Electrocoagulation diathermy.

With experience extending over an interval of 25 years, one single application of electrocoagulation diathermy has been substantiated as a most consistent and effective method of eradicating precancerous lesions of the cervix. Although there is a protocol for selection that must be adhered to, the vast majority of patients with CIN lesions are suitable for this method of ablative therapy. Ablation by electrocoagulation diathermy appears to have distinct advantages over other methods because of the following: 1. Very high cure rates (98%) with first-time treatment can be achieved, even for major dysplasia and/or carcinoma in situ. 2. Extensive and deep lesions can be effectively eradicated irrespective of the purported histological severity. 3. Electrodiathermy is capable of eradicating lesions extending into the endocervical canal, providing anatomical limits can be evaluated colposcopically. 4. The technique is simple and rapid. The versatility of the electrodes facilitates eradication of the lesion irrespective of the shape and contour of the cervix. 5. No expensive capital outlay nor costly maintenance of equipment is required. 6. There are no physical hazards for medical personnel. 7. It is cost-effective--the technique is readily adaptable as a true out-patient procedure on a 'walk in, walk out' basis. 8. It has a very low incidence of surgical morbidity and does not jeopardize physiological and reproductive function. 9. For practical purposes, the subsequent risk of development of invasive cancer of the cervix can be effectively eliminated.

The efficacy of electrocoagulation diathermy performed under local anaesthesia for the eradication of precancerous lesions of the cervix.

This study demonstrates the feasibility of performing electrocoagulation diathermy with intracervical infiltration of local anaesthetic for precancerous lesions of the cervix. A technique suitable for office procedure without need of any supplementary analgesia is described; 200 patients were treated in this fashion with results indicating the ability to obtain high primary cure rates with low morbidity similar to those previously obtained with general anaesthesia.

The natural history of human papillomavirus (HPV) atypia of the cervix.

This study examines the natural history of human papilloma virus (HPV) atypia of the cervix in 259 untreated patients who were followed for 3 to 74 months (median 18 months). Progression to cervical intraepithelial neoplasia (CIN) occurred in 41 patients (15.8%)--all but 3 progressions occurred within the first 24 months of follow-up. In no patient did invasive cancer develop during this study. Persistence occurred in 39.4% and regression in 44.8% patients. An increasing number of regressions were noted with the passage of time. Progression to histologically confirmed CIN which occurred in 23 of 46 (50%) patients in whom both the cytological and colposcopic assessment at the first visit suggested CIN did so significantly more frequently than when either the cytology or colposcopy alone suggested CIN (11 progressions in 83 patients--13.3%, p less than .00001) or when neither cytology nor colposcopy suggested CIN (7 progressions in 119 patients--5.9%, p less than .000001). We recommend that patients with both cytological and colposcopic features suggestive of CIN should be treated even though HPV atypia only is reported on biopsy. Those who are not treated should be followed closely until regression occurs and consideration should be given to treating those patients in whom the abnormality persists longer than 2 years.

The significance of human papilloma virus atypia ('wart virus infection') found alone on cervical cytology screening.

A series of 429 patients has been analysed in which the cytology smear report suggested human papillomavirus (HPV) infection alone. All patients were examined colposcopically and in 58 (13.6%) associated histologically confirmed cervical intraepithelial neoplasia (CIN) was demonstrated. CIN subsequently developed in an additional 10% of those patients who returned for follow-up over an ensuing 3-year period. Follow-up with repeat cervical cytology smears alone was unreliable as 4% of patients even with normal repeat smears has histologically proven CIN and a further 4% of these patients subsequently developed CIN. Colposcopy is recommended in all patients whose cytology smear shows HPV infection.

The association between vulvar condylomata acuminata, cervical wart virus infection and cervical intraepithelial neoplasia.

Vulvar condylomata acuminata are the commonest clinical expression of human papilloma virus infection of the female genital tract. Various epidemiological factors were examined in a group of patients with vulvar warts in whom the incidence of biopsy proven human papilloma virus infection of the cervix was 39.7% and the incidence of biopsy proven cervical intraepithelial neoplasia was increased significantly (16.2%).

Preclinical cancer of the cervix: diagnostic pitfalls.

This paper outlines the pitfalls encountered in the diagnosis of 127 preclinical cancers of the cervix. Each patient had cervical cytology, colposcopy, and histology performed within the same institution. Early stromal invasion was diagnosed in 55 patients and occult invasion was diagnosed in 72 patients. For preclinical cancers as a group, the possibility of invasive carcinoma was predicted cytologically in 36% and suspected colposcopically in 41%. However, in over 85% of patients the abnormal transformation zone (TZ) extended into or was totally confined within the endocervical canal and could not be adequately evaluated with the colposcope. A feature of this study was the high incidence of incomplete excision of abnormal tissue by cone biopsy and a high incidence of residual disease at hysterectomy. Cone biopsy was necessary to accurately assess the maximum depth and extent of invasion prior to definitive therapy whenever invasion was suspected colposcopically or on target biopsy. In 10 of 16 such patients, the cone biopsy demonstrated occult invasion. Colposcopy and directed target biopsy alone was adequate for the diagnosis of frank invasive cancer in 22 of the 72 patients in the occult invasion group, enabling definitive therapy to be undertaken without further delay.

Diethylstilboestrol (DES) exposure in utero.

