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PubMed1982

The frozen section analysis of conization. A reappraisal of the ends and means.

A retrospective review of 163 consecutive conizations of the cervix is reported to analyze the use of frozen section interpretation of the conization specimen in 115 patients. There were no failures to identify occult invasive cancer on the initial frozen section analysis and no differences of therapeutic significance when the permanent sections were reviewed. The frozen section conization-immediate hysterectomy technique was compared with the clinical course of 29 patients whose hysterectomy was delayed for 6-8 weeks after conization. The total operating time, estimates of operative blood loss, amount of blood required in transfusion, and morbidity were similar in both groups. Total hospital days were significantly decreased with the cone/frozen section/immediate hysterectomy technique. Because frozen section conization/immediate hysterectomy offers additional advantages of a single hospital admission, single anesthetic induction, and single postoperative recovery/convalescent period, this approach continues to deserve serious consideration in the management of patients with CIN when conization is necessary and subsequent hysterectomy is desired.

Adult↗

PubMed1982

Colposcopy, conization, and hysterectomy practices: a current perspective.

Data from the provincial cytology program has shown a progressive increase in the number of cases of cervical carcinoma in situ detected in the general population and a doubling of disease rate in third decade women, with most of the cases now in the 25- to 29-year-old age group. The introduction of a colposcopy service has led to a significant decrease in the number of diagnostic conizations performed over a 5-year period. Conization was still used for therapy in a substantial number of women despite the availability of cryotherapy and laser surgery. Eighty-five percent of all patients undergoing cone biopsy had sever dysplasia or carcinoma in situ (CIN III) on pathological examination. In 25% of patients, the conization specimen revealed either dysplasia or carcinoma in situ extending to resection margins. During review of 2249 patients, 1174 were spared a conization and were treated by either hysterectomy, cryotherapy, or laser surgery. It would appear that, although colposcopy can reduce dramatically the number of diagnostic cone biopsies, conization will still be required for therapy in a substantial number of patients.

Adult↗

PubMed1994

Hot-knife conization of the cervix: clinical and pathologic findings from a study introducing a new technique.

OBJECTIVE: To introduce an alternative method for conization of the cervix using a Teflon-coated hot knife and to evaluate thermal distortion, adequacy of excision, operating time, blood loss, and short- and long-term effects of this method. METHODS: Between 1987-1993, 88 patients underwent cervical conization using a Teflon-coated hot knife at temperatures ranging from 110-130C. Histopathologic slides were reviewed simultaneously by two pathologists, who assessed thermal distortion, adequacy of excision, and interpretability of the surgical margins. Clinical information was obtained prospectively, including operating time, blood loss, and depth and volume of the excised cone. In addition, data were accumulated retrospectively from 40 randomly selected patients who underwent cold-knife conization between 1985-1990. Short- and long-term data were assessed for healing and scarring and the adequacy of postoperative Papanicolaou smears in the hot-knife patients. RESULTS: Thermal injury was minimal, with 300 mu or less in 83 patients (92%) and 350-600 mu in four patients. One patient had thermal distortion of 1500 mu. All slides were interpreted adequately. Blood loss was mild to moderate in 84 of 88 patients (95%) in the hot-knife group and in 34 of 40 patients (85%) in the cold-knife group. No patient in the hot-knife group needed blood transfusion or hospitalization. Operating time was reduced by as much as 67% when the hot knife was used. Thirteen percent of the hot-knife patients developed stenosis of the external os. No patient in the hot-knife group developed recurrence within 2 years of surgery. CONCLUSION: Using a Teflon-coated hot knife for conization of the cervix produces adequate surgical margins and reduces blood loss and operating time over that with cold-knife conization. Long-term follow-up reveals no increase in cervical stenosis and demonstrates adequate cytologic smears in the hot-knife patients.

Adolescent↗

PubMed2000

Positive margins after conization and risk of persistent lesion.

