Large Loop Excision Of The Transformation Zone Specimens Research Articles

Does the New National Cervical Screening Programme Guideline Detect Cases of High-Grade Squamous Intraepithelial Lesions That Previously Would Have Been Missed?

The aim of this study was to determine the number of patients undergoing large loop excision of the transformation zone (LLETZ), for biopsy-confirmed high-grade squamous intraepithelial lesions (HSIL), where the original cervical screening test (CST) reported oncogenic human papillomavirus (HPV) and negative liquid-based cytology (LBC). This reflects the number of patients where a LLETZ procedure would not have occurred under the previous guideline. Retrospective observational chart review of all patients (n = 477) who underwent LLETZ procedure in a single tertiary unit over a 36-month period. Prevalence of negative histopathology, positive margins, incidental cervical cancer, and accuracy of HSIL identification at colposcopy were measured. Diagnostic accuracy of HSIL diagnosis from initial colposcopic impression was calculated; factors influencing accuracy were evaluated using multivariable logistic regression analysis. There were no comparators. Of 477 LLETZs, 5.9% (n = 28) were for oncogenic HPV and normal LBC on referral CST. Demographics between the "study" (oncogenic HPV and normal LBC on referral CST) and the "standard" group were similar, except the study group was less likely to be using contraception (25% vs 47%, p = .023). In the study group, initial colposcopic cervical biopsy confirmed HSIL in 91.6% (n = 27) and low-grade squamous intraepithelial lesions in 3.6% (n = 1). Histopathological analysis of LLETZ specimens confirmed HSIL in 20 patients (71.4%) and low-grade squamous intraepithelial lesions in 2 (7.1%). No microinvasion was detected. The renewed National Cervical Screening Programme (NCSP), is detecting more "at risk" patients, predicted to lead to a further reduction in incidence of cervical cancer in adequately screened patients.

Overtreatment rate after immediate local excision of suspected cervical intraepithelial neoplasia: A prospective cohort study

ObjectiveThe gold standard of cervical intraepithelial neoplasia (CIN) treatment is large loop excision of the transformation zone (LLETZ) after histopathological diagnosis from punch biopsies. In addition, treatment may be appropriate at initial colposcopy. Our objective was to study the applicability of immediate treatment strategy according to clinical parameters. MethodsWe conducted a prospective cohort study among patients referred to colposcopy at Helsinki University Hospital, Finland, between January 2014, and September 2018 (ISRCTN10933736). Patients treated with LLETZ, either after biopsies or immediately at initial colposcopy, were included. The main outcome measure was overtreatment (OT) rate defined as normal or low-grade histopathological findings in LLETZ specimen within both treatment groups. ResultsA total of 572 patients treated with LLETZ were included: 360 treated after biopsies and 212 treated immediately at initial colposcopy. When LLETZ was performed immediately after high-grade referral cytology and with colposcopic impression of high-grade disease, the overtreatment (OT) rate was 10.0% (95% CI 9.10 to 17.2), whereas when LLETZ was done after biopsy-confirmed high-grade lesions, the OT rate was 18.9% (95% CI 14.7 to 23.7), resulting in risk difference (RD) −8.91% (95% CI −16.0 to −1.82). Among HPV16/18 positive patients the OT rate was 8.22% (95% CI 3.08 to 17.0) for immediate treatment, resulting in RD of −10.7% (95% CI −18.3 to −3.04) compared to LLETZ after biopsies. ConclusionsImmediate LLETZ does not result in overtreatment when applied on selected cases, especially after high-grade referral cytology and when high-grade lesion is also colposcopically suspected.

Cervical intraepithelial neoplasia in women with transformation zone type3: cervical biopsy versus large loop excision.

