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PubMed2002

Adenocarcinoma in situ of the cervix: a prospective study of conization as definitive treatment.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of combination laser conization alone as definitive treatment of adenocarcinoma in situ (AIS) and to evaluate the safety of a conservative expectant strategy irrespective of cone margin status. METHODS: Sixty consecutive patients with histologically proven adenocarcinoma in situ were treated with combination laser conization from 1990 to April 2001. In 58 cases this was considered final therapy, and patients were followed for a mean period of 49 months. RESULTS: The mean age was 34.9 years. Preconization evaluation demonstrated AIS in 76.7%. In 58 cases conization was considered final therapy, and in these cone margins were involved in 15 cases. Twenty-seven patients (46.6%) were followed for more than 60 months. Totally, 4 recurrences (6.9%) were observed. One recurrence was observed in patients with involved margins (6.7%) 4 months after conization, and 3 recurrences in patients with uninvolved margins (6.9%) were registered, in 2 cases more than 5 years after conization. No case of invasive disease was diagnosed during follow-up. The mean cone height was 19 mm; 16.7% of the cone biopsies were more than 25 mm. CONCLUSIONS: Combination laser conization was an effective treatment of AIS, and an expectant follow-up schedule based on cytology was demonstrated to be safe irrespective of cone margin status after a significant follow-up period. A potential risk of overtreatment and unnecessary worrying of the patients exists if further treatment is based solely on the status of the cone margins. Only prospective studies of similar strategies will give sufficient evidence for valid recommendations concerning the management of AIS.

Adenocarcinoma↗

PubMed2003

Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions.

OBJECTIVE: The aim of the study was to evaluate human papillomavirus (HPV) testing during the follow-up of patients after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesion. METHODS: A prospective study was conducted on 205 patients who underwent conization for high-grade squamous intraepithelial lesion (CIN 2 or 3). Loop electrosurgical excision procedure (LEEP) was used in all cases. High-risk HPV testing was realized by the Hybrid Capture II system before and 3 months after conization. RESULTS: Of the 205 patients, 193 (94.1%) were positive for the HPV test before conization. Seventy-one were HPV positive after conization (34.6%). The margins were positive in 36.1%. Residual disease was observed in 27 cases (13.2%). Four patients (2%) developed a recurrence after a mean follow-up of 18.1 months (+/-12). There was no correlation between pretreatment HPV testing and the residual disease or recurrence. Patients with positive margins were significantly more likely to have residual disease than those with negative margins (P < 0.0001). Residual disease was more likely to occur when the posttreatment HPV test was positive (P < 10(-7)). All recurrences were observed in patients with a positive posttreatment HPV test (P < 0.05). Residual disease and recurrence were correctly predicted with a sensitivity of 81 and 100%, respectively, and a negative predictive value of 96 and 100%. CONCLUSION: Posttreatment HPV testing could be useful in the follow-up of patients after conization. In case of negative posttreatment HPV testing, the frequency of follow-up could be reduced, particularly in those patients with free margins.

Adolescent↗

PubMedDate not supplied

The expression of epidermal growth factor receptor, vascular endothelial growth factor, matrix metalloproteinase-2, and cyclooxygenase-2 in relation to human papilloma viral load and persistence of human papillomavirus after conization with negative margins.

