To assess the effectiveness of cryotherapy treatment delivered by general practitioners in primary care settings, as part of a screen-and-treat approach for cervical cancer prevention. Women aged between 25 and 49 years residing in San Martin, Peru, who were positive on visual inspection screening were treated, if eligible, with cryotherapy following biopsy. Cryotherapy treatment was performed for 1398 women; of these, 531 (38%) had a histology result of cervical intraepithelial neoplasia (CIN). Cryotherapy effectively cured CIN in 418 (88%) women, including 49 (70%) women with a baseline diagnosis of CIN 3. Cryotherapy is an effective treatment for cervical precancerous lesions; it can easily be administered by general practitioners in primary care settings following visual inspection screening (6).
The results from the TATI project are very promising because they show that cryotherapy is an effective treatment method for CIN, which can be delivered by primary care physicians following visual inspection screening in local health centers. In women with extremely high risk of developing cervical cancer–those with an initial histological diagnosis of CIN 3–only 18.6% of them had persistent CIN 2–3 following cryotherapy treatment. These results are consistent with findings from similar experiences with cryotherapy treatment reported from Thailand, India, and South Africa (6).
The advantage of using cryotherapy treatment following visual inspection is that precancerous lesions can be resolved at the primary care level without the need for sophisticated equipment or highly specialized medical personnel. This approach also has an advantage of ensuring that women receive immediate treatment by reducing the chance that women are lost to follow-up care, which is often a result of multiple referrals and referrals to secondary level care centers (6).
Concerns have been expressed that cryotherapy delivered by general practitioners following visual inspection screening could lead to overtreatment. The present analysis illustrates that 38% of women treated with cryotherapy had histologically confirmed CIN, and a large proportion of the women were not necessarily overtreated as a majority had cervicitis or metaplasia which also elicit acetowhite areas on the cervix with a VIA test. This treatment did not result in any severe side effects or complications. Furthermore, women reported that they were satisfied with the croytherapy treatment, found it acceptable, did not feel pain during the treatment, and felt that they were improving their health and were well cared for (6).
Concerns have been reported about the use of carbon dioxide gas in cryotherapy compared with nitrous oxide gas, mainly arising from the differences in the depth of freeze and in gas quality. In the TATI project, carbon dioxide gas was used because of its significantly lower cost and its availability for local purchase (6).
This study provides information on the short-term success of cryotherapy using carbon dioxide gas as delivered by primary care providers in low-resource settings; however, an evaluation of the long-term effectiveness of this approach is required (6).
Electrodiathermy destroys tissue more effectively than cryocautery. It requires general, regional or local anaesthesia. Under colposcopic control it is possible to destroy up to 1 cm depth using a combination of needle and ball electrodes. The needle is reinserted repeatedly at 1–2 mm intervals until the whole transformation zone has been covered. The apparatus required is cheap and easy to maintain. There may be considerable thermal necrosis, leading to discharge and slough following therapy. Fibrosis is more common than with other destructive therapies, but does not appear to affect fertility (2).
Electrodiathermy destroys tissue more effectively than cryocautery. It does require general, regional or local anaesthesia. Under colposcopic control, it is possible to destroy up to 1 cm depth using a combination of needle and ball electrodes. The needle is re-inserted repeatedly at 1–2-mm intervals until the whole transformation zone has been covered. The apparatus required is cheap and easy to maintain. There may be considerable thermal necrosis leading to discharge and slough following therapy. Fibrosis is more common than with other destructive therapy, but does not appear to affect fertility (8).
Cold coagulation: In the cold coagulation technique, heat is applied to tissue using a Teflon-coated thermosound, the ‘Semm cold coagulator’. The procedure does not usually require analgesia and the device is cheap and easy to maintain. Measurement of depth of destruction is difficult. The whole of the transformation zone is destroyed by overlapping applications of thermosound at 100 °C for 20 seconds per area. Depth of destruction is approximately 2.5–4 mm or more after treatment at 100 °C for 30 seconds and always exceeds 4 mm after treatment at 120 °C for 30 seconds. (2).