To compare the proportion of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in cervical biopsies with that in large loop excision of the transformation zone (LLETZ) specimens in women aged ≥45 years with transformation zone type 3 (TZ3). Multicentre cross-sectional study. Three colposcopy clinics in the Central Denmark Region. Women aged ≥45 years referred to colposcopy as a result of a positive human papillomavirus (HPV) test and/or abnormal cytology and with TZ3 at colposcopy. Women had multiple biopsies taken and an LLETZ was performed. Histologically confirmed CIN2+ in biopsies compared with that in LLETZ specimens. Of 166 eligible women at colposcopy, 102 women with paired data from biopsies and LLETZ specimens were included for final analysis. The median age was 67.7 years (IQR 62.6-70.4 years), and most were postmenopausal (94.1%) and had undergone HPV-based screening (81.3%). The CIN2+ detection rate was significantly higher in LLETZ specimens than in biopsies (32.4% vs 14.7%, difference 17.7%, 95%CI 6.3-29.0%), resulting in more than half of CIN2+ cases being missed in biopsies (54.5%, 95%CI 36.4-71.9%). The overall agreement between biopsies and LLETZ was 82.4% (95%CI 73.6-89.2%). CIN2+ detection is underestimated in women aged ≥45 years with TZ3 if detection relies on the results of biopsies alone. To reduce the risk of underdiagnosis and overtreatment, future studies should explore the use of new biomarkers for risk stratification to improve discrimination between women at increased risk of CIN2+ who need to undergo LLETZ and women who may undergo follow-up.

Risk factors for unsatisfactory colposcopy after large loop excision of the transformation zone: The results of a four-year multicenter prospective study

ObjectivesNot being able to completely examine the cervical squamocolummar junction (SCJ) in colposcopy after large loop excision of the transformation zone (LLETZ) is an important issue regarding surveillance, as high-grade cervical intra-epithelial neoplasia recurrence risk is high. This study was conducted in order to identify risk factors for post-LLETZ unsatisfactory colposcopy. MethodsThis prospective multicenter observational study was performed in nine French University hospitals, with inclusions running from December 2013 to December 2017. All patients scheduled for LLETZ were included and were divided into two groups after the two to four months post-procedure colposcopic examination: a satisfactory and an unsatisfactory post-LLETZ colposcopy group. ResultsIn total, 601 cases were analyzed and 71 post-LLETZ colposcopies (12%) were described as unsatisfactory (including 19 cervical stenosis). In a univariate analysis, we only observed a statistically significant increase of the following parameters in the unsatisfactory post-LLETZ group in comparison with the satisfactory post-LLETZ group: parity (2.11 [±1.55] and 1.49 [±1.24] respectively, p < .01), depth of the LLETZ specimen (10.9 mm [±3.37] and 9.76 [±3.79] respectively, p < .01), age (45.9 years [±11.7] and 37.9 [±9.42] respectively, p < .001) and an unsatisfactory pre-LLETZ colposcopy (43 satisfactory pre-LLETZ colposcopies [61%] and 456 [86%] respectively, p < .001). In a stepwise binary logistic regression analysis, only the two latter parameters were found to be independently associated with unsatisfactory post-LLETZ colposcopies. ConclusionsSurgeons should consider other therapeutic strategies when contemplating iterative diagnosis-LLETZ in older women with initially invisible SCJ, as an appropriate post-LLETZ surveillance is at higher risk of being impossible to achieve.

Do fertile women have an inferior treatment for high-grade precancerous lesions?

To investigate whether a concern for future pregnancy is reflected in the extent of large loop excision of the transformation zone (LLETZ) and to assess the clinical outcome. We reviewed the medical records of 275 women who underwent LLETZ for precancerous lesions in cervix. We divided them into two groups according to pregnancy possibility in the future: nonpotential versus potential group. The potential group was arbitrarily defined as women who met one of the following: (i) regardless of marital status, younger than 41 years with less than two parities and (ii) regardless of parity, younger than 46 years and unmarried. After propensity score matching (1:1, 44 women in each group), we compared the extent of LLETZ with respect to short-term recurrence. After LLETZ, similar percentages of patients were finally diagnosed with ≥CIN3 (cervical intraepithelial neoplasia 3) in the two groups (27 [61.4%] vs 32 [72.7%], P = 0.257). Notably, the largest transverse diameter of LLETZ specimen was significantly larger in the nonpotential group (2.74 ± 1.06 vs 2.37 ± 0.62 cm, P = 0.047). There were more women with exocervical resection margin involvement in the potential group than in the nonpotential group (14 [31.8%] vs 6 [13.6%], P = 0.042). However, there was no significant difference in the incidence of short-term recurrence ≥HSIL (high-grade squamous intraepithelial lesion) within 24 months after LLETZ between the two groups (1 [2.3%] vs 1 [2.3%], P > 0.999). Pregnancy possibility in the future may affect the extent of LLETZ, as assessed by the largest transverse diameter obtained. This finding may be associated with increased resection margin involvement in women with future pregnancy possibility.

