Postprocedural Pap Smears: a LEEP of faith?

Abstract

Loop electrosurgical excision procedure (LEEP) is gaining in popularity in the United States as an outpatient alternative to the diagnosis, and potentially the treatment, of cervical intraepithelial neoplasia (CIN). LEEP is fast, simple, performed under local anesthesia, readily learned, and without significant morbidity. As cytopathologists and cytotechnologists, immediate cytologic evaluation of cervico-vaginal smears following LEEP is not the routine; however, there are very specific artifacts, most of which are related to the transfer of thermal energy, which result from the procedure. It is important to recognize these cytomorphologic features for accurate interpretation. The indications and contraindications for LEEP are similar to those for other ablative or excisional procedures. There appears to sacrifice in the efficacy of diagnosing and treating CIN by this method. Factors predictive of disease clearance are as confounding as they are for any other cone procedure. At the University of Iowa Hospital and Clinics (UIHC), immediate post-LEEP endocervical brush (PLEB) is often performed as a method of assessing the endocervical canal for residual disease or skip lesions. The most common cytomorphologic features observed are: "taffy-pulled" nuclei in elongated endocervical cells; cell aggregates with coalesced cytoplasm; hockey stick nuclei; notched and enlarged nuclei; and, smudgy chromatin. The difficulties or most frequent diagnostic dilemmas in interpreting these smears initially include abundant blood and smudgy chromatin, often tempting an interpretation of "unsatisfactory". However, careful study reveals that these changes are related to the nature of the procedure and reproducible. Recognition and familiarization of these features enables more accurate interpretation of PLEB cytology. The significance of abnormal PLEB, with regard to disease clearance, is still uncertain.