoma and to determine whether any factors affect this risk. METHODS: We reviewed the charts and histopathology slides of 87 women who underwent a conization that contained microinvasive squamous carcinoma, followed by either a repeat conization or hysterectomy. Depth of invasion, number of invasive foci, and status of the internal margin and post-conization endocervical curettage (ECC) were assessed. The findings were correlated with the presence of residual invasion. RESULTS: Significant predictors of residual invasion included status of the internal margin (residual invasion present in 22% of women with an involved margin versus 3% with a negative margin; P < .03) and the combined status of the internal margin and post-conization ECC (residual invasion in 4% of patients if both negative, 13% if one positive, and 33% if both positive; P < .015). Depth of invasion and number of invasive foci in the conization specimen were not significant. The power of this study to detect a 25% difference in the risk of residual invasion was 73% for depth of invasion and 75% for number of invasive foci. CONCLUSION: Women with microinvasive squamous carcinoma in a conization specimen in which both the internal conization margin and post-conization ECC are negative have a low risk of residual invasion and are candidates for follow-up or simple hysterectomy. If either the internal margin or the post-conization ECC contains dysplasia or carcinoma, the risk of residual invasion is high and warrants repeat conization before definitive treatment planning.

Carcinoma, Squamous Cell↗

PubMed1995

Predictive factors from cold knife conization for residual cervical intraepithelial neoplasia in subsequent hysterectomy.

OBJECTIVE: The optimal management of cervical intraepithelial neoplasia after cold knife conization remains controversial. Reliable predictors of residual dysplasia in the cervix after cold knife conization have not been consistently identified. This study was initiated to examine the accuracy of the traditional factors used to predict residual dysplasia in hysterectomy specimens after cold knife conization. STUDY DESIGN: A retrospective 10-year chart review identified a cohort of 1272 patients who underwent cold knife conization, of whom 311 had a subsequent hysterectomy within 1 year of conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. All cone specimens were completely submitted for pathologic examination, and the following factors were analyzed for their predictive value: degree of dysplasia, margin involvement, endocervical gland involvement, and status of the endocervical curettage. The predictive value of age, race, gravidity, parity, socioeconomic status, cigarette smoking, and marital status were also examined. The chi 2 test, t test, and logistic regression were used for statistical analysis. RESULTS: Dysplasia or cancer were identified in 1066 (84%) of the 1272 patients who underwent cold knife conization. Of the 311 patients having a subsequent hysterectomy, 106 (34%) had residual disease in their hysterectomy specimen. By multivariate analysis only increasing age and degree of dysplasia were predictive of residual disease. The odds ratio of residual disease in the hysterectomy specimen for a 25-year-old woman was 2.7 (95% confidence interval 1.6 to 4.4) compared with a 40-year-old woman whose odds ratio was 4.9 (95% confidence interval 2.2 to 10.8). The presence of dysplasia in the cold knife conization specimen conferred an odds ratio of 12.1 (95% confidence interval 2.7 to 54.5) of identifying residual disease. Dysplasia involving the ectocervical margin, endocervical margin, and endocervical glands was not predictive of disease in the hysterectomy specimens. Endocervical curettage was not performed in 44% of the patients, preventing reliable statistical evaluation. Further analysis indicated that residual disease was found in 32% of the hysterectomy specimens with negative margins, in 31% with no endocervical gland involvement, and in 23% with a negative endocervical curettage sample. CONCLUSIONS: The presence or absence of dysplasia in the cold knife conization ectocervical margin, endocervical margin, and endocervical glands was not predictive of residual dysplasia in post-cold knife conization hysterectomy specimens. Increasing age and severity of disease in the cone specimen were the only factors that accurately predicted residual dysplasia. The traditional factors used to justify hysterectomy after cold knife conization may not be valid on the basis of these results.

Adolescent↗

PubMed1999

Conization of the cervix using harmonic scalpel.