Underdiagnosis of cervical intraepithelial neoplasia (CIN) 2 or Worse Lesion in Women with a Previous Colposcopy-Guided Biopsy Showing CIN 1.

Objective Expectant follow-up for biopsy-proven cervical intraepithelial neoplasia (CIN) 1 is the current recommendation for the management of this lesion. Nevertheless, the performance of the biopsy guided by colposcopy might not be optimal. Therefore, this study aimed to calculate the rate of underdiagnoses of more severe lesions in women with CIN 1 diagnosis and to evaluate whether age, lesion extent and biopsy site are factors associated with diagnostic failure. Methods Eighty women with a diagnosis of CIN 1 obtained by colposcopy-guided biopsy were selected for this study. These women were herein submitted to large loop excision of the transformation zone (LLETZ). The prevalence of lesions more severe than CIN 1 was calculated, and the histological diagnoses of the LLETZ specimens were grouped into two categories: "CIN 1 or less" and "CIN 2 or worse." Results The prevalence of lesions diagnosed as CIN 2 or worse in the LLETZ specimens was of 19% (15/80). Three women revealed CIN 3, and 1 woman revealed a sclerosing adenocarcinoma stage I-a, a rare type of malignant neoplasia of low proliferation, which was not detected by either colposcopy or previous biopsy. The underdiagnosis of CIN 2 was not associated with the women's age, lesion extension and biopsy site. Conclusions The standard methods used for the diagnosis of CIN 1 may underestimate the severity of the true lesion and, therefore, women undergoing expectant management must have an adequate follow-up.

Small lesion size measured by colposcopy may predict absence of cervical intraepithelial neoplasia in a large loop excision of the transformation zone specimen.

To evaluate whether colposcopic measurement of the lesion size at diagnosis and/or human papillomavirus (HPV) genotyping can predict the absence of dysplasia in a large loop excision of the transformation zone (LLETZ) specimen in women treated for squamous intraepithelial lesions/cervical intraepithelial neoplasia (SIL/CIN). Prospective observational study. Tertiary university hospital. A cohort of 116 women who underwent LLETZ because of biopsy-proven low-grade SIL/CIN that had persisted for 2 years, or because of a high-grade SIL/CIN diagnosed in the referral visit and squamocolumnar junction completely visible (types 1 or 2, according to the International Federation of Cervical Pathology and Colposcopy, IFCPC). After LLETZ the women were classified by histology into the study group (absence of SIL/CIN in the surgical specimen, 28/116, 24.1%) and the control group (SIL/CIN in the LLETZ specimen, 88/116, 75.9%). The size of the lesion determined in the diagnostic colposcopy and the HPV genotype were evaluated in all women. The lesion size was significantly smaller in the study group (25.7 ± 37.8 versus 84.5 ± 81.7 mm2 ; P < 0.001). A lesion size of ≤12 mm2 and HPV types other than 16 or 18 were associated with an absence of SIL/CIN in the LLETZ specimen (P < 0.001 and P = 0.016, respectively). On multivariate analysis only a lesion size of ≤12 mm2 predicted the absence of SIL/CIN (odds ratio, OR 10.6; 95% confidence interval, 95% CI 3.6-30.6; P < 0.001). A lesion size of ≤12 mm2 had a specificity of 90.9% (95% CI 83.0-95.3%) and a negative predictive value of 86.0% (95% CI 77.5-91.6%) to predict the absence of SIL/CIN in the surgical specimen. Small lesion size in diagnostic colposcopy could predict the absence of SIL/CIN in the LLETZ specimen. Colposcopy measurement of lesion size prior to LLETZ may avoid unnecessary treatment. Small lesion size in colposcopic evaluation might predict the absence of SIL/CIN in an LLETZ specimen.