OBJECTIVE: The aim of this study was to investigate a method to reduce the frequency of uterine reoperation with no persistent lesion and to identify factors predictive of persistent or recurrent lesions. MATERIALS AND METHODS: Of 505 conizations performed by the same surgeon, 71 had positive margins (average patient age = 35.7 +/- 7.7 years). The patients underwent either immediate reoperation or monitoring with a Pap smear and colposcopy. RESULTS: Histologic assessment of the cervical cone after conization showed positive margins in 14.1% of cases [endocervical and exocervical margins affected in 50 of 505 (9.9%) and 21 of 505 (4.2%) cases, respectively]. Of 59 of these patients (83.1%) who underwent follow-up monitoring over an average of 35.2 months (range: 2.6-180. 8), 12 patients (average age: 40.8 +/- 6.4 years) underwent immediate hysterectomy and 47 (average age 34.0 +/- 7.4 years) benefited from monitoring first [secondary discovery of 19 persistent lesions within 6 months and 9 recurrences within 18 months on average (range: 8.8-48 months)]. Of the 9 patients with recurrent lesions, 7 underwent reintervention and 2 monitoring. Of the 19 patients with persistent lesions, 18 underwent reintervention and 1 monitoring. Normal histology was observed in 29.4% of patients undergoing secondary reoperation for an abnormal smear compared with 66.7% of patients undergoing immediate reoperation (P = 0.04). Severity of lesion and age of patients could not be used to predict the incidence of a persistent or recurring lesion. Seventy-nine percent of conizations had positive endocervical margins in patients with a recurring or persistent lesion compared with 48% in patients with normal follow-up (P = 0.03). CONCLUSION: Cytology and colposcopy follow-up in cases of positive conization margins may help to establish justification for the choice of reoperation, thereby limiting morbidity following repeated surgery.

Adult↗

PubMed2000

Prospective management of stage IA(1) cervical adenocarcinoma by conization alone to preserve fertility: a preliminary report.

OBJECTIVE: Microinvasive cervical adenocarcinoma has an excellent prognosis and emerging data support the hypothesis that it should be treated in the same way as its squamous counterpart. We report our preliminary experience prospectively treating stage IA(1) cervical adenocarcinoma by conization alone in women who strongly desired to preserve their fertility. METHODS: Since May 1998, all patients with stage IA(1) cervical adenocarcinoma who expressed a strong desire to preserve fertility have been offered cold knife conization (CKC) and careful surveillance without hysterectomy. Women with lesions identifiable only microscopically, up to 3 mm invasive depth, up to 7 mm tumor width, and a conization specimen including the entire lesion with negative margins were eligible for conservative management. Postconization surveillance consisted of a Pap smear and endocervical curettage every 4 months. Medical records were reviewed for clinical data, follow-up, and disease status. RESULTS: Five women ages 26-33 elected CKC and surveillance. Four were nulliparous and one primiparous. Four tumors were endocervical cell type; one was adenosquamous. Three were grade 1, one was grade 2, and one grade 3. None had lymph-vascular space invasion. None of the patients has developed recurrent disease after 6-20 months of follow-up. CONCLUSIONS: Our preliminary data suggest that patients with FIGO stage IA(1) cervical adenocarcinoma who strongly desire to preserve their fertility may be treated by conization alone if they are fully informed of the unknown risks for disease recurrence and are carefully followed. A multicenter trial is the next logical step to test the efficacy of this approach.

Adenocarcinoma↗

PubMed2000

Persistence of human papillomavirus infection after therapeutic conization for CIN 3: is it an alarm for disease recurrence?