Conization, as a surgical treatment for cervical intraepithelial neoplasm (CIN), is a good method that preserves reproductive functions. Technological developments have introduced a wide variety of energy sources for surgical procedures. Traditional cold knife conization has been replaced by laser conization and by the loop electrosurgical excisional procedure (LEEP). However, laser conization and LEEP have some disadvantages. Laser conization requires expensive equipment. LEEP induces electrocautery artifacts and cannot excise the cervical tissue as a single-piece, because of the various extensions and depths of lesion, so that evaluation of the margins is sometimes not possible. Laser conization and LEEP both generate smoke. The presence of smoke is not only inconvenient, but also dangerous. Harmonic Scalpel (HS), ultrasonic cutting and coagulation system, is a new surgical tool that cuts and coagulates using ultrasonic mechanical vibrations. Eleven women with CIN III underwent conization using HS. HS eliminated the major disadvantages of electrosurgery and laser surgery. No complications during conization were observed. Postoperative hemorrhage was noted in only one patient. Histological diagnosis was not affected by heat or ultrasound. This surgical method using HS is characterized by negligible bleeding, a good visual field not obscured by smoke and resection of an ideal shape that fits the size of the lesion. It is concluded that this method overcomes most problems associated with conization using conventional methods.

Adult↗

PubMed1995

Loop diathermy and cold-knife conization in patients with cervical intraepithelial neoplasia: a comparative study.

One hundred and sixty-eight cases of cervical conization were performed for cervical intraepithelial neoplasia (CIN) in a 32-month study. The indications for conization were unsatisfactory colposcopic finding, abnormal epithelium that extended into the endocervical canal, a microinvasive cervical cancer, and significant discrepancy among cytology, colposcopy, and/or punch biopsy histology. In the early period of the study, conization was done by the cold-knife method (N = 107), whereas loop diathermy was used in the latter part of the study (N = 61). Both groups were similar in terms of age, indications for conization, and size of cervical cone specimens. Loop diathermy conization was done in a significantly shorter time (5.7 +/- 1.8 minute vs 15.2 +/- 6.1 minute)(P < 0.05) than cold-knife conization. However, the difference in the postoperative complications between loop diathermy(3.0%) and cold-knife conization(4.7%) was not significant. The incidence rate of residual CIN III lesions in the subsequent hysterectomy specimens, found by histological documentation on these specimens was 25.0 and 26.1 percent after loop diathermy and cold-knife conization respectively. These results suggest that loop diathermy is much easier to perform and a more time-conserving treatment modality than cold-knife conization in the management of patients with cervical intraepithelial neoplasia.

Adult↗

PubMed1997

Influence of diagnostic conization on surgical morbidity and survival in patients undergoing radical hysterectomy for stage IB and IIA cervical carcinoma.

The purpose of this retrospective study was to investigate whether diagnostic conization influenced surgical morbidity of a subsequent radical hysterectomy in patients with early cervical carcinoma. Furthermore, the impact of an irradical conization on nodal metastases and prognosis was analysed. Included were 271 patients with stage IB and IIA cervical carcinoma who underwent an Okabayashi radical hysterectomy between 1982 and 1991. There were 68 patients who underwent conization prior to radical hysterectomy. The conization-radical hysterectomy interval was approximately six weeks. Surgical morbidity in patients with a previous conization was not significantly different from that in patients without a previous conization. Survival was also not significantly different between these groups (95% vs. 91%, p = 0.23). Multivariate analysis showed that an irradical conization was not associated with an increased risk for nodal metastases or a poorer prognosis. We suggest that in early cervical carcinoma, a diagnostic conization does not adversely affect early morbidity of a following radical hysterectomy. An irradical conization does not seem to influence prognosis.

Adult↗

PubMed1994

[Increased risk of preterm delivery in women with earlier conization].

