Controversia en el tratamiento de la lesión intraepitelial escamosa de alto grado (NIC II) / Controversy in the treatment of high-grade squamous intraepithelial lesion (CIN II)

Contexto: el cono LLETZ actualmente es el tratamiento de las NIC de alto grado. La resistencia al procedimiento es argumentada por los efectos del sobretratamiento (estenosis e insuficiencia cervical), sobre todo cuando se utilizan métodos ablativos destructivos en lugar de la resección quirúrgica ambulatoria (LLETZ). Objetivo: analizar el diagnóstico y tratamiento del NIC II mediante cono y legrado en pacientes que acuden al servicio de Patología del tracto genital inferior del Hospital Oncológico SOLCA-Quito Ecuador. Sujetos y métodos: en este estudio epidemiológico descriptivo observacional de corte transversal se analizaron expediente clínicos de 820 pacientes con diagnóstico histopatológico por biopsia de NIC II; mujeres entre 17 a 82 años que acudieron al servicio de patología del tracto genital inferior sujetas a control, en estas pacientes se realizó 530 legrados. El estudio fue realizado en el Hospital Oncológico SOLCA de Quito Ecuador, de los años 2004 a 2013. Resultados: la histopatología de los conos libres de neoplasia representa el 98,66% (n=809); existen 11 casos de neoplasias residuales (1,34%). El 53,7% de casos presenta una lesión igual o mayor que en biopsia, lo que justifica el cono. Conclusión: el procedimiento de cono LLETZ tiene gran utilidad diagnóstica, terapéutica y pronóstica en mujeres que presentan NIC II y otras patologías similares. (AU)

Background: the LLETZ cone is currently the treatment of high grade NICs. The resistance to the procedure is argued by the effects of overtreatment (stenosis and cervical insufficiency), especially when destructive ablative methods are used instead of ambulatory surgical resection (LLETZ). Objective: to analyze the diagnosis and treatment of CIN II by means of cone and curettage in patients attending the pathology department of the lower genital tract of the SOLCA-Quito Ecuador Oncology Hospital. Subjects and methods: in this cross-sectional descriptive epidemiological observational study, we analyzed clinical records of 820 patients with histopathological diagnosis by CIN II biopsy; women between 17 and 82 years old who visited the pathology service of the lower genital tract subject to control, in these patients 530 catheters were performed. The study was conducted at the SOLCA Oncology Hospital of Quito, Ecuador, from 2004 to 2013. Results: the histopathology of neoplasm-free cones represents 98.66% (n = 809); there are 11 cases of residual neoplasms (1.34%). 53.7% of cases present a lesion equal to or greater than in biopsy, which justifies the cone.(AU)

Human papillomavirus test for prediction of recurrent and residual disease after treatment for cervical intraepithelial neoplasia / 대한산부인과학회지

OBJECTIVE: The aim of this study was to evaluate high-risk (HR) HPV DNA test to predict recurrence/residual disease in patients treated for CIN (cervical intraepithelial neoplasia). METHODS: Four hundred and fifty-two patients treated with LLETZ (large loop excision of the transformation zone) were followed by HR HPV DNA test, cytology and colposcopy. The sensitivity, specificity and diagnostic odds ratios in predicting recurrence/residual disease were compared to those of cytology and HPV DNA test. RESULTS: Fourteen patients (3.1 %) developed recurrent/residual disease, during follow up. Of these women, 7 were diagnosed at the time of recurrence with a CIN 1 lesion, 5 with a CIN 2 lesion, and 2 with a CIN 3 lesion. The sensitivity and specificity of the HPV DNA test were 92.9% (CI 68.5%, 98.7%) and 75.3% (71.1%, 79.1%). The sensitivity and specificity of the cytology were 71.4% (45.4%, 88.3%) and 92.5% (89.6%, 94.6%), respectively. The likelihood ratio of a positive and negative HPV DNA test were 3.77 (3.03, 4.69) and 0.09 (0.01, 0.63). And the likelihood ratio of a positive and negative cytology were 9.48 (5.95, 15.11) and 0.31 (0.13, 0.71). The accuracy of cytology and HPV DNA test were 94.7% and 78.3%. The sensitivity and specificity of the combination test (PAP and/or HPV DNA test) were 92.9% (68.5%, 98.7%) and 73.1% (68.7%, 77.0%). The likelihood ratio of a positive and negative combination test were 3.45 (2.79, 4.26) and 0.10 (0.01, 0.65). CONCLUSION: Cytology remains the base in the follow up after of CIN. HPV DNA test increase the sensitivity of cytology. Negative HPV test can rule out recurrent/residual disease.