OBJECTIVE: The aims of this study were (1) to examine whether HPV DNA is persistently detected in the cervix after therapeutic conization for CIN 3 and (2) to explore whether a patient with persistence of HPV infection is at risk of developing recurrent disease. METHODS: Of 74 patients referred with CIN 3, 58 who were tested for HPV DNA in the pretreatment cervical lesions were enrolled in the study. After standard therapeutic conization, patients were followed prospectively at the outpatient clinic. Our follow-up protocol was to follow patients without therapeutic intervention as long as they developed no recurrence or recurrence of CIN 1 or 2, while patients who experienced recurrence of CIN 3 were recommended for reconization or hysterectomy. The polymerase chain reaction for detecting HPV DNA was performed using fresh cell samples from the cervix. RESULTS: In 56 of 58 patients (96.6%), HPV DNAs were detected in their primary cervical lesions prior to conization. With regard to the distribution of HPV types, HPV type 16 family (types 16, 31, and 35) was identified in 28 cases (50.0%), type 18 family (types 18, 33 and 58) in 15 (26.8%), and type X in 18 (32.1%). Up to August 1999, all of the 58 patients have been followed with a mean follow-up period of 31.8 months (range: 12 to 73 months). After treatment, HPV DNA was persistently detected in 11 (19.6%) but negative in 45 (80.4%) of 56 HPV DNA-positive patients. HPV DNA was not detected in both HPV DNA-negative patients. Five of 11 persistently HPV DNA-positive patients (45.5%) developed CIN recurrence, while none of 45 persistently HPV DNA-negative patients did. Thus, there was a significant difference between the recurrence rates of these two groups (P < 0.0001). Both patients who were initially HPV DNA-negative developed no recurrence. Accordingly, the overall recurrence following conservative treatment for CIN 3 was 5 of 58 patients (8.6%). CONCLUSIONS: Patients with persistent HPV infection after conization for CIN 3 should be especially closely followed because they are at increased risk of developing disease recurrence.

Adult↗

PubMed2002

Endocervical curettage at conization to predict residual cervical adenocarcinoma in situ.

OBJECTIVE: To determine if performing an endocervical curettage (ECC) at the time of conization is a useful diagnostic tool for predicting residual cervical adenocarcinoma in situ (AIS) among women who might wish to preserve their fertility. METHODS: All patients diagnosed with AIS from 1995 to 2000 at four institutions were identified. Data were retrospectively extracted from clinical records. Women included in the statistical analysis were (1) younger than 40 years, (2) had an ECC performed at the time of the initial cone biopsy, (3) had a clearly demarcated surgical margin pathologically, and (4) underwent a second surgical procedure. RESULTS: Twenty-nine (24%) of 123 AIS patients met criteria for inclusion. The median age was 33 years (range, 17 to 39) and 13 (46%) were nulliparous. Initial surgery was a cold-knife conization (n = 17) or loop electrosurgical excision procedure (n = 12). Twelve (41%) ECCs and 15 (52%) cone margins were histologically positive. Sixteen patients underwent a repeat conization; 13 underwent hysterectomy. Thirteen (45%) patients had residual AIS at the time of their second surgical procedure. ECC had a superior positive predictive value (100% vs 47%; P < 0.01) and negative predictive value (94% vs 57%; P = 0.01) compared to cone margin in predicting residual AIS. None of the women undergoing fertility-sparing surgery developed recurrent AIS or adenocarcinoma. CONCLUSION: ECC performed at the time of conization may be a useful tool for predicting residual AIS in women considering fertility preservation.

Adenocarcinoma↗

PubMed2002

Residual and recurrent lesions after conization for cervical intraepithelial neoplasia grade 3.

OBJECTIVES: To evaluate the importance of regular and long-term follow-up of patients who had conization for cervical intraepithelial neoplasia grade 3 (CIN 3); and to assess the risk of residual/recurrent lesions of the cervix uteri. METHODS: Retrospective analysis of 934 patients with CIN 3 who underwent conization over the period 1 January 1985-31 December 1997. The analysis included 38 (4.1%) patients who had involved resection margins and 896 (95.9%) patients who had free resection margins. RESULTS: Twenty-three out of 934 (2.5%) patients had another operation (reconization in 17 and hysterectomy in six) whereas one patient had a biopsy. Residual or recurrent lesion after conization was found in 23 patients out of 934 (2.5%). Three patients had invasive cervical cancer (0.3%), 19 had CIN 3 (2.0%) and one patient had CIN 1 (0.1%). One of the 24 patients (4.2%) was diagnosed with no lesion after repeated operation. Eleven patients out of 38 (28.9%) with involved resection margins during the first conization had residual/recurrent disease, compared with eight out of 896 patients (0.9%) who had free resection margins. CONCLUSION: Another operation is recommended only in cases when, on the basis of cytological, colposcopical and histological findings, the gynecologist suspect the residual/recurrent lesions.