The aim of this study was to investigate the correlations between human papillomavirus (HPV) load and vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR), matrix metalloproteinase-2 (MMP-2), and cyclooxygenase-2 (COX-2), and to identify biomarkers that may predict high-risk HPV clearance or persistence after conization with negative margins. The following samples were analyzed: 77 paraffin-embedded specimens from patients with cervical intraepithelial neoplasia (CIN), including 27 CIN 2 conization specimens and 50 CIN 3 conization specimens. Immunohistochemical analysis was performed with antibodies to VEGF, EGFR, MMP-2, and COX-2. Hybrid capture II testing was used to detect HPV DNA. VEGF expression was significantly associated with HPV load (rho = 0.27186, P = 0.0191), while COX-2 expression was significantly and inversely associated with HPV load (rho = -0.34309, P = 0.0028). In univariate analysis, HPV load (P = 0.0112) and VEGF expression (P = 0.0274) were significantly associated with high-risk HPV clearance or persistence after conization with negative margins. In multiple regression analysis, high viral load (relative light unit/positive control > 500) and positive VEGF expression were significantly associated with high-risk HPV persistence after conization with negative margins (odds ratio [OR]: 9.915, CI: 1.891-51.994; OR: 6.661, CI: 1.208-36.722, respectively). In conclusion, VEGF expression is related to HPV load, while COX-2 expression is inversely related to HPV load, and immunohistochemical analysis of VEGF expression and HPV viral load are a significant and an independent prognostic indicator of high-risk HPV persistence after conization with negative margins.

Adult↗

PubMedDate not supplied

Outcome after conization for cervical intraepithelial neoplasia grade III: relation with surgical margins, extension to the crypts and mitoses.

AIMS AND BACKGROUND: Factors linked to residual neoplasia and recurrence following conization of the uterine cervix for treating cervical intraepithelial neoplasia grade III (CIN III), such as the surgical margins, extension of CIN into the crypts and the number of mitoses, have been studied with contradictory results. We evaluated patients submitted to conization for CIN III and analyzed the aforementioned factors, relating them to recurrence and residual neoplasia in hysterectomy specimens. METHODS: The surgical specimen of cold-knife conization for CIN III performed in 63 patients (average age, 37.3 +/- 9.3 years) was fixed in 4% formaldehyde. The ectocervical and endocervical margins were removed and the cone was cut into fragments perpendicular to the surface of the endocervical mucosa (1 mm thick). One histological section (5 microm thick) was cut from each block and stained with hematoxylin-eosin. We studied the total number of fragments from each cone and affected by CIN, endocervical and ectocervical margins, extension to the crypts, number of mitoses and tripolar mitoses in 100 microscope fields using a 100x objective. RESULTS: The endocervical margin was involved in 34.9% vs 9.5% (P = 0.001) of ectocervical margins. Recurrence affected 53.8% of cases presenting involved margins versus 12.9% in the cases without involved margins (P = 0.0078). The average interval to recurrence was 3.2 years. CIN was present in 2.5 to 100% (median, 28%) of the cone fragments (median no., 28; range, 7-95). A median of 44.4% and 25% of cone fragments presented CIN with and without recurrence, respectively. Correlation of the number of mitoses with tripolar mitoses and the percentage of fragments involved by CIN with the number of mitoses and tripolar mitoses showed, respectively, P = 0.02, 0.05 and 0.005. A median of 142 mitosis and 4 tripolar mitosis were observed per case with disease recurrence versus 104 and 3 (P = 0.02, 0.6), respectively, when recurrence did not occur. Of 14 patients who underwent hysterectomy after conization (mean, 3.6 +/- 3 months afterwards) for endocervical or both margins involved by CIN in the cone specimen, 8 (57.1%) presented CIN III and one (7.1%) microinvasive carcinoma. In 96.8% of the conizations, the CIN extended to the crypts. CONCLUSIONS: Involved margins and mitoses are associated with a greater recurrence rate for CIN. Residual neoplasia in the hysterectomy specimen after an involved margin with conization is frequent.

Adult↗

PubMed1999

Loop diathermy or laser excisional conization for cervical intraepithelial neoplasia.

