The oncological and obstetric outcomes of cervical squamous cell carcinoma at stage IA1 managed with the loop electrosurgical excision procedure

ObjectiveTo evaluate the efficacy and superiority of loop electrosurgical excision procedure (LEEP) in managing stage IA1 cervical microinvasive squamous cell carcinoma (MISCC) without lymph-vascular space invasion (LVSI).Materials and methodsThe oncological and reproductive outcomes of a series of patients affected by stage IA1 MISCC without LVSI, initially treated by LEEP between February 2006 and December 2017, were retrospectively reviewed.ResultsUltimately, 109 patients were included. The mean age at diagnosis was 35.4 years old, and 36 patients were nulliparous. Multifocal lesions were identified in 15 patients (13.8%). The mean cone depth was 17.4 mm. Resection margins were positive/unevaluable and negative in 26 (23.9%) and 83 (76.1%) cases, respectively. Among cases undergoing salvage treatments, the residual disease rate for patients with positive/unevaluable margins was significantly higher than those with negative margins (P = 0.003). During the follow-up period of 43.0 ± 28.9 months, no relapse was identified. Fifteen of 20 patients (75.0%) conceived successfully, with a full-term live birth rate of 93.3%.ConclusionsFor stage IA1 MISCC without LVSI unexpectedly found in a loop excision, initial LEEP with clear margin is efficient and adequate. For cases with multifocal MISCC, or for those young patients who wish to become pregnant in the future, LEEP is the optimal choice.     

妊娠期行宫颈环形电切除术的安全性及对妊娠结局的影响

随着宫颈病变的年轻化以及宫颈环形电切除术的广泛开展,妊娠期行宫颈环形电切除术的安全性及对妊娠结局的影响成为医患双方共同关注的焦点。妊娠期宫颈病变有较小的恶化趋势,妊娠期可予随访,定期行细胞学及阴道镜检查,于产后6周复查,根据病理结果按宫颈病变妇科治疗原则处理。宫颈癌前病变及原位癌的稳定状态与分娩方式无关,分娩方式的选择取决于产科指征,无特殊指征的患者仍提倡阴道分娩。宫颈环形电切除术对妊娠结局的影响尚有争议,须进一步大样本研究证实。     

子宫颈上皮内瘤变患者行宫颈环切术对妊娠结局的影响

目的探讨对宫颈上皮内瘤变患者行宫颈环切术对妊娠结局的影响。方法回顾性分析1995年5月～2002年4月因宫颈上皮内瘤变行宫颈环切术27例患者的妊娠结局。结果占同期宫颈环切术手术的13．3％(27／203),患者年龄为23～40岁,中位年龄为30．3岁。27例中,10例因计划生育行人工流产术,1例异位妊娠,2例妊娠6～8周自然流产。14例足月分娩,其中阴道分娩9例。剖宫产5例。所有分娩孕妇的分娩孕周均大于38周,胎儿体重2905～4000g。新生儿1分钟Apgar评分：9分2例;10分12例,无新生儿窒息。结论宫颈环切术是治疗子宫颈上皮内瘤变的安全有效方法,只要掌握手术指征和手术切除范围,对其后的妊娠生育是安全的。     

Cyclooxygenase-2 expression predicts recurrence of cervical dysplasia following loop electrosurgical excision procedure

OBJECTIVE: To evaluate the expression of Cox-2 protein by immunohistochemistry in cervical dysplasias, and to determine any relationship to clinical factors such as degree or recurrence of dysplasia. METHODS: Immunohistochemical expression of p27 and Cox-2 was initially examined in 62 cervical LEEP specimens, which spanned the histologic spectrum from benign to severe dysplasia. Histology and cytology from colposcopic follow-up exams were reviewed for 1 year after LEEP procedure. Primary outcome variable was recurrent dysplasia, either cytologic or histologic. Statistical analysis utilizing chi-square test for trend and Fisher's Exact tests were performed to determine relative risk of recurrent dysplasia. RESULTS: A total of 62 LEEP specimens were examined by immunohistochemistry (IHC). This included 18 mild, 19 moderate, and 25 severely dysplastic LEEP specimens. The percentage of tumor cells in each specimen that stained for p27 protein or Cox-2 enzyme was documented. A specimen was considered positive for p27 or Cox-2 if 50% or more of the cells in a specimen were stained: 94% of mild, 89% of moderate, and 44% of severe dysplasias stained positive for p27; 50% of mild, 42% of moderate, and 68% of severe dysplasia specimens stained positive for Cox-2. The average intensity of Cox-2 staining increased with severity of dysplasia-1.6 for mild, 1.8 for moderate, and 2.1 for severe dysplasia. There was a significant increase in both Cox-2 and p27 staining when severely dysplastic specimens were compared to mild and moderate dysplasia (P < 0.001). Of the 35 specimens that stained positive for Cox-2 protein, 59% of these specimens had positive Cox-2 staining that extended to the margins of the LEEP resection specimen. The average length of Cox-2 protein staining beyond the histologic dysplasia was 1.64 mm. Positive margin status for Cox-2 was a significant independent risk factor for persistent and recurrent dysplasia, RR 1.68 95% CI (1.07 < RR < 2.65), P < 0.027. CONCLUSION: Cox-2 and p27 protein expression could be involved in squamous cervical cancer carcinogenesis. Cox-2 staining is often found outside the dysplastic lesion and this factor is associated with an increased risk of persistent and recurrent dysplasia following LEEP procedure. Should the histologic margin of LEEP resection approach 2.0 mm, follow-up algorithms for these patients should include intensive surveillance to ensure adequate treatment of disease.     