The object of the study was to determine the relation between cervical conization and preterm birth. All Danish women with singleton pregnancies who gave birth to their first infant in 1982 and second infant in 1982-1987 were included in a register-based cohort study. Information on pregnancy outcome and cervical conization in 1977-1987 was obtained from the Medical Birth Register and the National Register of Hospital Discharges. It was found that in a cohort of 14.233 women, 170 had had cervical conization. Thirty-four had had cervical conization before the first delivery, 62 between the first and the second, and 74 after the second delivery. Women with cervical conization had a significantly higher risk of preterm birth. Also, women with subsequent cervical conization had a higher risk of preterm birth in previous pregnancies. However, the risk of preterm birth was higher in women with previous than with subsequent cervical conization. It is concluded that cervical conization is correlated with preterm birth. Since women with subsequent cervical conization are at increased risk of preterm birth in preceding pregnancies, other factors than the surgical intervention may contribute to the significantly increased risk of preterm birth.

Adult↗

PubMed1993

Diagnostic and therapeutic conization using loop radiothermal cautery.

A group of 173 patients with abnormal cervical cytology underwent diagnostic or therapeutic conization following colposcopic examination. The series includes 23 patients with cold knife conization in the hospital under general anesthesia, 12 patients with an outpatient KTP laser procedure under local anesthesia, 53 patients with an outpatient CO2 laser procedure under local anesthesia, 10 patients with hospital-based loop radiothermal cautery conization and 75 patients with loop radiothermal cautery conization in the office under local anesthesia. Loop radiothermal cautery conization was advantageous, with a shorter duration of surgery, lower cost, reduced operative bleeding, less of a need for pain-relieving medication and shorter duration of postoperative disability. Cold knife conization patients had the most intraoperative bleeding and the longest hospitalization. KTP laser conization produced specimens of inferior quality, resulting in the least satisfactory histologic diagnosis. Office-based loop radiothermal cautery conization may be preferable to other methods of conization in the diagnosis and management of squamous intraepithelial lesions.

Colposcopy↗

PubMed1993

Increased risk of preterm birth in women with cervical conization.

OBJECTIVE: To determine the relation between cervical conization and preterm birth. METHODS: All Danish women with singleton pregnancies who gave birth to their first infant in 1982 and second infant during the time period 1982-1987 were included in a register-based cohort study. Information on pregnancy outcome and cervical conization in 1977-1987 was obtained from the Medical Birth Register and the National Register of Hospital Discharges. RESULTS: In a cohort of 14,233 women, 170 had cervical conization. Thirty-four had cervical conization before the first delivery, 62 between the first and the second, and 74 after the second delivery. Women with cervical conization had a significantly higher risk of preterm birth. In addition, women with subsequent cervical conization had a higher risk of preterm birth in previous pregnancies. However, the risk of preterm birth was higher in women with previous than with subsequent cervical conization. CONCLUSIONS: Cervical conization is correlated with preterm birth. Because women with subsequent cervical conization have an increased risk of preterm birth in preceding pregnancies, factors other than the surgical intervention may contribute to the significantly increased risk of preterm birth.

Adult↗

PubMed1976

[Conization of the uterine cervix in prevention and diagnosis of cancer (author's transl)].

The result of conization of the uterine cervix in 446 cases was reviewd regarding the diagnostic and preventive therapeutic value of the procedure with special attention to post-operative complications. Conizations for benign lesions of the cervix in 33 patients resulted in a well formed cervix with squamous epithelium covering of the ectocervix in 32 patients. There was only 1 failure. In 413 diagnostic conizations with extensive microscopic work-up the lesion was only completely removed in 62% of the cases. In spite of careful colposcopy and Schiller iodine marking the external margin of the cone biopsy material went through the atypical lesion in 51% of the cases. It is therefore necessary to extend the limits of the cone biopsy specimen in all cases as far to the periphery and upwards into the canal as feasible. The incidence of early and late complications was 10.9%. In 133 conizations with hemostasis by cauterization the complication rate was 22.6%. This rate was reduced to a complication rate of 5.2% in 261 cases with hemostasis by suture. The commonest early complication was cervical bleeding. The only late complication was stenosis of the cervical canal. After conization of the cervix 18 of 22 pregnancies were uncomplicated. The increased incidence of cervical dystocia following conization of the cervix is significant and was the indication for Caesarean Section in 6 cases. For the prevention of cancer, the indication for conization of the cervix should be diminished in favor of an increase of the indication for hysterectomy because of the high failure rate of conization to prevent cancer (37%) and because of the relatively high incidence of complications of conization.