BACKGROUND: Cervical intraepithelial neoplasia (CIN) can be managed by ablative or excisional procedures. We have compared the excision time, effectiveness, and safety of loop diathermy (loop) against laser conization. METHODS: In a prospective study in two hospital departments 222 women were randomized to loop or laser conization. Data were collected by questionnaires after operation and at two follow-up examinations. RESULTS: At department A (122 women), two physicians performed 27% of the loop and 35% of the laser excisions; at department B (100 women), the corresponding figures were 69% and 59%. Loop was quicker than laser conization in both departments (median 3-4 min versus 10-20 min), while laser conization was more time consuming in department A (median A/B = 20/10 min). Peroperative bleeding dominated during the laser procedure in both departments and complicated the loop procedure more frequently in department A. Postoperative bleeding occurred with equal frequency in the four groups (41.8%, 52.7%, 59.2%, 64.7%). At both departments, bleeding for more than two weeks was reported twice as often after laser conization (A:13.8%, B:24.2%), when compared to loop excision (A:7.1%, B:13.7%). Residual CIN was found in all of three re-conizations and in one of eight hysterectomy specimens. CONCLUSIONS: Loop was quicker than laser excision, per- and postoperative bleeding diminished, and the success rates were comparable. Physicians mastered Loop excision after a few attempts. However, the results improved, when performed by a restricted number of physicians. Histological incomplete excision indicates close colposcopic and cytologic follow-up to identify residual CIN.

Adult↗

PubMed1985

Carbon dioxide laser for combination excisional-vaporization conization.

Extensive cervical intraepithelial neoplasia may simultaneously involve large areas of the ectocervix, even extending to the vaginal fornices, as well as the endocervical canal. In such instances conventional sharp knife conization would result in virtual removal of the cervix if the surgeon wished to completely circumscribe the entire lesion. By combining a narrow carbon dioxide laser excisional conization with ectocervical vaporization, cervical intraepithelial neoplasia may be eradicated by a virtually bloodless surgical procedure and fertility may be preserved. Sixty-one combination conizations with 6 months to 4 years of follow-up are reported. In 95% of the cases biopsy demonstrated cervical intraepithelial neoplasia in three or more ectocervical quadrants, and 16% had extension of disease into the vagina. The technique of combination conization uses 20 to 30 W of power and 1/2 to 1 mm spots for excision and 10 to 15 W and 1 to 1.5 mm spots for vaporization. The average time to complete the entire procedure was 21 minutes. In three of 61 cases endocervical margins were positive; there were no instances of persistence of neoplasia at either the ectocervical or the vaginal margins. Four complications were observed, all related to delayed bleeding; however, only two patients required the placement of a suture. The volume of tissue removed by a large excisional conization is more than two times greater than that of a laser combination conization.

Adolescent↗

PubMed1992

Diagnostic value of conization of the uterine cervix in the management of cervical neoplasia: a review of 756 consecutive patients.

A review of 584 consecutive cases of conizations performed over a 15-year period showed that 320 patients (54.8%) had conizations because of the presence of neoplastic cells in the endocervical curettings. Of these patients, 268 (83.4%) had cervical intraepithelial neoplasia of various grades on conization, and 12 (3.6%) had microinvasive cancer. The remaining 40 patients had normal cervical epithelium. One hundred seven (18.3%) patients had conization because of cytological smear and colposcopy discrepancy. Seventy-six (71.0%) patients in this category had cervical intraepithelial neoplasia. Two (2.0%) had superficially invasive cancer; the remaining 29 patients had normal cervical histology. Sixty-seven (11.5%) had conizations because of unsatisfactory colposcopic evaluations. This review indicates that although conization is less frequently performed, it is still a useful tool in the management of patients with abnormal cytology in whom colposcopy evaluation cannot rule out invasive cancer.

Adolescent↗

PubMed1983

A comparison of complications of laser and cold knife conization.

A comparison was made of intraoperative and postoperative complications of laser conization and cold knife conization. Of 428 women hospitalized for cold knife conization, 23.6% had one or more complications; 14.3% had postoperative hemorrhages, 6.8% had infections, and 4.7% suffered from stenosis. Two hundred sixteen women were hospitalized for laser conization; 5.1% of them suffered complications. Postoperative hemorrhages occurred in 2.8% and infections in 2.3%. No case of stenosis occurred. Laser conization as an outpatient procedure was undertaken in 240 women; 4.2% had complications. Postoperative hemorrhages occurred in only 2.5%, infections in 1.3%, and stenosis in 0.8%. Laser conization has the same complication rate as laser vaporization and can be safely performed on an outpatient basis, thereby reducing hospital costs.