In the cold coagulation technique, heat is applied to tissue using a Teflon-coated thermosound, the ‘Semm cold coagulator’. The procedure does not usually require analgesia, and the device is cheap and easy to maintain. Measurement of depth of destruction is difficult. The whole of the transformation zone is destroyed by overlapping applications of thermosound for 20 s at 100°C per area. Depth of destruction is approximately 2.5–4 mm or more after treatment at 100°C for 30 s and always exceeds 4 mm after treatment at 120°C for 30 s (8).
The rate of posttreatment bleeding with LLECC was 1%, compared with the rates of 2% and 2.6% reported by others for LLETZ. This low incidence of short-term bleeding complications with LLECC is encouraging, but needs to be addressed further in prospective trials (4). The potential long-term cervical complications of LLECC, such as cervical stenosis and cervical incompetence, were not assessed in this study. Wright et al. reported a rate of cervical stenosis of less than 1% following treatment with LLETZ, and Luesley et al. reported an incidence of cervical stenosis (defined as the inability to pass a Hegar 3 probe into the endocervix) of 1.3% (all women with cervical stenosis had an excision deeper than 14 mm). Furthermore, Duncan reported cases of cervical stenosis requiring dilatation because of interference with menstrual flow in up to 1% of patients as a late complication after cold coagulation. It would be unlikely for LLECC to have a high incidence of these complications since the maximum depth of cervical destruction using cold coagulation (30 s at 120 °C) is only 4 mm (4).
Since 1992, women with CIN attending our unit have been treated using a modified version of LLETZ combined with a single application of the cone probe of a Semm Cold Coagulator (Wisap, Sauerlach, Germany). The probe is heated to 120 °C, then applied for 20 s to the crater produced by LLETZ. This method, large loop excision and cold coagulation (LLECC), was introduced to our colposcopy unit by one of the authors (GS) to minimise hemorrhagic complications. Regular audits of the colposcopy clinic performance have suggested that LLECC might be beneficial both as a hemostatic technique and for reducing the proportion of abnormal smears at follow-up. With conventional LLETZ, ball diathermy is frequently used for hemostasis rather than the Semm Cold Coagulator (4).
Laser ablation: The term ‘laser’ is an acronym for ‘light amplification by stimulated emission of radiation’. A micromanipulator attached to the colposcope is used to manipulate the laser and treatment is conducted under direct vision. As the technique is precise, it gives good control over depth of destruction, good haemostasis and excellent healing, because there is minimal damage to the adjacent tissue. The technique is particularly useful for treating lesions with vaginal involvement. As there are no gland crypts in the vaginal epithelium, destruction to a depth of 2–3 mm is adequate. Healing is rapid; new cells appear within 10–12 days (2).
Laser is an acronym for Light Amplification by Stimulated Emission of Radiation. A micromanipulator attached to the colposcope is used to manipulate the laser, and treatment is conducted under direct vision. As the technique is precise, it gives good control over depth of destruction, good haemostasis and excellent healing, as there is minimal damage to the adjacent tissue. The technique is particularly useful for treating lesions with vaginal involvement. As there are no gland crypts in the vaginal epithelium, destruction to 2–3 mm depth is adequate. Healing is rapid, with new cells appearing within 10–12 days (8).
Excisional treatments
Excision of the lesion in the form of a cone can be performed using a knife, laser, or electric (hot) loop. Most of these procedures can be performed in an outpatient setting under local anesthesia or even under no anesthesia (3).
A majority of centres have now moved towards using excisional methods. This allows better histopathological interpretation of the excised specimen and, in certain circumstances, allows a ‘see and treat’ strategy under local anaesthetic at the initial visit. This policy, however, can lead to overtreatment of insignificant lesions. Therefore, a ‘select and treat’ strategy is recommended, as is practiced in most colposcopy units (8).