Benefits of Direct Colposcopic Vision for Optimal LLETZ Procedure

The aim of the study was to assess whether direct colposcopic vision (DCV) of the cervix during large loop excision of the transformation zone (LLETZ) is associated with a decrease in the volume and dimensions of specimens or affects margin status at histology. A prospective multicenter observational study of 216 women who underwent LLETZ for grades 2 and 3 cervical intraepithelial neoplasia was conducted. The volume and dimensions (circumference, length, and thickness) of the surgical specimens were measured before fixation. Data were compared according to the use of colposcopy during LLETZ. The following 3 groups were considered: LLETZ performed without colposcopy (n = 91), LLETZ performed immediately after colposcopy (n = 51), and LLETZ performed under DCV (n = 74). Patient characteristics were comparable with regard to age, parity, history of excision, indication of the procedure, and the size of the cervix. We found a significant decrease in all dimensions of the specimens obtained under DCV (p < .001). Margin status was not affected. After adjusting for confounders, the mean volumes were significantly lower in the DCV group (adjusted mean difference = -0.66 mL; 95% CI = -1.17 to -0.14). The probability that negative margins would be achieved together with the attainment of a volume less than 5 mL and a thickness less than 10 mm was the highest in the DCV group (adjusted OR = 2.80; 95% CI = 1.13 to 6.90). Direct colposcopic vision is associated with a significant decrease in the volume and in all dimensions of LLETZ specimens with no compromise in the margin status.

LLETZ Specimen Fragmentation: Impact on Diagnosis, Outcome, and Implications for Training.

This study was designed to assess fragmentation of Large loop excision of the transformation zone (LLETZ) specimens, its influence on short-term cytological outcome, and the risk factors for specimen fragmentation, as we well as trainee performance on clinical outcome. This retrospective study was performed at a cancer center. Women who underwent LLETZ for suspected high-grade cervical intra-epithelial neoplasia (CIN) over a 5-year period were included. Patients were identified through a regional database. Data were obtained from hospital and regional databases. Fisher's exact test was used. 75% of all specimens were obtained intact. When the LLETZ specimen was intact, 89% of smear tests were reported as negative, against 86% when the specimen was fragmented. Fragmentation was significantly associated with high-grade smear results at 6 months. Trainee status was significantly related to specimen fragmentation. Fragmentation of LLETZ specimens is associated with an increased likelihood of obtaining a high-grade smear at 6months post treatment. Enhancing the colposcopy training may help improve clinical outcome.

Image assessment of cervical dimensions after LLETZ: a prospective observational study

To assess the impact of large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia (CIN) on cervical morphology as assessed by three-dimensional ultrasound. Prospective observational study. University Hospital in Dublin. Women with CIN who underwent an LLETZ procedure. All 106 participants had a three-dimensional transvaginal ultrasound scan (3DTVS) performed immediately before and 6months after LLETZ. The excised LLETZ specimen dimensions were also recorded. Blind analysis of the images was performed. The volume of the uterus and cervix was documented. The relationship between the extirpated LLETZ dimensions and subsequent cervical and uterine biometry, as assessed by 3DTVS. LLETZ induced a statistically significant reduction in both the length (mean, -0.46cm; P<0.001) and the volume (-6.12cm(3) ; P<0.001) of the uterus, and in the volume of the cervix (-1.60cm(3) ; P<0.001). The volume of the excised specimen had a significant impact on the reduction of the length of the uterus (β, -0.038; P=0.012), the volume of the uterus (β, -0.791; P=0.036) and the volume of the cervix (β, -0.121; P=0.046). The circumference of the excised specimen appeared to have a significant impact on the length (β, -0.016; 95% CI, -0.028 to -0.003; P=0.013) and volume (β, -0.413; 95% CI, -0.719 to -0.107; P=0.009) of the uterus 6months after LLETZ. The volume of tissue removed at LLETZ is related to the subsequent cervical volume, as well as the uterine length and volume, 6months after the procedure.