Cervix Uteri↗

PubMed2002

Cervical intraepithelial neoplasia III: long-term follow-up after cold-knife conization with involved margins.

OBJECTIVE: To evaluate the long-term outcome of patients with severe cervical intraepithelial neoplasia (CIN) III or squamous carcinoma in situ after cold-knife conization with involved margins. METHODS: A total of 390 patients (median age 39 years, range 20-69) with positive margins after cold-knife conization for CIN III were followed expectantly for a mean of 19 (range 6-30) years. Follow-up consisted of colposcopy, cytology, histology, and pelvic examination. RESULTS: Overall, 306 (78%) patients remained free of CIN III, and 84 (22%) had persisting or recurrent CIN III (n = 78) or developed invasive carcinoma (n = 6). Fifty-three patients had persisting CIN III (diagnosed within 1 year of conization), 25 developed recurrent CIN III after a median of 3 (range 2-28) years, five developed microinvasive carcinomas (at 3, 6, 7, 12, and 23 years), and one developed a stage IB carcinoma at 8 years. Persisting or recurrent disease was more common in patients in whom both the endocervical and the ectocervical cone margins were involved than in those in whom only the ectocervical or the endocervical margin was positive (52% versus 17% and 21%, respectively, P <.001). CONCLUSION: Expectant management is reasonable for patients with CIN III and positive margins after cold-knife conization. However, these patients require careful follow-up, particularly during the first year.

Adult↗

PubMed1996

Risk of cervical stenosis after large loop excision or laser conization.

OBJECTIVE: To assess the frequency of cervical stenosis in patients treated by laser conization or the loop electrosurgical excision procedure and to determine the preoperative and therapeutic factors associated with its occurrence. METHODS: Two hundred fifty-five women treated by laser conization and 277 treated by loop electrosurgical excision procedure were followed regularly by postoperative colposcopy for mean periods of 38 and 16 months, respectively. Stenosis was defined as cervical narrowing that prevented insertion of a 2.5-mm Hegar dilator. RESULTS: Thirty-eight cases of cervical stenosis, of which seven were complete, were diagnosed up to 28 months after treatment. The risk of postoperative cervical stenosis was higher for patients over 50 years of age (relative risk [RR] 3.07, 95% confidence interval [95% CI] 1.30, 7.26; P = .031), for those with a totally endocervical lesion (RR 3.79, 95% CI 1.88, 7.62; P = .001), for those with an excision 20 mm high or greater (RR 2.96, 95% CI 1.63, 5.38; P = .005), and for those with laser conization (RR 2.35, 95% CI 1.24, 4.46; P = .009). Parity, menopause, previous treatment for cervical intraepithelial neoplasia, satisfactory colposcopy, size of the lesion, its histologic diagnosis, and the extent of excision did not increase the risk for cervical stenosis. Excision was not as high with loop electrosurgical excision as with laser conization (14.3 +/- 5.0 mm versus 20.2 +/- 6.0 mm). The height of excision (RR 1.95, 95% CI 1.02, 3.76; P = .04) and a totally endocervical lesion (RR 5.07, 95% CI 1.96, 14.44; P = .001) were the only independent factors associated with postoperative stenosis identified by a multivariate analysis using logistic regression. CONCLUSION: The height of excision and a totally endocervical lesion were the main factors associated with cervical stenosis. The decreased risk associated with the loop electrosurgical excision procedure seems to be due to a shorter endocervical excision.

Adolescent↗

PubMed2000

Conization by harmonic scalpel for cervical intraepithelial neoplasia: a clinicopathological study.

The Harmonic Scalpel((R)) (HS) is a new surgical tool that cuts and coagulates by converting electrical energy into ultrasonic mechanical vibrations. The purpose of our study was to compare HS conization and the loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia (CIN) with respect to both clinical and pathological features. Fifty-one consecutive women conservatively treated (29 with LEEP and 22 with HS conization) for CIN III were retrospectively reviewed. The background of the patients was similar. Operative time, intra- and postoperative blood loss were not significantly different. With HS conization all specimens were removed in one piece, but with LEEP the median number of specimens obtained per patient was 3.3 (p<0.0001) with a maximum of 5. The depth of thermal artifacts at the endocervical margin was significantly less with HS conization (0.20 mm) than with LEEP (0.30 mm; p = 0.0006). This new method produced an ideal-shaped specimen without increasing complications and thermal artifacts compared with LEEP.