Most centres have now moved towards using excisional methods. These allow better histopathological interpretation of the excised specimen, and in certain circumstances enable a ‘see and treat’ strategy under local anaesthesia at the initial visit. This policy can lead to over-treatment of insignificant lesions, however, and a ‘select and treat’ strategy is recommended, as is practiced in most colposcopy units. Meta-analysis has shown no obviously superior surgical technique for eradicating CIN (2).
Success rates following local excisional techniques are similar to those for laser ablation and cold coagulation (2).
Diathermy loop excision using low-power voltage apparatus is now widely practiced. The technique is referred to as LLETZ in Europe and the loop electrosurgical excision procedure in North America. In the UK, it is now the most common method of local treatment for CIN lesions. Excisional techniques for ectocervical lesions should remove tissue to a depth of more than 7 mm. This is because the CIN may involve the gland crypt. This can vary from mean depth of 1–2 mm to a maximum of 5.22 mm (2).
The use of a one-step treatment plan is recommended in patients with HSIL on cytology, acetowhite lesions visible on the cervix but with no sign of invasive carcinoma (5).
In 1981, Cartier et al reported on an electrically charged wire loop to take cervical biopsies and offer treatment for premalignant lesions. The concept of the large loop brought a huge change in the approach of clinicians to cervical premalignancies. This was described in 1989 by Prendiville et al who published their results of treatment using a wide, large, thin wire loop. The results showed a low complication rate and morbidity coupled with a 98% success rate of treatment. In comparative studies, LLETZ was found to be as effective or better treatment for cervical preneoplasia than laser or cryotherapy (5).
In many clinics, LLETZ has now become the standard of care for cervical premalignant lesions. As it maintains cervical reproductive function, it is suitable for patients who wish to retain their fertility (5).
Use of LLETZ in treating cervical premalignant lesions
An electrocautery system capable of cutting/coagulation functions (and preferably including a suction function), an insulated handpiece with controls, and various sizes of large, thin wire loops that fit into the handpiece are required. Ball cautery electrodes are also required for control of bleeding. These bipolar cautery systems require a negative (earth) plate to be attached to the patient (5).
Large loop excision of the transformation zone (LLETZ) is the preferred method of treating CIN in both the United Kingdom and the United States. It is associated with low morbidity, provides tissue for histopathologic assessment, and is as effective in the short term as ablative treatments, which it has largely replaced (4).
The reported rates of therapeutic effectiveness for LLETZ and other treatment procedures range from 60% to 95% (4).
Diathermy loop excision using low-power voltage apparatus is now widely practiced. The technique is referred to as large loop excision of transformation zone (LLETZ) in Europe and as loop electrosurgical excision procedure (LEEP) in North America. In the UK, this is now the most common method of local treatment for CIN lesions. Excisional techniques for ectocervical lesions should remove tissue to a depth of greater than 7 mm. This is because there may be gland crypt involvement by the CIN. This can vary from a mean depth of 1–2 mm to a maximum depth of 5.22 mm (8).
An important development in treatment of CIN was the modification by Prendiville of Cartier's original technique and the description of large loop excision of the transformation zone. LLETZ has revolutionized the management of CIN and has been shown to be safe and effective, with a 95% cure rate at 1 year (1).
Large loop excision of the transformation zone (LLETZ) biopsy has been found to be more accurate in detecting CIN than colposcopically directed biopsy. Under-diagnosis of 20% of all cases was found when histopathological diagnosis of directed biopsies was compared with large LLTEZ. Some investigators advise LLETZ rather than directed biopsy when investigating high-grade cervical lesions (2).
The most widely used excisional techniques today are LLETZ, also known as LEEP. Both techniques can be performed on an outpatient basis using local
anaesthetic. Prior to performing LLETZ/LEEP, the criteria for ablative techniques should be fulfilled. Furthermore, wherever expert colposcopy is available, and especially in resource-restricted settings, “look and LLETZ/LEEP” may be appropriate --- that is, the procedure is performed on the basis of the colposcopic assessment alone and without histologic confirmation. Because LLETZ yields a high rate of negative results (i.e., no CIN is found on the specimen obtained with LLETZ), this approach is not recommended for low-grade lesions (3).