A comparative study of efficacy and outcomes of large loop excision of the transformation zone procedure performed under general anaesthesia versus local anaesthesia

Although Australian National Health and Medical Research Council (NHMRC) guidelines do not specify targets for mode of anaesthesia for large loop excision of the transformation zone (LLETZ) procedures, UK NHS Cervical Screening Programme (NHSCSP) guidelines recommend that >80% of LLETZ procedures be performed under local anaesthesia. There is a paucity of clinical data regarding both the proportion of women receiving general anaesthesia for treatment, factors underpinning this choice and the impact of mode of anaesthesia on treatment outcomes. To identify the proportion of women who have a LLETZ under general anaesthesia and to establish the impact of mode of anaesthesia on outcomes including treatment efficacy, overtreatment (negative histology), short-term morbidity and attendance for follow-up. Single-centre retrospective analysis of all women treated with LLETZ for suspected cervical dysplasia between 1, May 2005 and 1, May 2009. Thirty-three percent of a total 465 LLETZ procedures were carried out under general anaesthesia, although the reason for anaesthesia choice was not recorded in 52% of cases. There were no significant differences in the primary outcomes of unclear LLETZ margins or negative LLETZ histology, or in the secondary outcomes of depth and surface area of LLETZ specimen, short-term morbidity or rates of incomplete follow-up. Although reasons underpinning selection of anaesthesia mode remain elusive, at this centre, outcomes following LLETZ procedure for the management of suspected cervical dysplasia are not affected by the mode of anaesthesia used.

The thickness and volume of LLETZ specimens can predict the relative risk of pregnancy‐related morbidity

The aim of this study was to determine if the individual physical characteristics of the extirpated transformation zone after large loop excision of the transformation zone (LLETZ) might predict the relative risk of adverse obstetric outcome, specifically preterm labour (PTL). A retrospective observational study. University teaching hospital in Dublin (Coombe Women & Infants University Hospital, CWIUH). Women who had LLETZ treatment for cervical intraepithelial neoplasia (CIN) in the colposcopy service between 1999 and 2002, and who subsequently had a pregnancy at the CWIUH. Case records and histology reports for eligible women were examined. Age, parity, smoking history, pregnancy complications and CIN grade were recorded. Exclusion criteria were age >42 years, previous treatment for CIN, previous premature labour or twin pregnancies. The Student's t-test, Mann-Whitney U-test, analysis of variants (ANOVA) and logistic regression were employed to analyse the data. Gestational age at birth, PTL (i.e. <37 weeks of gestation) and miscarriage rate (<24 weeks of gestation). Out of 1808 women who underwent LLETZ treatment, a total of 353 women were identified who subsequently had a pregnancy at the CWIUH, with 321 being eligible for inclusion in the study. Of these, 76.3% delivered at term, 9.1% delivered at <37 weeks of gestation and 14.6% miscarried at <24 weeks of gestation. There was a three-fold increase in the risk of PTL if the excision volume exceeded 6 cm(3) (RR = 3.00; 95% CI 1.45-5.92), or when the thickness of the excised tissue was greater than 12 mm (RR = 2.98; 95% CI 1.27-7.01). The time interval between LLETZ and pregnancy did not appear to have an effect on PTL rates. We found no association between the grade of CIN and the risk of PTL. This study reveals that the thickness and the total volume of the excised transformation zone are associated with an increased risk of PTL. Excisions thicker than 1.2 cm and larger than 6 cm(3) carry a three times greater risk for PTL.

Persistent minor smear abnormalities: is large loop excision of the transformation zone (LLETZ) the solution?

This prospective observational study was carried out to evaluate the efficacy of large loop excision of the transformation zone (LLETZ) as a management strategy for women with four or more smears showing borderline changes or mild dyskaryosis. A total of 102 women with four or more smears showing minor abnormalities and no colposcopic evidence of high-grade disease opted to undergo LLETZ in preference to continued cytological surveillance. Histology of the LLETZ specimens showed 11 cases of CIN2/3, one CGIN, 32 CIN1 and 10 HPV changes. In 97 of the 102 (95%) women, the follow-up cervical smear reverted to negative.