Persistent and recurrent cervical dysplasia after loop electrosurgical excision procedure

OBJECTIVE: Our objective was to determine whether demographic, colposcopic, and pathologic variables are predictive of recurrent cervical dysplasia. STUDY DESIGN: A retrospective review of patients who underwent loop electrosurgical excision procedure (LEEP) was performed. The medical records of the subjects were reviewed to identify demographic, pathologic, and procedural characteristics that predict recurrent dysplasia. RESULTS: A total of 514 subjects were identified who underwent LEEP between 1996 and 2003. Multivariate analysis revealed that advanced age, immunosuppression, and a positive endocervical margin were associated with recurrent dysplasia. CONCLUSION: Demographic and pathologic data can be used to predict the risk of recurrence of cervical dysplasia after LEEP.     

Outcome after loop electrosurgical excision procedure for cervical high-grade squamous intraepithelial lesion

ObjectiveThe dilemma in treating cervical high-grade squamous intraepithelial lesion (HSIL) is how to achieve complete excision to minimize the risk of cervical cancer while sparing the anatomy of the cervix and its ability to function during pregnancy. The optimal management for positive margins after excisional treatment is still controversial. This study was conducted to determine the clinical and histologic predictors of residual/recurrent HSIL and assess the outcome of women with positive margin.Materials and methodsThis retrospective cohort study included 386 women who had excisional treatment for HSIL during 1st January 2012 to 31st December 2015 in a university-affiliated hospital.ResultsOverall, 212 (54.9%) women had negative margins and 155 (40.2%) had positive margins. The cumulative rate of residual/recurrent HSIL at 2 and 5 years was 15.7% and 16.8% respectively in positive margins and 1.8% and 5.0% respectively in negative margins (p < 0.001). Of women who had residual/recurrent HSIL, significantly more women had positive margins compared to negative margins (74.1% vs 25.9%, p = 0.001). Positive margin was significantly associated with higher rate of subsequent abnormal cervical smear (48.2% vs 28.9%, p < 0.001), requiring further colposcopy (32.1% vs 14.4%, p < 0.001) and further treatment for SIL (7.5% vs 4.8%, p < 0.001) compared to negative margin.ConclusionMost women (85%) with positive margin went without residual/recurrent HSIL, of which the option of close surveillance with cytology is reasonable. Repeat excision may be considered in selected women with positive margin, endocervical glandular involvement and those who are older or unable to comply with follow-up.     

宫颈电圈环切术诊治宫颈上皮内瘤变的临床观察

目的探讨宫颈电圈环切术(LEEP)在诊治宫颈上皮内瘤变(CIN)中的作用。方法选择304例CIN患者作为研究对象,采用LEEP行宫颈锥切术,比较术前宫颈活检与术后病理结果,术后3个月和6个月复查宫颈薄层液基细胞学检测(LCT)、HPV结果。结果与术前活检结果相比术后病理结果降级占3.6%(11/304),相同占91.1%(277/304),升级占5.3%(16/304),浸润癌1例;切缘阳性率为3.9%(12/304)。LCT随访结果,术后3个月正常者99.3%;术后6个月正常者93.8%。HPV随访结果,术后3个月HPV阴性者占91.7%,术后6个月HPV阴性者占92.7%。结论LEEP是诊断及治疗CIN安全且有效的方法。     