One of the most commonly reported short-term complications of LLETZ is hemorrhage, which occurs in up to 2.6% of women in the first 24 h after treatment (4).
The risk of overdiagnosis and overtreatment does exist. Chia et al treated 327 patients including women with ‘borderline’ abnormal smears. On histology after large loop excision of the transformation zone (LLETZ), 103 had no CIN lesions detected. Colposcopically directed punch biopsy was not found to reduce the incidence of negative LLETZ cones (5).
LLETZ is commonly performed under local analgesia. Lignocaine 1% solution is injected in a circular fashion around the cervix using a dental syringe and thin needle. If bleeding is anticipated, 2–4 ml of a 1-in-20 dilution of ornipressin can also be injected into the cervical tissue. The LLETZ is performed by first placing the loop at the edge of the lesion ensuring a free margin of 1–2 mm. The ‘coagulation’ or ‘blend’ control button on the handpiece is then pressed, enabling the current to flow. A cone-shaped excision of the transformation zone is accomplished by spooning the cervical tissue out when the hand is moved in a gentle unidirectional curve. The cervical sample is sent for histology. Bleeding points on the cervix are cauterized using the ball electrode. The procedure is completed if there is no bleeding. A sanitary tampon is inserted into the vagina to be removed after 4 hours. Sexual intercourse is actively discouraged for the next 4 weeks. Results are discussed with the patient when available. A follow-up visit is arranged for 4 months later (5).
In some settings, LLETZ is performed under general anaesthesia. This may hold some comfort for the patient but it cancels the massive cost-saving characteristics of LLETZ under local analgesia (5).
LLETZ can be performed even if the upper limit of the lesion cannot be identified with colposcopy. In this situation, a deeper LLETZ resection must be spooned out. Similarly, if a patient presents with HSIL on cytology and no lesion is visible, LLETZ can be performed to identify an endocervical lesion (5).
LLETZ histology reports will frequently include a reference to the cauterization artefact (heat artefact). This artefact is to be expected as coagulation as well as cutting occurs during LLETZ. In some cases, this artefact will lead to uncertainty on the part of the histopathologist on the completeness of the excision (5).
LLETZ procedures are regarded to be safe and of low morbidity. However, complications are not absent. The minor complications included abdominal pain, vaginal bleeding, vaginal discharge (5).
Suh-Burgmann et al detected asymptomatic cervical stenosis (defined as the inability to pass an endocervical brush) in 10 (6%) of 164 women after LLETZ. The most important associated factor was found to be the volume of cervix that was removed. Post-LLETZ stenosis is not easy to treat. A new canal may be created by careful use of the CO2 laser (5).
Follow-up after LLETZ
LLETZ has been demonstrated to be a very effective way of treating CIN. The majority of studies reported abnormal cytology findings in less than 15% of cases but there are some exceptions (5).
Factors associated with an increased risk of recurrence have been identified as involved margins at LLETZ, grade of disease, age of the patient, HPV status and also human immunodeficiency virus (HIV) status (5).
Excisional margins may be positive in as many as 48% of cases, and the ectocervical margin, endocervical margin or both margins may be involved. More concern is caused by involved endocervical margins as this represents invisible disease. Furthermore, in many cases, marginal ectocervical lesions may have been destroyed with the use of the ball cautery. Clear margins have not been found to guarantee normal cytologic follow-up, and only some of the patients with involved margins had abnormal cytology at follow-up. The histological assessment of completeness of LLETZ excision cannot be used as a strong predictor of persistent or recurrent disease (5).
Such treatment has been shown to have no significant adverse effect on delivery except for a shorter duration of labour (5).
Consent must be recorded if treatment is planned; the patient must not be pregnant or have a clotting diathesis. Colposcopy must accompany treatment and, if excision is used, a single pass of the loop should be used to excise the colposcopic abnormality to a depth of ≤8 mm. The lowest cut wattage is used to allow a clean cut and avoid diathermy artefact which may cause difficulty in determining completeness of excision (7).