Feasibility of Cytology-Based Cervical Cancer Screening in Rural Cameroon

To determine the prevalence of cervical cancer and its precursors in a rural population in Cameroon and to evaluate the feasibility of a cytology-based screening program in such areas. A prospective study was conducted in the rural town of Bafang. Following an advocacy campaign, 750 women were recruited. After a clinical examination, all women had a Pap smear with the Cervex Brush. Each sample had two preparations, conventional and liquid based. The conventional smears were interpreted in Bafang. Cytologically abnormal cases, those with clinical inflammation and/or macroscopic cervical lesions, had a colposcopic examination and directed biopsy. HSIL and colposcopically abnormal cases were treated with large loop excision of the transformation zone (LLETZ). The liquid-based preparations and histopathology were performed in Geneva and the results sent to Cameroon for patient follow-up. Mean age and parity of the women screened were 43.7 years and 7.8, respectively. The conventional smears showed 3.6% cervical abnormalities: 2% (15/740) ASCUS/LSIL and 1.6% (12/740) HSIL. The liquid-based preparations showed 12.6% (91/722) cervical abnormalities: 10.1% (73/722) ASCUS/LSIL and 2.5% (18/722) HSIL. Fifty percent of samples in both preparations showed evidence of inflammation. Histology was performed on 64 colposcopically directed punch biopsies and LLETZ specimens. The histologic diagnoses agreed with the cytologic findings in 60% (14/23) of conventional smears and 85% (12/14) of liquid-based preparations. There is a high rate of cervical intraepithelial neoplasia in the unscreened rural population of Cameroon. The situation is complicated by a high rate of cervical infection. A population-based cytologic screening program for cervical cancer would not be feasible in rural Cameroon because of high cost, low quality and limited technical facilities. Rural Africa requires an algorithm using a simple, low-cost technique of mass screening and an improved cytology service only to triage selected patients.

The management and follow-up of patients with high-grade cervical glandular intraepithelial neoplasia

Maini M, Lavie O, Comerci G, Cross PA, Bolger B, Lopes A, Monaghan JM. The management and follow-up of patients with high-grade cervical glandular intraepithelial neoplasia. Int J Gynecol Cancer 1998; 8: 287–291. The purpose of this study was to evaluate if the status of the margins on large loop excision of the transformation zone (LLETZ) can predict the presence of residual cervical glandular intraepithelial neoplasia (CGIN) and to assess the efficacy of cervical conization as primary management of CGIN. Between January 1989 and March 1997 fifty patients with a diagnosis of CGIN made by LLETZ were treated in the Department of Gynaecological Oncology at the Queen Elizabeth Hospital, Gateshead. Presence or absence of CGIN at cone margins, results of cervical cytological examinations before and following conization, colposcopic examination, and results of histopathologic assessment of any surgical specimens taken after initial cone biopsy were analyzed in this study. Of the 50 patients with CGIN, managed by conization, in 34 (68%) CGIN was present at the surgical margins and in 16 (32%) the margins were clear. Eleven (32.3%) patients with CGIN at the margins of excision had evidence of residual disease and there was only one of the 16 (6.25%) patients with clear margins (P= 0.03). Two cases of invasive adenocarcinoma were identified in the group of patients with positive margins. In a mean follow-up time of 32.35 months, no case of invasive carcinoma was identified in the completely excised group. In our retrospective study LLETZ was found to be an adequate primary management for CGIN, and the excision margin status of the LLETZ specimen did appear to be a prognostic factor for residual disease.

Histopathological variables predicting high-grade squamous intraepithelial lesions after large-loop excision of the transformation zone.

Our aim was to determine whether histopathological variables predict persistent high-grade squamous intraepithelial lesions (HGSIL) after large-loop excision of the transformation zone (LLETZ). All patients with cervical intraepithelial neoplasia (CIN) grade 2 or 3 on a LLETZ specimen with at least one follow-up Papanicolaou (Pap) test were identified. Histopathological variables were evaluated for the potential to predict HGSIL on a follow-up Pap test. Variables examined included endocervical margin status, ectocervical margin status, endocervical curettage (ECC) result, presence or absence of endocervical glandular involvement, and presence or absence of koilocytosis. Two hundred and nineteen cases were identified. A follow-up Pap test showed HGSIL in 16 patients (7.3%). Of the histopathological variables studied, only a positive ECC at the time of LLETZ conization predicted HGSIL on follow-up cytology (p =.0002). Endocervical margin status, ectocervical margin status, presence or absence of glandular involvement, and presence or absence of koilocytosis were not associated significantly with HGSIL at follow-up. Most histopathological factors from LLETZ conization do not predict reliably the presence of HGSIL at the time of follow-up Pap test. A positive ECC at the time of LLETZ, however, may predict those patients destined to have persistence or recurrence. These findings suggest that conservative follow-up is warranted after LLETZ conization.