Adult↗

PubMedDate not supplied

Early cervical neoplasia confirmed by conization: diagnostic accuracy of cytology, colposcopy and punch biopsy.

OBJECTIVE: To investigate the accuracy rates of cytology, colposcopy and punch biopsy in early cervical neoplasia confirmed by conization. STUDY DESIGN: During the 10 years from 1984 to 1993, cold knife conization was performed on 151 patients with early cervical neoplasia proven by punch biopsy at our department. The accuracy rates of cytology, colposcopy and punch biopsy were investigated. RESULTS: The accuracy rates of cytology, colposcopy and punch biopsy were 52% (78 of 151), 66% (100 of 151) and 66% (100 of 151), respectively. CONCLUSION: These results suggest that a composite diagnosis with cytology, colposcopy and punch biopsy is necessary for a correct evaluation. Early cervical neoplasms are frequently seen in young women, and conservative procedures, such as conization, cryosurgery and laser vaporization, are the treatments of choice in order to preserve reproductive function. We recommend conization as the best conservative procedure, with preservation of reproductive function.

Biopsy↗

PubMed1997

[Consequences and treatment of cervical stenoses after laser conization or loop electrosurgical excision].

OBJECTIVE: To assess the frequency and the consequences of cervical stenosis in patients treated by laser conization or loop electrosurgical excision procedure (LEEP) and to analyse the results of cervical enlargement plastic surgery or neostomia. METHODS: Two hundred and fifty-five women treated by laser conization and 277 by LEEP were regularly followed by postoperative colposcopy, for a mean period of 38 and 16 months, respectively. Stenosis was defined as cervical narrowing which could not admit a 2.5 mm-diameter Hegar's dilator. RESULTS: Stenosis complicated 10.2% of the laser conizations and 4.3% of the LEEP. Thus, 38 cases of cervical stenosis of which 7 were complete were diagnosed 2 to 40 months after treatment. Among the 34 non-menopaused women who developed a stenosis, 5 had a secondary amenorrhea, 6 a severe dysmenorrhea and one an infertility related to oligoamucorrhea. In the patients with stenosis, endocervical cell retrieval was possible in 21 (55%) cases and in none the squamocolumnar junction was visible at colposcopy. Seven patients underwent an enlargement plastic surgery of the cervical canal for incomplete stenosis and two a neostomia for complete stenosis. Cervical restenosis has been observed in 7 of 9 cases in a mean delay of 12 months (3 to 48 months). Nevertheless, the endocervical cell retrieval remained possible in 8 of 9 cases and after a mean follow-up of 26 months no menstrual troubles recurred. CONCLUSION: LEEP provides fewer cervical stenosis than laser conization. The enlargement plastic surgery allows to correct durably the menstrual troubles in spite of the very frequent restenosis.

Adult↗

PubMed1997

Clinicopathologic variables predictive of residual dysplasia after cervical conization.

OBJECTIVE: To evaluate the clinicopathologic variables that are important for predicting residual dysplasia after cervical conization or the loop electroexcisional procedure. STUDY DESIGN: A retrospective review of 80 cases was performed on patients with squamous dysplasia in the conization specimen, endocervical curettage (ECC) performed immediately after resection, margin status reported by the pathologist and adequate postprocedure follow-up. RESULTS: Twelve patients had residual dysplasia. No case progressed to invasive carcinoma. A multivariate analysis was performed with presence or absence of residual dysplasia as the dependent variable and patient age, type of procedure (cold knife conization or loop excision), grade of dysplasia, margin status and ECC status as independent variables. Margin status was the strongest predictor of residual disease, followed by ECC status. Patient age had a minimal association with persistence. Of the 12 patients with residual dysplasia, 11 had a positive margin, and 8 had a positive ECC. Only 38% of patients with a positive margin had residual disease, but 67% with a positive margin and ECC had residual dysplasia. CONCLUSION: Margin status and ECC are useful in predicting residual dysplasia after conization.