Laser excision is technically more demanding than laser ablation and requires a high-power density beam with a small spot size that can function in a cutting mode. Both laser and diathermy loop can be used to obtain cone biopsies of the cervix (2).
Cold knife cone biopsy and hysterectomy still retain a place in the management of CIN. The size and shape of the cone biopsy is governed by the colposcopic findings. The internal os and as much of the endocervical canal as possible are left intact, within the confines of disease eradication. This limits haemorrhage, and fertility is little compromised (2).
Cold knife cone biopsy
Cold knife cone biopsy (CKC) was initially the only uterus-conserving excisional treatment for cervical preneoplasia. CKC performed under general anaesthesia is still used in certain circumstances, as follows.
• Post-menopausal patients with abnormal cytology where the portio vaginalis of the cervix is too small to perform a correct LLETZ.
• Cytology results indicating adenocarcinoma in situ (AIS).
• Cytology results of invasive cervical cancer where no lesion is visualized (5).
Patients with clear margins at CKC have a very low risk of subsequent abnormal smears of less than 1%. The risk of recurrence was higher in cases of involvement of both endo- and ectocervical margins than when only one margin was involved (5).
Cone biopsy is essentially a diagnostic procedure and is performed when there is significant disparity between the results of different diagnostic tests --- e.g., a HSIL cytologic finding when no lesion is seen on colposcopy. Other indications for a cone biopsy include the following: the upper limit of the acetowhite lesion is not seen; abnormal glandular cells are observed on the cervical smear; there is a suspicion of microinvasion; or there is a high-grade cytologic finding but no access to colposcopy. Cone biopsy may be performed using a knife (cold-knife cone), usually under general anesthesia, or using a large electric loop (hot-knife cone) or laser under
local anesthesia (3).
Conization should be performed for lesions that cannot be seen in their entirety because they extend into the endocervical canal. It is important to realize that it is not possible to perform colposcopy of the endocervical canal and if the upper limit of the lesion cannot be visualized it is impossible to rule out occult microinvasive disease (3).
Hysterectomy may need to be performed in a woman with CIN who has other gynaecological conditions such as fibroids, menorrhagia or prolapse. Before the operation, colposcopy is used to identify the extent of the lesion and avoid incomplete excision, which may result in vaginal intraepithelial neoplasia. If the lesion is seen to extend to the vagina, this may be excised as part of the hysterectomy procedure. An alternative is to ablate the vaginal extension of the CIN by laser or diathermy, and then proceed to excision or hysterectomy as indicated (2).
Hysterectomy
Hysterectomy was widely used as treatment for cervical preneoplasia; however, in recent years, it has been replaced by conservative treatment of which LLETZ is possibly the most widely used. Hysterectomy may still be indicated or considered in the following situations.
• H-SIL completely treated with LLETZ in a patient whose family is completed, in particular where follow-up may be problematic.
• Involved margins after LLETZ or CKC in a patient whose family is completed.
• H-SIL in a post-menopausal patient.
• SIL confirmed on cervical biopsy or LLETZ co-existing with benign uterine pathology (e.g. fibroids) or complaints (e.g. excessive menstrual blood loss) (5).
Hysterectomy is rarely indicated in the absence of other indications and is not a superior treatment to local excision or ablation for the prevention of cervical cancer (3).
In case of a patient with a completed family, a hysterectomy can, of course, be offered. Annual follow-up consultations must then take place (5).
Although data suggest that cone biopsy and hysterectomy are effective forms of management, there is a 0.3–0.4% incidence of invasive cancer following these procedures (2).
Obstetric outcome after conservative treatment of CIN
Meta-analysis confirms that cold knife conisation is significantly associated with preterm delivery, low birth weight and Caesarean section. LLETZ is also significantly associated with preterm delivery, low birth weight and premature rupture of membranes. The other local treatments have not been significantly associated with increased risks for obstetric outcome. Excisional procedures to treat CIN carry similar pregnancy-related morbidity without apparent neonatal morbidity (2).