A clinical review of the first 200 patients who attended the DES Referral Clinic at The Royal Women's Hospital, Melbourne, has been undertaken. To date, clear-cell adenocarcinoma has not been detected in patients attending the Clinic. Fifteen per cent of patients who allegedly were exposed in utero to diethylstilboestrol (DES) showed no clinical stigmata. Vaginal adenosis was found in 41% of patients. On its own, cytological examination of vaginal smears was found to be unreliable as routine screening for detection of adenosis. Painting of the cervix and vagina with Lugol's iodine proved to be a more reliable screening test. Colposcopy is recommended in all patients who are suspected of having been exposed in utero to DES.

PIP: This paper presents the results of a review of the frequency of stigmata attributable to diethylstilbestrol (DES) exposure in the 1st 200 patients who attended the DES Referral Clinic at the Royal Women's Hospital in Melbourne, Australia. The value of cytological examination of vaginal and cervical smears as a screening method was also evaluated. Only 147 of the 200 patients were judged to have been exposed to DES. Of these, 22 (15%) had completely normal cytology findings and a normal vagina and cervix. There were no abnormal microscopic findings in an additional 31 patients (21%), although colposcopy revealed some atypical features in the transformation zone. The remaining 94 patients (64%) showed gross structural changes. Vaginal adenosis was present in 60 (41%) of the patients reviewed. There was complete correlation between the presence or absence of colposcopically detected vaginal adenosis and the presence or absence of glandular of metaplastic cells in the vaginal smears of 101 patients (69%). False positive results were obtained in 26 patients (18%) and false negative results occurred in 20 patients (13%). Painting of the cervix or vagina with Lugol's iodine was a more reliable screening test. No patients with clear-cell adenocarcinoma were detected in this series. It is recommended that, in cases of suspected DES exposure, the vagina and cervic should be carefully palpated and inspected, vaginal and cervical smears should be taken for cytologic examination, and Lugol's iodine should be applied to the vagina. Colposcopy, with biopsy of any suspicious areas, should also be performed.

Adenocarcinoma in situ of the cervix.

Adenocarcinoma in situ (ACIS) of the cervix is rare and is frequently overlooked. To characterize this disease more fully, 21 cases were studied. All except two patients presented with abnormal smears. The distribution of ACIS was focal in two cases, multicentric in three, and diffuse and continuous in 15 (in one case it was unknown). The depth of crypt involvement varied from 0.5 to 4 mm and the volume was estimated to range from 0.25 to 1,500 mm3. ACIS should and can be distinguished from early ("microinvasive") adenocarcinoma in most cases by its limitation to the glandular field, by the constant admixture of neoplastic and normal glands, and by the lack of stromal response. Invasive adenocarcinoma cannot be excluded by target biopsy, the diagnosis of ACIS requiring conization. If the surgical margins are disease free, conization alone may be adequate therapy.

Electrocoagulation diathermy for cervical dysplasia and carcinoma in situ: a 15-year survey.

The present report assesses 15 years' experience with electrocoagulation diathermy in the treatment of cervical intraepithelial neoplasia (CIN). Selection is based on the ability to visualize the boundaries of the lesion colposcopically. Visualization, together with cytology and target biopsy, should exclude invasive carcinoma. Histologically confirmed CIN of varying severity (almost two thirds were CIN III) was treated by diathermy in 1864 patients. The size of the lesion varied, and at times the lesion extended into the endocervical canal. Cervical intraepithelial neoplasia was eradicated in 97.3% of patients by a single diathermy treatment. Ninety-three percent of all patients under the age of 30 with CIN were treated by this method. Progression to invasive carcinoma after diathermy has not been demonstrated. A single treatment with electrocoagulation diathermy has proved consistently to be the most effective superficial ablative method for primary eradication of CIN whether deep, extensive, or of major severity.

Cervical function following treatment of intraepithelial neoplasia by electrocoagulation diathermy.

At the Royal Women's Hospital Melbourne, treatment of cervical intraepithelial neoplasia has consisted mainly of electrocoagulation diathermy. A random group of 420 consecutive patients attending the follow-up clinic has been studied to assess subsequent cervical function. Long-term follow-up has revealed minimal adverse effects on fertility, parturition, and menstrual function.

Electrocoagulation diathermy treatment of cervical intraepithelial neoplasia.

Although there are other physical methods of destruction which may be effective for small areas of dysplastic change, the author believes that D&C and electrocoagulation diathermy under general anesthesia is a more reliable and more effective method of destruction of abnormal T-Zone. It has the distinct advantage of being able to eliminate large areas, and in particular, changes of major atypia extending into the gland crypts. To date, no patient treated in this fashion has developed invasive carcinoma of the cervix.

An endocervical speculum.

An endocervical speculum has been devised for use with the colposcope in the evaluation of abnormal cytologic smears. It allows inspection of the endocervical canal and helps delineate the uppermost limits of the dysplastic and/or CIS lesion in those patients in whom it extends into the endocervical canal.

Electrocoagulation diathermy for the treatment of cervical dysplasia and carcinoma in situ.

This report presents further experience in the use of electrocoagulation diathermy for the treatment of patients with cervical intraepithelial disease. By means of the colposcope it was possible to select a group of nonpregnant patients, in whom a proven noninvasive lesion was located entirely within range of the colposcope. This group, comprising 450 patients, has been treated by means of electrocoagulation diathermy, and with followup, only 28 patients have shown evidence of a residual lesion; in 8 of these the residual lesion has been eradicated subsequently by repeat diathermy treatment. Significant complications following electrocoagulation diathermy occurred in 13 patients (3%). The overall apparent cure rate for electrocoagulation diathermy was 95.4%.