When should human papillomavirus (HPV) testing be done after conization? / 대한산부인과학회지

OBJECTIVE: To know when human papillomavirus (HPV) testing should be done after conization. METHODS: Between 1997 to 2004, Large Loop Excisions of the Transformation Zone (LLETZ) were done for conization to women with cervical pathology at A University Hospital. The Pap and HPV typing were done before LLETZ procedures. After conizations, HPV typing were planned to be done every 3 months. Every HPV typing was done by HPV oligonucleotide microarray (Biomedlab Co., Seoul, South Korea). RESULTS: For 8 years, 120 LLETZ were enrolled in this study. There were 8 cases of no neoplasm, 9 cases of CIN 1, 17 cases of CIN 2, 74 cases of CIN 3, 10 cases of microinvasive cervix cancer, and 2 cases of adenocarcinoma in situ. HPV DNA before LLETZ procedures was found about 85.0% and subtype 16 was the most common type among the patients with cervical lesion (40.8%). After LLETZ, 190 HPV typing were done through 1,307 total months (average, 6.9 months/typing). 95 (79.2%) cases had negative results, and 25 (20.8%) cases had positive results. Our data showed that, after conization, about 80% turned out to negative in 6 months. CONCLUSION: Our data suggested HPV DNA testing should be done after 6 months of LLETZ, as about 80% were destined to negative in 6 months.

Analysis of the attitude to the LLETZ as a treatment of CIN according to the subspecialty / 대한산부인과학회지

OBJECTIVE: The aim of this study is to compare the clinician's attitude to the large loop excision of transformation zone (LLETZ) according to the subspecialty; gynecologic oncology or not. METHODS: Eighty-one patients who had LLETZ at Seoul National University Bundang Hospital from June 2003 to September 2004 were reviewed. The pathologic reports for LLETZ were compared with the results of punch biopsy according to the operator's subspecialty. RESULTS: Gynecologic oncologist had 38 patients (GO group) and non-gynecologic oncologist had 43 patients (NGO group). The age distribution was not different between two groups (40.3 +/- 8.3 in GO group, 42.4 +/- 9.4 in NGO group; p=0.301). The histopathology of punch biopsy and LLETZ correlated well each other in both groups (p=0.01 in both groups). In NGO group, 11 patients (25.6%) had chronic cervicitis or mild dysplasia on punch biopsy while only a patient (2.6%) had mild dysplasia on punch biopsy in GO group. CONCLUSION: This study shows that the non-gynecologic oncologist used LLETZ more frequently in the management of low-grade cervical intraepithelial neoplasia than gynecologic oncologist.

Pregnancy Outcome after Large Loop Excision of the Transformation Zone of Cervix / 대한산부인과학회잡지

OBJECTIVE: This study was performed to determine whether large loop excision of the transformation zone (LLETZ) affects the outcome of pregnancy after 20 weeks gestation. METHODS: In a retrospective case control study 20 women who had undergone large loop excision of the transformation zone and were subsequently delivered at Ilsin Christian Hospital were identified between 1991 and 2003. 40 controls were identified and matched for age and parity from women delivered immediately before and after index cases. Maternal factors were analyzed such as pregnancy gestation, use of oxytocin, analgesia, whether labor was induced, mode of delivery, length of labor, estimated blood loss and birth weight of previous delivery. Perinatal outcome measured fetal weight and admission to the neonatal unit. RESULTS: There was no significant difference between the women who had undergone LLETZ and the controls except women delivered after LLETZ had increased rate of emergency cesarean section and amount of blood loss. CONCLUSION: Previous studies investigating pregnancy outcome after LLETZ have been generally reassuring and this study also have no difference. However, in this study women who were delivered after LLETZ had slight increased rate of emergency cesarean section, this may be related to adverse obstetrical history (recurrent abortion, infertility etc.). However socioepidemiological factors were not controlled and the small number of case groups were included, so larger controlled studies will be necessary to confirm this findings.

Efficacy of Large Loop Excision of the Transformation Zone (LLETZ) in the Treatment of Cervical Intraepithelial Neoplasia / 대한산부인과학회잡지

OBJECTIVE: This study was performed to assess the efficacy of large loop excision of transformation (LLETZ) and to evaluate of clinicopathological factors with the probability of residual disease. METHODS: Retrospective study was performed in 56 patients treated with LLETZ from September, 1998 to October, 2001 in department of Obstetrics and Gynecology at Boramae Hospital. The patients underwent either immediate reoperation or monitoring with a cytologic smear and colposcopy. we investigate the significance of clinicopathological factors to predict residual disease after LLETZ. We used the Hybrid capture II test (Digene, USA) for presence of human papillomavirus (HPV). Residual disease was defined as histologic diagnosis of cervical intraepithelial neoplasia (CIN). RESULTS: Histologic assesment after LLETZ showed margin involvements in 28.6% (16/56) of cases but the residual lesion was only seen in 21.4% (12/56). There was no other serious complication. Positive margins was significantly associated with severity of lesion but not presence of HPV. Severity of lesion and margin involvements was significantly associated with residual disease (p<0.05). But age of patients and the presence of HPV was not significantly associated with residual disease. CONCLUSION: LLETZ is an effective, quick and reliable procedure on accurate diagnosis of cervical pathology and conservative treatment of CIN. Margin status and severity of lesions could be used to predict residual disease.