Adult↗

PubMed1984

[Evaluation of cervical conization as a definitive treatment for borderline lesions of the uterine cervix].

Therapeutic efficacy of cervical conization was examined on 93 patients with borderline lesions of the uterine cervix who underwent hysterectomy following conization. No lesions or only minimal residual lesions were found at subsequent hysterectomy when the surgical margins of cone specimens were not involved in the malignant or premalignant lesions. From these results, we concluded that cervical conization could be considered as a therapeutic procedure when the following conditions were fulfilled. Cone specimens are sufficient in size. Both endocervical and exocervical margins are negative. No malignancy is found on endocervical curettage. No abnormal cytologic findings are found after conization. Another follow-up study was performed on 69 patients who received therapeutic conization between 1971 and 1981. Among them one developed stage II cervical cancer two years after the last follow up. Two other patients had recurrent CIN in the cervix and another patient was found to have an endometrial cancer. These patients were successfully treated after early detection of the lesions by the cytological examination. From these facts, cytological examination is recommended in the follow-up after therapeutic conization.

Adenocarcinoma↗

PubMed1994

Thermal tissue damage following laser and large loop conization of the cervix.

OBJECTIVE: To compare thermal injury zones produced with laser and diathermy loop conization. METHODS: Excisional cervical specimens (cones and cervices) were obtained from 40 consecutive women who underwent abdominal hysterectomy. The subjects were assigned to have either laser or diathermy loop conization (20 in each group). The duration of each procedure was recorded. Histopathologic measurements of thermal injury zones were performed in all specimens. RESULTS: The techniques produced cone specimens of similar depth. The mean depth of thermal injury produced with laser conization in cone specimens (mean +/- standard deviation 0.49 +/- 0.16 mm) and cervical craters (0.58 +/- 0.24 mm) was significantly greater (P < .001) than the corresponding depth in cone specimens (0.22 +/- 0.09 mm) and cervical craters (0.27 +/- 0.11 mm) obtained by diathermy loop excision. The mean time of the two procedures was also significantly different (P < .001); laser conization 11 +/- 4.5 minutes and loop conization 2 +/- 1.2 minutes. CONCLUSION: For routine conization, loop diathermy causes less thermal damage to the specimen and is a faster procedure than laser.

Adult↗

PubMed1994

[Relation between cervical conization, microbial colonization and threatening preterm labor].

UNLABELLED: The relationship between prior cervical conization, the cervical microbial colonization and threatening preterm delivery was investigated in 35 women with preterm premature rupture of the membranes (PPROM), 38 women with idiopathic preterm labor and 75 normal pregnant women at 26-34 weeks of gestation. Prior cervical conization occurred with a significantly higher frequency in PPROM patients than in patients with preterm labor (p < 0.01) and normal pregnant women (p < 0.001). The prevalence of lactobacilli was lower in patients with PPROM than in patients with preterm labor (p < 0.05) and control patients (p = 0.05)--and lower in patients with prior cervical conization than in patients without prior conization (p < 0.05). All other microorganisms occurred with the same frequencies in all groups. CONCLUSIONS: Prior conization was associated with PPROM. Women with prior conization and women with PPROM had a reduced prevalence of lactobacilli in the cervix. The "absence" of lactobacilli may indicate changes in the cervical microflora, which could be of importance for PPROM.

Adult↗

PubMed1996

Loop electrocautery excisional procedure: therapeutic effectiveness as an ablation and a conization equivalent.