Biopsy↗

PubMed1995

Adequacy of conization margins in adenocarcinoma in situ of the cervix as a predictor of residual disease.

In this retrospective analysis, 18 patients with adenocarcinoma in situ (AIS) of the cervix diagnosed on cervical conization between April 1988 and June 1994 were identified. The margins of all specimens were assessed for disease involvement. If hysterectomy or repeat conization was performed, the presence of AIS in the specimen was ascertained. Eleven of 18 conizations (61%) had AIS with negative margins of resection. Two of these 11 patients (18%) were followed conservatively and have had negative Pap smears for a mean of 1.7 years. The remaining 9 patients (82%) were treated by hysterectomy, with 4 (44%) showing residual AIS in the final surgical specimen. Six of the 18 conizations (33%) had positive margins for AIS. Five of these patients (83%) were treated with hysterectomy and one patient was treated with a repeat conization. Three of the five hysterectomy specimens as well as the repeat conization specimen (67%) contained residual AIS. One conization (6%) had margins that could not be assessed. The absence of residual AIS in the final surgical specimen was not predicted by the negative margin status on the conization.

Adenocarcinoma↗

PubMed1999

A study of diagnostic failure of loop conization in microinvasive carcinoma of the cervix.

OBJECTIVE: The aim of this study was to evaluate the specimen adequacy and the histological interpretation of loop conization for microinvasive cervical carcinoma. METHODS: We retrospectively reviewed the histopathological findings of the original cone specimens together with the final hysterectomy specimens in patients with microinvasive carcinoma of the cervix. From 1990 to 1995, 63 consecutive patients with microinvasive carcinoma of the cervix were included in the study, of which 35 patients underwent loop conization and 28 underwent cold-knife conization. All patients had a hysterectomy. RESULTS: The mean width, depth, and cone volume of the conization specimens were 2.44 cm, 2.15 cm, and 3.96 cm3, respectively, in the loop group versus 2.3 cm, 2.35 cm, and 4.38 cm3 in the cold-knife group. No significant differences were seen between the two groups. The application of loop conization was completed in a single slice in 27 patients (77.1%) and multiple slices by the loop in 8 (22.9%), in spite of the attempt to perform conization in a one-pass application when possible. In assessing these cone specimens microscopically, the rate of transection of tissue was significantly higher in the loop cone than in the cold-knife cone (17.1% versus 0%, P = 0.02). Because of transection of tissue and misorientation, pathologic determination of the depth and width of stromal invasion was undetermined in two loop cone specimens compared with none in the cold-knife cones. CONCLUSION: Our study suggests that cold-knife conization is a preferred method in assessing microinvasive carcinoma of the cervix if multiple applications of loop conization are inevitable.

Adult↗

PubMed2000

[LEEP versus cold knife conization for treatment of cervical intraepithelial neoplasias].

OBJECTIVE: This study was performed to evaluate the effectiveness and side effects of loop electrosurgical excision procedure (LEEP) in comparison to cold knife conization for the treatment of cervical intraepithelial neoplasia (CIN). MATERIAL AND METHODS: Between January 1996 and July 1998, 177 patients underwent conization. In a matched-pair setting, 50 cases with LEEP were compared with 100 classical conization cases. LEEP was performed with ectocervical and endocervical excision. RESULTS: Perioperative complications were less in the LEEP group (6% vs. 11%). The mean volume of LEEP specimens (1.6 cm3) was significantly smaller than the volume of cone specimens (2.6 cm3). Thermal artifacts were negligible. There were no significant differences in the proportion of margin involvement (20% vs. 19%) and residual/recurrent CIN. The endocervical excision contained dysplastic tissue in 38% of the cases; more important, a positive endocervical excision was found in 14/21 CIN 3 cases (67%). The success rate, was similar in both groups (96% vs. 97%). Hospitalization time was less for the LEEP group. CONCLUSIONS: LEEP conization is a safe and cost effective procedure with a lower complication rate providing a significantly smaller specimen compared to cold knife conization. Therefore, LEEP conization may substitute cold knife conization. However, we do recommend to perform LEEP conization with an endocervical excision to reduce residual CIN.