Predictive Factors for Residual Neoplasia after Large Loop Excision of Transformation Zone(LLETZ) in the Treatment of Cervical Intraepithelial Neoplasia / 대한산부인과학회잡지

OBJECTIVE: Large loop excision of transformation zone(LLETZ) is gaining popularity as an alternative to other ablative or cone methods for the treatment of cervical intraepithelial neoplasia(CIN). The optimal management of CIN after LLETZ, however, remains controversial and the reliable predictors of residual disease after LLETZ have not been consistently identified. This study was performed to identify factors to predict residual disease after LLETZ. METHODS: From August 1993 to July 1995, 133 patients who received subsequent hysterectomy after LLETZ in Department of Obstetrics and Gynecology at Seoul National University Hospital were retrospectively reviewed. Residual disease was defined as positive findings of CIN or further advanced findings in hysterectomy specimen. The age of patients, the severity of disease and the status of resection margin(RM) were analyzed for predictive values of residual disease. The Chi-square test, Fisher's exact test and Student t-test were used for statistical analysis. RESULTS: The residual disease after hysterectomy was negative in 85.7%(114/133) and positive in 14.3%(19/133). Among 19 cases with positive residual disease, 3 cases were revealed to be microinvasive cervical cancer. The mean age of patients with no residual disease was 42.5 years(range; 27-71) and that of patients with residual disease was 49.1 years(range; 33-72). Nine out of 94 cases(9.6%) with negative RM and 10 out of 39 cases(25.6%) with positive RM in LLETZ had residual disease. Two out of 14 cases(14.3%) with CIN II and 17 out of 119 cases(14.3%) with CIN III in LLETZ had residual disease. The success of LLETZ which means no residual disease was influenced by the age of patients(p=0.005) and the status of resection margin of LLETZ(p=0.032). CONCLUSION: The negative resection margin in LLETZ does not always guarantee that there is no residual disease. Close preoperative workup and more aggressive treatment plan(wide conization or hysterectomy) should be considered in patients who has higher possibility of positive residual disease such as old age and positive resection margin in LLETZ.

The clinical experience of LLETZ / 대한산부인과학회잡지

OBJECTIVE: To evaluate how resection margin involvement after LLETZ affect treatment of CIN and microinvasive cervical cancer, and several factors affecting the resection margin involvement. METHOD: Retrospective analysis was performed in 160 patients that underwent LLETZ at Gachon Medical College, Gil Medical Center from March, 1997 to September , 1998. The several factors affecting the resection margin involvement were analyzed. RESULT: The following results were obtained. 1. 127 patients were diagnosized finally with CIN, 30 patients with microinvasive SCC and 3 patients with chronic inflammation. 2. The rate of the negative resection margin involvement was 81% and that of the positive was 19%. 3. No case among 129 cases with the negative resection margin had residual lesion, but 9 cases among 31 cases with the positive resection margin had residual lesion. As a whole, the rate of residual lesion was 6.2%. 4. In CIN, 3 cases of 19 cases with the positive resection margin had residual lesion, but none with the negative resection margin had. 5. The degree of histopathology, glandular involvement, menopause, colposcopic evaluation were correlated with the resection margin involvement but delivery mode and HPV infection not correlated. CONCLUSION: LLETZ is a enough method to reduce unnecessary hysterectomy in the treatment of CIN, if followed up, in spite of the positive resection margin because of low rate of lesidual lesion, and is a effective method in the treatment of microinvasive cervical cancer when the case with negative resection margin and no lymphovascular invasion was followed up.

Clinical Study of Cervical Intracpithelial Neoplasm / 대한부인종양콜포스코피학회잡지

Colposcopic examination and biopsy were performed on 197 patients with abnormal cervical cytology. The patients subsequently underwent electrocoagulation, LLETZ, conization and hysterectomy depending on their diagnosis from January, 1989 to December, 1994. The comparison between the diagnosis of cytology and that of colposcopic biopsy showed fair agreement with only 35% of cases(K=20%). The abnormal lesion was underestimated by cytology in 49.7% of cases. Thirty three cases(16.8%) were threated by LLETZ. Histological comparison between the colposcopic biopsies and LLETZ samples showed fair agreement with 39% of cases (K=25%). 5 cases(15%) of the colposcopic biopsy have been underestimated when compared to the LLETZ histology. Sixty two cases were done conization after colposcopic biopsy. Histological comparison between the colposcopic biopsies and conization samples showed fair agreement with 59% of cases(K=38%). The colposcopic biopsies were underestimated in 24.2% of cases compared to the cone biopsy specimen. The correct diagnosis rates of colposcopic biopsy of dysplasia, carcinoma in situ, and microinvasive carcinoma were 70%, 82%, and 20% respectively. (continue)