宫颈环形电切术治疗宫颈上皮内瘤变的价值

目的 探讨宫颈环形电切术(LEEP)治疗宫颈上皮内瘤变(CIN)的价值.方法 回顾性分析2004年1月至2007年5月在重庆医科大学附属第一医院宫颈疾病门诊接受LEEP术的452例患者(CIN 420例,原位癌32例)的相关资料,对患者一般情况、术前阴道镜定位活检、术中情况、术后病检结果和随访资料进行统计分析.结果 (1)所有患者均于月经干净后3～7d手术,手术时间5～20min,术中出血量平均为14.6mL,患者反应轻.(2)术前、术后宫颈环切组织病理结果比较:病变分级一致者270例(59.73%);级别下降者132例(29.20%);其余50例(11.06%)级别上升,其中5例术前为CIN Ⅰ而术后证实为CIN Ⅲ(不包括原位癌).25例术后病检发现切缘有病变累及者(其中CIN 18例,原位癌7例),8例随后行全子宫切除,3例行二次LEEP术.(3)对所有患者定期随访至2007年8月,CIN治愈387例(92.14%),病变残留33例(7.86%).CIN中2例(0.48%)术后12个月复发,6～18个月后复发病变自然消退.(4)切缘无病变累及者术后CIN病变残留复发率为6.22%(25/402),切缘阳性者CIN术后病变残留复发率高达44.44%(8/18),二者比较差异有统计学意义.结论 LEEP术治疗CIN治愈率高,病变残留复发率低.术后切缘累及情况是CIN残留复发的影响因素之一,切缘阳性者病变残留复发率高.     

Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis

Objective

This study aimed at assessing the association of the relative risk (RR) of adverse pregnancy outcomes with previous treatment of loop electrosurgical excision procedure (LEEP) for the management of cervical intraepithelial neoplasia (CIN).

Methods

Data sources were from MEDLINE, EMBASE, and SCI citation tracking. Selection criteria: The eligible studies had data on pregnancy outcomes of women with or without previous treatment for CIN. Considered outcomes were severe preterm delivery (<34/32 weeks), extreme preterm delivery (<28 weeks), low birth weight (<2,500 g), stillbirth, preterm spontaneous rupture of membranes, perinatal mortality, and neonatal mortality and induction.

Results

36,954 cases and 1,794,174 controls in 4 prospective cohort and 22 retrospective studies were included in this meta-analysis. LEEP was associated with a higher risk of severe preterm delivery (<32 weeks, relative risk 1.98, 95 % CI [1.31, 2.98] 159/11,337 vs. 7,830/860,883), extreme preterm delivery (<28 weeks, RR, 2.33, 95 % CI [1.84, 2.94] 97/9,611 vs. 1,559/618,332), preterm premature rupture of the membranes (RR, 1.88, 95 % CI [1.54, 2.29] 126/2,837 vs. 7,899/313,094), and low birth weight (<2,500 g, RR, 2.48, 95 % CI [1.75, 3.51] 110/1,451 vs. 55/1,742). A cervical length of less than 3 cm was significantly increased in LEEP as compared with that of control group (RR, 4.88, 95 % CI [1.56, 15.25]), but increasing LEEP volume or depth was not associated with an increased rate of preterm birth <37 weeks. And LEEP was not associated with a significantly increased risk of perinatal mortality, cesarean section, stillbirth mortality, neonatal mortality, induction, and neonatal intensive care unit admission.

Conclusions

LEEP is associated with an increased risk of subsequent preterm delivery (<32/34, <28 weeks) and other serious pregnancy outcomes. But increasing LEEP volume or depth is not associated with an increased rate of preterm birth.     

Cold-knife conization versus the loop electrosurgical excision procedure for treatment of cervical dysplasia

INTRODUCTION: Classical conization is a standard procedure for treatment of cervical lesions. Conization with loop diathermy is well established and lesions can be excised in more than 90% of cases. OBJECTIVE: To compare two methods of conization for the treatment of cervical dysplasia. METHOD: The study included 172 patients who had conization for diagnosed cervical dysplasia. A retrospective analysis was conducted on incidence of complications and presence of dysplasia on the specimen edges after classical conization compared to conization with loop diathermy. The possibilities for analyzing specimen edges were reviewed. RESULTS: A significantly higher incidence of complications was found among patients who underwent classical conization compared to those who had the loop diathermy procedure. The loop procedure is sufficient for treatment of cervical dysplasias. CONCLUSION: The authors suggest loop diathermy conization as the method of choice for treatment of cervical dysplasia.     