This study was designed to compare the effectiveness of loop excision procedures as ablation and conization equivalents, and their use in recurrent cervical high-grade dysplasia patients. We retrospectively reviewed patients undergoing loop procedures between January 1992 and April 1994. Conization equivalents were defined as procedures performed for unsatisfactory colposcopy, positive endocervical curettage, discordant cytology and histology, and cytology suggestive of invasion. Effectiveness in high-grade recurrent lesions was evaluated separately. Therapeutic failure was defined as any recurrence of high-grade dysplasia. One hundred sixty-two patients underwent loop procedures, of which 123 (75.9%) had follow-up examinations and are included. Mean follow-up was 17.9 months. Seventy-six patients (61.8%) had the loop procedure performed as an ablation equivalent, 29 (23.6%) as a conization equivalent, and 18 (14.6%) for recurrent disease. Overall effectiveness was 82.1 % and for ablation and conization equivalent procedures was 82.9 and 82.8%, respectively. There was no significant difference between effectiveness when performed for initial therapy (82.9%) and for recurrent disease (72.2%) (P = 0.46). In conclusion, loop excision procedures are effective as ablation and conization equivalents and as treatment for recurrent high-grade dysplasia.

Conization↗

PubMed2005

Laser CO2 conization in postmenopausal age: risk of cervical stenosis and unsatisfactory follow-up.

OBJECTIVE: To assess chances of adequate cyto-colposcopic follow-up after laser conization performed in postmenopausal screening population by the evaluation of postoperative cervical stenosis and unsatisfactory colposcopy rates. PATIENTS AND METHODS: One thousand two hundred eighteen patients were submitted to laser CO2 conization for cervical intraepithelial neoplasia (CIN). Incidence and risk factors for cervical stenosis and unsatisfactory follow-up were retrospectively evaluated comparing fertile with postmenopausal patients. RESULTS: Global incidences of postoperative unsatisfactory colposcopy and cervical stenosis were 46.2% and 7.1%. These rates were higher in postmenopausal patients compared with fertile ones, revealing a statistical correlation between unsatisfactory follow-up and postmenopausal status at the time of conization. Association between CIN relapse and cervical stenosis was significantly higher in postmenopausal group (66.7% vs. 8.6%; P <0.05), where two cases of recurrence were detected only after hysterectomy, because of an insurmountable cervical stenosis. Univariate and multivariate analysis revealed HRT use as the only significant factor in influencing postoperative cervical stenosis. CONCLUSION: Conization is still considered as the standard treatment for CIN at any woman's age, when excisional management is indicated, but all postmenopausal patients should be counseled about the possibility of postoperative stenosis that could exclude an adequate follow-up, configuring a failure of the conservative treatment. HRT use is associated with a low risk of stenotic complications; therefore, if possible, users should be encouraged to continue therapy at least 1 year after laser conization.

Adolescent↗

PubMed2006

Clinicopathologic features of early adenocarcinoma of the cervix initially managed with cervical conization.

OBJECTIVE: To evaluate the clinicopathologic features of microinvasive adenocarcinoma of the cervix in order to guide the management of patients with this disease. MATERIALS AND METHODS: A retrospective review was conducted of patients diagnosed with early invasive, 1 mm and 2 mm and 3 mm and 4 mm and <or=5 mm. Three patients were treated with a conization only, 4 patients were treated with a simple hysterectomy, 25 patients were treated with a radical hysterectomy (RH) and PLN dissection (PLND), and 1 patient was treated with a radical trachelectomy and PLND. Ten patients had positive conization margins for invasive cancer, 3 patients had margins positive for adenocarcinoma in situ, 14 patients had negative margins, and in 6 patients the margin status could not be evaluated. Of the 10 patients with positive margins, 5 of 10 (50%) had residual disease in the subsequent surgical specimen. Three patients who underwent definitive management with conization alone originally had positive margins, underwent a second repeat conization, and are included in this group. Of the 16 patients with negative margins, no patient had residual disease in a subsequent surgical specimen. Of the 25 patients who underwent a RH and PLND, none had parametrial involvement and none had PLN involvement. All patients remained without evidence of disease at median follow-up of 30 months. CONCLUSIONS: Historically, the standard management of early invasive adenocarcinoma of the cervix has been controversial, and some clinicians continue to favor radical treatments. Based on the absence of parametrial spread and PLN involvement in early lesions, physicians and patients should consider treatment with conization with negative margins (when future fertility is desired) or simple hysterectomy. Prospective studies are required to document the safety of this approach.