The use of large loop excision of the transformation zone (LLETZ) in an outpatient setting.

An audit of the results of 129 patients treated in the first 12 months of operation of an outpatient large loop excision of the transformation zone (LLETZ) clinic was performed. It confirmed the efficacy of the procedure in treatment of cervical intraepithelial neoplasia (CIN) with a cure rate of 93.8%. Major deficiencies identified were the lack of compliance with recommended follow-up, a major discrepancy between predicted diagnosis on colposcopically directed punch biopsy and LLETZ specimen histology, and a large proportion of LLETZ specimens which had negative histology and may be regarded as overtreatment. Suggested strategies to address these include observation of low-grade lesions and treatment with LLETZ at the first clinic appointment.

Large loop excision of the transformation zone: A histological audit

SummaryPrevious studies on large loop excision of the transformation zone (LLETZ) report a high incidence of negative histology on the LLETZ specimens. Overtreatment may occur when there is a low threshold to treat at the first visit. In 1993, we performed LLETZ on 276 patients: in 97 (35 percent) the treatment was undertaken at the first visit. The diagnosis of neoplasia was not confirmed in 10 (3·7 percent) patients. Our study shows that a policy of selective ‘see and treat’ may minimise overtreatment of patients referred for colposcopy. We recommend that the negative histology rate after LLETZ is used as an index of the quality of care in colposcopy services.

Serial quantitation of HPV‐16 in the smears of women with mild and moderate dyskaryosis

The aim of this study was to examine the efficacy of semi-quantitative polymerase chain reaction (PCR) testing in cervical smears as an adjunct to cytological surveillance in a cohort of women with mild or moderate dyskaryosis. The study population comprised a group of 62 women who underwent twelve months of cytological and colposcopic surveillance as part of a larger randomised prospective study of women with mild and moderate dyskaryosis. Semi-quantitative PCR for HPV-16 DNA was carried out on the initial and twelve month study smears before a large loop excision of the transformation zone (LLETZ) was carried out. Smears from a control population which comprised 167 women without a history of abnormal cervical cytology who were attending family planning and general practitioner clinics for routine cervical smears were tested similarly. The presence of high or intermediate levels of HPV-16 DNA on both the initial and twelve month study smear was positively associated with the identification of cervical intraepithelial neoplasia (CIN) grades II or III in the LLETZ specimen (P = 0.01). While the combination of HPV-16 DNA testing with cytology on a repeat cervical smear improved the selection of women with underlying CIN II/III, there was still a false negative rate of 53%. Twenty-nine women had 'low risk' levels of HPV-16 DNA and mild dyskaryosis or less on both repeat smears indicating suitability for surveillance, but in fact 34% of them had CIN II/III. This study supports the finding reported previously of an association between high and intermediate levels of HPV-16 DNA and CIN II/III.(ABSTRACT TRUNCATED AT 250 WORDS)

LLETZ Is an Acceptable Alternative to Diagnostic Cold-Knife Conization

Large loop excision of the transformation zone (LLETZ) provides a pathologic specimen similar to a cold-knife cone (CKC) biopsy of the cervix. One hundred twenty women with indications for a cone biopsy were evaluated with LLETZ to determine if this procedure is an acceptable alternative to traditional cold-knife conization of the cervix. All patients had LLETZ performed in the clinic under local anesthesia. An average of 2.1 slices was required to remove the transformation zone. Coagulation artifact interfered with histologic diagnosis in only 1.8% of specimens. The number of slices taken during the LLETZ procedure significantly correlated with the amount of heat artifact in the pathology specimen (P = 0.02) and interfered with the ability of the pathologist to determine complete excision of dysplasia (P = 0.03). LLETZ is an acceptable alternative to diagnostic CKC and can offer a substantial cost savings. To facilitate histopathologic interpretation, every effort should be made to minimize the number of slices and to maintain orientation of the LLETZ specimen. Endocervical curettage performed after LLETZ can identify a group of patients who are at high risk for CIN recurrence.