高频电波刀行电圈切除治疗宫颈病变的临床应用探讨

目的　评价高频电波刀行电圈切除 (LEEP)治疗宫颈病变中的临床应用价值。方法　回顾性分析我院 2 71例LEEP治疗宫颈病变的临床资料 ,所有病例均行阴道镜下多点活检和LEEP术后病理诊断 ,在炎症和赘生物病变外缘 3mm进出电极 ,对于CINI与HPV感染患者 ,电极在病变边缘外 5mm进出。结果　阴道镜下多点活检与LEEP术标本的病理诊断差别有显著性 (P <0 0 5 )。 2 71例患者术后随访 2 4 3例 ,术后复查宫颈细胞学 ,仅 9 0 5 %出现细胞核肥大和核异质。结论　LEEP对包括炎症、损伤、癌前病变、HPV感染等宫颈病变是一种非常理想的诊断、治疗手段。宫颈细胞学检查、阴道镜下多点活检、LEEP术后病理诊断构成了宫颈病变系统的诊断模式。LEEP可以广泛地应用于治疗CIN各级病变 (原位癌除外 ) ,LEEP也适用于CINI的治疗 ,LEEP治疗的范围可以在病变边缘外 5mm处进出电极     

Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure.

In selected patients with cervical intraepithelial neoplasia (CIN), outpatient ablative procedures represent a readily accepted and highly effective treatment modality. The recently introduced loop electrosurgical excision procedure offers a quick and simple alternative to cryotherapy and laser ablation for treating CIN, and has the distinct advantage of allowing both diagnosis and treatment of selected patients at a single visit. This report presents our clinical experience treating 432 patients with CIN using the loop electrosurgical excision procedure on an outpatient basis. Small loop electrodes were used to excise CIN lesions in 275 patients, and large loop electrodes were used in 157. When performed on an outpatient basis under local anesthesia, loop excision was well tolerated by patients with only minimal discomfort. Post-treatment bleeding occurred in less than 2% of the subjects and responded to either recauterization or packing of the cervix. Post-treatment stenosis occurred in less than 1%. The success rate of the loop electrosurgical excision procedure, as defined by absence of cytologic, histologic, or colposcopic lesions 4-48 months after therapy, was 80% for women treated using the small loop electrodes. Ninety percent of all patients treated using the large loop electrodes were free of disease during 6-12 months of follow-up. For women being treated for primary (as opposed to recurrent) disease, the success rate with large loop electrodes was 94%.     

A simple trainer for the loop electrosurgical excision procedure

This article describes the construction and use of a simple trainer for the loop electrosurgical excision procedure (LEEP), also known as large loop excision of the cervical transformation zone (LLETZ).     

Effectiveness and safety of loop electrosurgical excision procedure for cervical neoplasia in rural India

Objective

To evaluate the effectiveness and safety of loop electrosurgical excision procedure (LEEP) to treat cervical intraepithelial neoplasia (CIN) in rural India.

Method

Women with CIN colposcopic features unsuitable for cryotherapy were treated with LEEP using a “see-and-treat” approach. Women with unsatisfactory colposcopy had diagnostic LEEP. Cure was defined as no clinical or histologic evidence of CIN at 1-year follow-up. Factors influencing cure rates were evaluated by χ² tests.

Results

Of the 1141 women who underwent LEEP (569 see-and-treat; 572 unsatisfactory colposcopy), 634 had histologically proven CIN. Of those, 489 reported for follow-up and 459 (93.9%) had no evidence of disease. Cure rates were 98.1% for women with CIN 1, 93.6% for CIN 2, and 85.0% for CIN 3. Patients with CIN 2-3 had significantly lower cure rates.

Conclusion

Cure rates for LEEP provided by newly trained doctors in rural India were similar to those reported in the gynecological literature.     

Pregnancy outcome after loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia

Objective: Previous studies have shown conflicting results on the outcome of pregnancy following loop electrosurgical excision procedure (LEEP). The purpose of this study was to evaluate whether LEEP affects the outcome of pregnancy after 20 weeks gestation. Methods: This is a matched cohort study of all women who had a LEEP for a biopsy-confirmed cervical intraepithelial neoplasia (CIN) in between December 1995 and December 2000 and subsequently delivered (after 20 weeks gestation) at the University Hospital of Northern Norway. Women who had an ectopic pregnancy or an abortion (spontaneous or induced) following LEEP were excluded from analysis. Two controls matched for the date of delivery, age, parity, previous obstetric history and smoking habit were identified for each case using routinely entered data from the birth register. The main outcome measures were the duration of pregnancy and birth weight. Other variables recorded included the grade of cervical dysplasia, size of the electrosurgical loop, age, parity, pregnancy complications, mode of delivery, and perinatal outcome. Results: Of a total of 428 women of reproductive age who had LEEP performed during the study period, 89 had a pregnancy after the procedure. Ten women were excluded (three ectopic pregnancies, two induced abortions and five spontaneous abortions) from the study. Data from 79 women whose pregnancies progressed beyond 20 weeks and 158 matched controls were analysed. The mean age at the time of LEEP was 27 (range 19–36) years. The histological diagnosis was normal in 3 (3.8%), CIN1 in 5 (6.3%), CIN2 in 18 (22.8%), and CIN3 in 53 (67.1%) of the cases. Overall, mean gestation at delivery (38.3 vs. 39.1 weeks), mean birth weight (3,412 vs. 3,563 g), prevalence of preterm birth (11.4% vs. 10.8%) and low birth weight (10.1 vs. 5.1%) were not significantly different among the cases and controls. But when a relatively large loop (25 mm) had been used, the risk of preterm delivery (odds ratio 4.0) and low birth weight (odds ratio 14.0) was significantly higher than in controls. Pregnancy complications occurred more frequently (20 vs. 7%; p=0.006) among the cases than the controls. Conclusion: LEEP in women with CIN did not significantly increase the risk of low birth weight or preterm birth in subsequent pregnancy in comparison to their controls, except when the size of electrosurgical loop was relatively large. However, the prevalence of pregnancy complications was significantly higher after LEEP.     

Assessment of cervical intraepithelial neoplasia (CIN) with colposcopic biopsy and efficacy of loop electrosurgical excision procedure (LEEP)

Purpose

Conization for suspected high grade cervical intraepithelial neoplasia (CIN) is often performed based on abnormal cytology only. Loop electrosurgical excision procedure (LEEP) is a very common technique in this context. The present study analyses the accuracy of preoperative assessment of CIN with cytology plus colposcopic biopsy and assesses the efficacy of LEEP for the treatment of CIN.

Methods

Two-hundred and sixty-six consecutive patients treated with LEEP for suspected CIN at our center were retrospectively analyzed. Cytology, HPV-DNA testing, colposcopically directed cervical biopsy and/or endocervical curettage were performed to assess cervical lesions before and 3–6?months after surgery.

Results

Median age of the patients was 34?years. Median follow-up was 50?months. Preoperative HPV testing was positive for high risk types in 77.9?%. All patients underwent LEEP without further ablative procedures. Complete excision of the lesion could be achieved in 84.3?%; in 13.5?% margins were not securely cleared and in 2.2?% the lesion was not excised entirely. Overall complication rate was 5.4?% (mainly postoperative bleeding and pain). Overall concordance of colposcopic biopsy and cone histology was 85.8?%. The concordance rate was higher for CIN 2/3 (95.1?%) compared with CIN 1 (63.2?%). Nine patients (3.4?%) had persistent disease after 3?months, 4 (1.5?%) developed disease recurrence and underwent re-conization. HPV testing at 3–6?months after surgery was negative in 78.5?%; 2 of the patients developing disease recurrence had a persistent HPV infection after surgery.

Conclusions

Assessment of cervical lesions with colposcopic biopsy is an accurate method (concordance with cone histology 85.8?%). Surgical treatment of high grade CIN with LEEP is a safe procedure with low recurrence rates, resulting in a clearance of cervical HPV infection in the majority of cases.     

Predictors of cervical dysplasia after the loop electrosurgical excision procedure in an inner-city population

OBJECTIVE: To identify factors associated with persistence or clearance of cervical intraepithelial neoplasia (CIN) following loop electrosurgical excision procedure (LEEP) in high-risk patients. STUDY DESIGN: In a retrospective database review, we identified 343 patients who had 2 LEEP procedures or LEEP followed by hysterectomy for CIN at Grady Memorial Hospital. We compared margin status, endocervical curettage (ECC) at LEEP and follow-up cytology for patients characterized as having persistent or nonpersistent dysplasia. RESULTS: Seventy-nine percent (71/90) of patients with positive LEEP margins had persistent disease vs. 50% (45/90) with negative margins (odds ratio [OR]=3.7, 95% confidence interval [CI] 1.9-7.2, P<.0001). Ninety-one percent (29/32) with positive margins and positive ECC had persistent disease vs. 47% (26/55) with negative margins and negative ECC (OR=10.8, 95% CI 2.9-39.6, P<.0001). Sixty-eight percent (149/218) with at least 1 positive Pap smear following LEEP had persistent disease vs. 37% (11/30) with all negative follow-up Pap smears (OR = 3.7, 95% CI 1.7-8.3, P = .0007). CONCLUSION: Although the risk of persistent CIN increased with positive LEEP margins, ECC and cytology, these variables, when negative, offered no ensurance of a future disease-free state in this high-risk population.