Impact of LLETZ on pregnancy and childbirth
One of the perceived advantages of all local treatment forms for cervical preneoplasia is the possibility to retain fertility. As LLETZ is the current recommended form of treatment, the impact of treatment on reproductive outcome received much attention. Initial and recent observational and case–control studies showed no adverse effects of LLETZ on reproduction, one proviso being the LLETZ not measuring wider than 1.8 cm and deeper than 1.5 cm. Gentry et al performed ultrasound measurements of the cervix before and after LLETZ and found no significant differences in cervical length. The postulate was that the cervix remodels as it heals. This report was in contrast with the findings of Ricotti et al where cervical shortening after LLETZ was detected (5).
However, some reservations should be noted. In a systematic review, Crane found an increased risk of preterm birth after LLETZ (odds ratio 1.81, 95% confidence intervals 1.18–2.76; P=0.006) and also a non-significant risk of low-birth-weight babies. No increased risk was demonstrated for other pregnancy outcomes including Caesarean section, precipitous labour, induction of labour or admissions to neonatal intensive care units. Recently, Sadler et al reported on a retrospective cohort study of 652 patients treated with laser ablation, laser cone or LLETZ and 426 untreated controls. Laser-cone- or LLETZ-treated patients had a significantly increased risk of preterm prelabour rupture of membranes (pPROM) compared with non-treated or laser-ablation-treated patients. The higher occurrence of pPROM resulted in a higher preterm delivery rate. Of patients who had a measured cone length of more than 1.7 cm, 25% had preterm delivery and 18% had pPROM; a three-fold increase above non-treated patients (5).
Follow-up
Women who have undergone treatment for CIN remain at high risk of invasive cervical disease. This necessitates close surveillance, cytologically and colposcopically, following treatment. There is a higher risk of residual disease if the endocervical margin is involved compared with the ectocervical margin. Women over the age of 40 years are particularly at risk of persistent/residual disease. Cytological abnormality following treatment, no matter how minor, should be considered an indication for colposcopic assessment. Colposcopic assessment is technically more difficult in women who have undergone treatment. Foci of CIN and/or invasive disease may be buried under an apparently normal epithelium, and the transformation zone may be difficult to visualise in its entirety because of scarring. In cases of failed initial treatment, it is recommended to use an excisional method in preference to an ablative technique (2).
Patients should undergo a colposcopic as well as a cytologic evaluation 6 to 12 months following surgical treatment for preinvasive high-grade intraepithelial lesions. Post-treatment surveillance with annual cervical smears should continue for a minimum of 5 years. If the lesion persists or recurs, repeated treatments should be offered. A return to a normal screening program should only be considered after a minimum of 5 continuous years of normal cytologic findings at intervals of 6 to 12 months (3).
Most treatment failures of CIN, regardless of the technique employed, will become apparent during the first year of follow-up (4).
While LLETZ is the accepted treatment for the management of CIN in the United Kingdom and the United States, recent Cochrane systematic reviews concluded that there is no superiorly effective treatment or hemostatic technique for the management of CIN. The recommended standard percentage of persistence of abnormal smear 6 months after treatment, 10%, set by the National Health Service Cancer Screening Programmes, is yet to be met by many units in the United Kingdom. A persistence rate of abnormal cytologic results between 15% and 39% is not infrequently quoted. Failure rates between 5% and 22% 1 year after treatment with the Semm Cold Coagulator are cited, and the higher percentages are associated with high-grade CIN (4).
It is now well established that women with clear margins have a low risk of recurrence, approximately 5%. The management of women in whom margins of resection are involved, on the other hand, remains unresolved because these women have a higher and variable risk of recurrence. The reported rates of treatment failure following incomplete excision of CIN vary between 3.6% and 44%. In our cohort, there was a relatively high rate of incomplete excision (16%) associated with a shallow depth of LLETZ (mean depth, 6 mm)—which may be related to the number of colposcopists and their various levels of experience (4).