Adenocarcinoma↗

PubMed2001

Cervical intraepithelial neoplasia III: long-term outcome after cold-knife conization with clear margins.

OBJECTIVE: To evaluate the long-term outcome of patients with severe cervical intraepithelial neoplasia or squamous cell carcinoma in situ (CIN III) after cold-knife conization with clear margins. METHODS: A total of 4417 women (mean age 36, range 18-72 years) with histologically confirmed CIN III had cold-knife conization with clear margins at our institution between 1970 and 1994. All patients were followed up with colposcopy, cytology, and pelvic examination for a mean of 18 years (range 5-30years). RESULTS: New high-grade squamous intraepithelial lesions (SILs) (CIN II and III) developed in 15 (0.35%) patients (mean age 35, range 25-65 years) after a median of 107 (range 40-201) months. A total of 4402 (99.65%) patients (mean age 36, range 18-72 years) were free of high-grade SILs after a mean follow-up of 18 (range 5-30) years. High-grade glandular intraepithelial lesions developed in two (0.05%) patients 14 and 17 years after conization. Twelve (0.3%) patients had metachronous vulvar intraepithelial neoplasia (VIN) grade III or vaginal intraepithelial neoplasia (VAIN) grade III, and one (0.02%) patient had invasive vaginal carcinoma 10 years after conization. CONCLUSION: Cold-knife conization with clear margins was an adequate method to definitively treat CIN III.

Adolescent↗

PubMedDate not supplied

Residual disease and presence of human papillomavirus after conization.

The objective of this study was to evaluate the incidence of residual disease and the presence of human papillomavirus (HPV) after conization. Data on 53 patients with carcinoma in situ or microinvasive carcinoma who underwent hysterectomy less than 2 months after conization were examined. Seven of 53 patients (13%) had positive margins. In 4 of these 7 patients (57%), residual disease was found in the postconization hysterectomy specimen. Two of 46 patients (4%) with negative margins also had residual disease. HPV DNA was detected by PCR in 27 of 53 conization specimens and in 2 postconization hysterectomy specimens. Of 2 patients, 1 did not have residual disease. Residual disease could be present even with a negative conization margin, and HPV DNA may be found in a histologically normal cervix after conization.

Adult↗

PubMed1996

Outpatient loop electrosurgical excision procedure for cervical intraepithelial neoplasia. Can it replace cold knife conization?

OBJECTIVE: To determine if loop electrosurgical excision procedure (LEEP) can replace cold knife conization. STUDY DESIGN: In a population at high risk for invasive carcinoma, 163 cases of LEEP conization were performed with the same indications as cold knife for cervical conization. RESULTS: Seventy-five percent of LEEP surgical specimens were positive for dysplasia. Six cases showed invasive squamous cell carcinoma. No complications were seen. CONCLUSION: LEEP conization is a quick, simple and economical procedure that can safely replace most cases of cold knife conization.

Adult↗

PubMed1998

Management of cervical intraepithelial neoplasia of the uterine cervix: 110 cases treated by cold-knife conization.

PURPOSE OF INVESTIGATION: The purpose of this study was to evaluate treatment by cold-knife-conization in women carriers of cervical intraepithelial neoplasia (CIN). METHODS: The histologic findings of pre-clinical neoplasia of the cervix after conization were compared to the previous findings of cytology, colposcopy and punch-biopsy in 110 women examined between 1985 and 1995. The chi square test (chi2) was used for the statistical analysis. RESULTS AND CONCLUSIONS: A close correlation is clinically important where complementary roles of these three methods are used to identify lesions suitable for local ablative therapy. The Pap test alone is no longer sufficient for the screening of the pre-cancerous lesion of the cervix and colposcopy is compulsory each time the smear is inadequate or altered. Conization permitted us to single out 13 (11.8%) cases of carcinoma. After cold-knife conization we had six (5.4%) recurrences within two years and two (1.8%) within three years. Our data show that conservative therapy by conization in women with CIN reduces the risk of invasive cancer of the cervix but careful follow-up of these patients is essential.

Adult↗