Adult↗

PubMed2000

Margin clearance and HPV infection do not influence the cure rates of early neoplasia of the uterine cervix by laser conization.

A lesion existing in the endocervical and/or ectocervical conized margin and HPV-DNA existing in a conized specimen are reported to be at risk of persistence or recurrence of early neoplasia of the cervix when treated by conization. The aim of this study was to investigate whether margin clearance and HPV infection influenced the outcome in our series of laser conization. Excisional conization with the KTP/YAG Surgical Laser System or Nd-YAG laser was performed in this study. Eighty patients with cervical neoplasias were included: 47 with dysplasia, 25 with carcinoma in situ (CIS) and eight with microinvasive carcinoma. The endocervical and ectocervical conized margins were examined microscopically. HPV-DNA was analyzed with the primer for types 16, 18, 31, 33, 35, 52b and 58 amplified by the PCR method. The margins of the conized specimens were confirmed histopathologically to be clear in 58 cases (73%), whereas in 22 cases (27%) they were involved by neoplasia. HPV-DNA was positive in 38% of dysplasias, 40% of CISs and 50% of microinvasive carcinomas. The overall rate of the initial cure at 10 weeks after treatment appeared to be 100% in all 80 cases. Primary cure rates were 100% for 47 cases with dysplasia, 96% for 24 cases with CIS and 100% for four cases with microinvasive carcinoma regardless of margin positivity and HPV-DNA status. Involved margins and HPV infection did not influence the cure of early neoplasia of the uterine cervix achieved by our laser conization procedure. The favorable results may be due to the procedure of vaporizing the cut surface forming a dome-shaped tissue defect.

Conization↗

PubMed1992

Cervical conization: cold knife and laser excision in residency training.

During a 2-year period, 293 consecutive conizations performed by residents in obstetrics and gynecology were reviewed. One hundred sixty-one patients underwent laser excision and 132 women were treated by cold knife conization. Average operating times for laser excision and knife conization were 31 and 33 minutes, respectively. Combined minor and major complication rates for laser and knife cones were 19 and 30%, respectively. Major complications including cervical stenosis and heavy bleeding were seen in 20% of knife conizations and 6% of laser excisions. Average blood loss for knife conization was 65 mL, and average blood loss for laser conization was 34 mL. Among those examined in follow-up with cervical cytology and colposcopy, no patient in the laser excision group showed evidence of persistent dysplasia, compared with one patient (3%) in the knife conization group. The reported data suggest no difference in operating time, length of anesthesia, or success of treatment between laser excision and knife conization performed by residents in training. Fewer complications were seen in the laser excision group.

Anesthesia, Obstetrical↗

PubMed1992

Laser vaporization conization.

Laser vaporization conization is a modified technique for the diagnosis and treatment of cervical intraepithelial neoplasia. Two circles are marked on the cervix with the laser; the inner circle outlines the circumference of the conization specimen, while the outer one outlines an area 3 mm peripheral to all colposcopically abnormal tissue. The area between the circles is vaporized to 7 mm. This initial vaporization allows easier manipulation of the conization specimen. Laser conization is then performed. This technique is significantly easier to perform than laser excisional conization or combination excisional-vaporization conization and thus is ideal for teaching residents laser conization. Besides ease of performance, laser vaporization conization retains the advantages of laser vaporization and provides a specimen for pathologic review. In this study the median laser time was 14 minutes. There was minimal operative hemorrhaging, and only one patient (2%) developed a secondary cervical hemorrhage. A significant laser artifact was present in one case (2%). One case of invasive squamous cell cancer was diagnosed.