Some studies identified increasing age as an independent risk factor for persistent or recurrent cervical preneoplasia. Patients aged 50 years or more with involved endocervical margins constituted the highest risk group for recurrent disease. This should be kept in mind when arranging follow-up schedules (5).
Patients treated for cervical preneoplasia remain at risk to develop invasive cervical carcinoma even after years of follow-up. While this may represent the natural history of the disease, error may also contribute to poor outcome of treatment. Common types of error include violations of treatment protocols, inaccurate assessment, inadequate diagnosis and patient non-compliance. Use of protocols should help to eliminate the first three types of error. Motivation of and communication with the patient may help to eliminate the fourth type of error (5).
Future developments in electrosurgical excision techniques
Attempts to improve the quality of the resection specimen with possible subsequent decrease in persistent/recurrent disease have been reported with the use of needle excision of the transformation zone. Sadek described successful excision in 58 patients with the specimen in one piece, while the mean artefact size was 0.29±0.21 mm. Recently, a randomized controlled trial on 404 patients suspected of having CIN lesions was reported, comparing LLETZ with needle excision of the transformation zone. On histology, 347 of 400 (87%) patients had CIN and were included in the analysis. Needle-excision specimens were larger and more commonly had clear margins (85 vs 75%) than LLETZ specimens, and were less likely to be removed in multiple pieces (2.5 vs 29.5%). Needle excision took somewhat longer (210 vs 90 seconds) and was rated to be difficult more often than LLETZ (5).
Conclusion.
Cervical intraepithelial neoplasia (CIN) has been treated in many different ways that include various ablative and excisional procedures. Treating women with CIN reduces the risk of invasive cervical cancer by 95% and metaanalyses has had concluded that there is no obviously superior surgical or hemostatic technique for the management of CIN (4).
Treating cervical preneoplasia offers an excellent opportunity to prevent the occurrence of cervical cancer in the large majority of women with abnormal cervical smears. Women with atypical squamous cells on cytology should, if possible, be assessed colposcopically and followed cytologically. All women with HSIL cytology should be referred promptly for colposcopic assessment. LLETZ treatment is recommended as the first-line treatment. A one-step approach is recommended for such patients. Patients must be followed-up carefully. The best possibility for predicting which patients may have persistent/recurrent disease seems to be HPV status of the cervix at follow-up, although involved margins, grade of disease and increasing age all have some impact on recurrence risk as does infection with HIV. LLETZ is appropriate treatment for patients with HSIL who also suffer from HIV infection (5).
Table 2. Treatment methods.
TZ, transformation zone; LLETZ, large loop excision of transformation zone; LEEP, loop electrosurgical excision procedure. 8
Figure 5. Diagramatic representation of large loop excision of the transformation zone. 8
References:
-
Lacey, C.J.N. (2005). .
Journal of Clinical Virology 32: 82-90.
-
Shafi, M.I., Welton, K. (2007). .
Obstetrics, Gynaecology & Reproductive Medicine 17: 173-180.
-
Ngan, H.Y.S., Trimble, C.L. (2006). .
International Journal of Gynecology & Obstetrics 94: S44-S49.
-
Allam, M., Paterson, A., Thomson, A., Ray, B., Rajagopalan, C., Sarkar, G. (2005). . International Journal of Gynecology & Obstetrics 88: 38-43.
-
Lindeque, B.G. (2005). .
Best Practice & Research Clinical Obstetrics & Gynaecology 19: 545-561.
-
Luciani, S., Gonzales, M., Munoz, S., Jeronimo, J., Robles, S. (2008). .
International Journal of Gynecology & Obstetrics 101: 172-177.
-
Leeson, S. (2008). . Obstetrics, Gynaecology & Reproductive Medicine 18: 163-167.
-
Nazeer, S., Shafi, M.I., Todd, R. (2004). . Current Obstetrics & Gynaecology 14: 104-114.
-
Schiffman, M., Castle, P.E., Jeronimo, J., Rodriguez, A.C., Wacholder, S. (2007). . The Lancet 370: 890-907.