Adolescent↗

PubMed1998

Evaluating cervical neoplasia. LEEP as an alternative to cold knife conization.

OBJECTIVE: To determine how the loop electrosurgical excision procedure (LEEP) compares to cold knife conization in providing an adequate diagnostic specimen. STUDY DESIGN: Between 1991 and 1995, 95 patients underwent either diagnostic LEEP or cold knife conization at Allegheny University Hospitals. The indications for the procedure were a cytologic/histologic discrepancy, unsatisfactory colposcopic evaluation, positive endocervical curettage or exclusion of invasion. RESULTS: Severe thermal artifact rendered the LEEP specimens uninterpretable in 4.4% of cases. A median number of two passes were required for LEEP excision of the transformation zone. The number of passes correlated with the amount of thermal artifact detected (P = .034). Regarding recurrence patterns, normal follow-up cervical cytology was similar for both groups: 96.7% in the LEEP group vs. 100% in the cold knife conization group. CONCLUSION: We conclude that LEEP is an acceptable diagnostic alternative to traditional cold knife conization. Thermal artifact remains a disadvantage that can be minimized by limiting the number of passes required to obtain a complete specimen.

Adolescent↗

PubMed1976

Conization as only treatment of carcinoma in situ of the uterine cervix.

Knife conization was performed in 2,099 cases with abnormal vaginal smears. The frequency of complications was low. Carcinoma in situ was diagnosed in 1,500 cases and follow-up showed that conization was curative in 87%. The curative rate was depending on whether the resection margins were free of pathologic epithelium or not. If smears were repeatedly negative the first year after conization a new diagnosis of cancer was made in 0.4%. It was not possible to decide whether these lesions were residual changes or true recurrences. Treatment of carcinoma in situ by conization has so far reduced the frequency of invasive cervical cancer by 60%.

Adolescent↗

PubMed1992

The relationship between prior cervical conization, cervical microbial colonization and preterm premature rupture of the membranes.

The occurrence of prior cervical conization and the cervical microbial colonization was investigated in 38 women with idiopathic preterm labor, 35 women with preterm premature rupture of the membranes (PPROM) and 75 normal pregnant women at 26-34 weeks of gestation. Data were analyzed by Fisher's exact test (two-tailed). The frequency of prior cervical conization was significantly higher in PPROM patients compared to normal pregnant women (P < 0.001) and to patients in preterm labor (P < 0.01). Lactobacilli occurred with a lower frequency in patients with PPROM compared to patients in preterm labor (P < 0.05) and control patients (P = 0.0543)-and with a lower frequency in patients with prior cervical conization (P < 0.05). All other microorganisms occurred with the same frequencies in all groups. The absence of lactobacilli may indicate changes in the cervical flora, which could increase the risk of PPROM. Prior cervical conization may impair the antimicrobial defense-mechanisms in the cervix, which could facilitate ascending microbial colonization. This may lead to a release of prostaglandins and proteolytic enzymes and subsequently preterm labor and rupture of the membranes.

Adult↗

PubMed1992

Human papillomavirus types and cervical squamous intraepithelial lesions that recur after cold-knife conization.

The purpose of this study was to analyze the HPV types and histological margins of cervical squamous intraepithelial lesions (SILs) treated by cold-knife conization and to correlate this with recurrent disease. Of 203 cone biopsies done for SILs primarily because the entire lesion could not be visualized at colposcopy, follow-up information was available for 85 cases. Of these 85 cases, biopsy-proven recurrences were documented for 10 (12%) women. In the SILs which recurred after conization, the lesion was noted on the surgical margin in 7/10 (70%) cases. In contrast, SILs that did not recur after cold-knife conization were detected on the surgical margin in only 12% of cases. In 7 of the recurrences, the HPV type detected in the pretreatment SIL was the same as that detected in the SIL that occurred after conization. In the other 3 recurrences, one of either the primary or recurrent SILs was HPV positive and the other corresponding lesion HPV negative. It is concluded that detection of a SIL on the surgical margin is a marker for recurrent disease and that recurrences are often associated with the same HPV type as that noted in the pretreatment SIL.

Biopsy↗