Adult↗

PubMed1986

[Determination of residual lesion in remaining uterus after conization].

For the purpose of predicting the residual lesion in the remaining uterus after conization, the relationship between the residual lesion in the extirpated uterus and the foci in conization specimens was examined. Seventy-seven cases with severe dysplasia, carcinoma in situ and early invasive carcinoma of the uterine cervix diagnosed by punch biopsy were reviewed. The histopathologic diagnosis, the distance from the conization stump to the focus, the length of the focus along the cervical canal, the size of the conization specimens, the number of blocks containing a focus and so on were investigated. It is concluded that there is no residual lesion in the remaining uterus after conization when the following criteria are satisfied. The histopathologic diagnosis is Ia or less. The conization stump is not involved. The distance from the conization stump to the focus is more than 3.1mm and the length of the lesion along the cervical canal is less than 8.5mm. The distance from the conization stump to the focus is no more than 3.1mm, gland involvement is not recognized in this area and the length of the lesion along the cervical canal is less than 8.5mm.

Adult↗

PubMed1976

[Results of the conservative management of carcinoma in situ of the uterine cervix by conization (author's transl)].

From 1958 to 1969 conizations for carcinoma in situ of the uterine cervix were carried out in 683 women. In 523 cases no further therapy was instituted immediately. Step serial sections of the conization specimens showed that carcinoma in situ was completely removed in 346 (66.2%) of the cases. In 177 (33.8%) of the cases, the excision of the atypical epithelium was incomplete or not with certainty complete, by the conization. Of these patients 43 women were older than 45 years. Follow-up examinations after conization with complete removal of all atypical epithelium showed that only one case showed again a pathological epithelium. In this case, hysterectomy for an adnexal tumor four years after conization showed a mild dysplasia of the endocervix. Follow-up examination of the cases with incomplete or possibly incomplete conization showed no further pathological finding in 90% of the cases. In 19 (10.7%) of the women, atypical epithelium reappeared after varying lengths of follow-up. In 4 women, invasive carcinoma had developed and in 2 women, microinvasive carcinoma had developed. Following operative treatment, further follow-up examinations in these patients were negative. Conization of the uterine cervix with complete removal of all atypical epithelium is shown to be adequate treatment for carcinoma in situ. In cases with incomplete or not with certainty complete removal of atypical tissue by conization, individual follow-up is necessary. If further pregnancies are desired the small risk of observation is justifiable. Diagnosed persistence of atypical epithelium is an indication for a hysterectomy. Hysterectomies are also necessary if the patient does not comply adequately with the follow-up protocol.

Adult↗

PubMedDate not supplied

Cold knife conization and loop excision for cervical intraepithelial neoplasia.

AIMS AND BACKGROUND: Our aim was to investigate whether loop excision is an acceptable alternative to traditional cold knife conization of the cervix. PATIENTS AND METHODS: 240 with cervical intraepithelial neoplasia (CIN) were randomly assigned to loop excision (n = 120) or cold knife conization (n = 120). Success and complication rates of both methods were analysed. RESULTS: 100% of cold knife conization and 98% of loop excision surgical specimens were positive for dysplasia. The rate of complete resection was 91% in the cold knife and 82% in the loop excision group, but histologic confirmation of residual CIN was obtained in only 2 (1.7%) women after cold knife conization and in 5 (4.2%) after loop excision. Loop excision cones were significantly shallower than those obtained by a cold knife. Secondary surgical procedures due to early hemorrhage were performed in 9 (7.5%) patients treated with cold knife conization and in 8 (6.7%) treated with loop excision. Elevated temperature postoperatively was observed in 16.4% of patients after cold knife conization and in 13.9% after loop excision. There were no other postoperative complications. CONCLUSIONS: The results suggest that cold knife conization and loop excision are comparable and equally effective diagnostic and therapeutic procedures for CIN.

Adult↗