Large Loop Excision Of The Transformation Zone Treatment Research Articles

What is the Obstetric Outcome with a Large Loop Excision of the Transformation Zone (LLETZ) for Cervical Intraepithelial Neoplasia?

Objective: To find out the association of large loop excision of the transformation zone (LLETZ) at or less than 36 weeks of gestation, extreme preterm delivery at or less than 28 weeks gestation and perinatal mortality with premature birth. Design: Data was collected from euroking, ‘joe’ and e-searcher systems of 407 retrospective cases. The data were analysed pre and post cervical histology between 20-43 weeks of pregnancy to identify live births. Setting: East Sussex Healthcare Trust Population: The selected population were women who became pregnant after LLETZ treatment at the East Sussex hospital. Their case notes and histology reports were taken into account. The women who were not included in this study were those in age group greater than 42 years, previous premature labour or twin pregnancies. Result: Total number of deliveries in East Sussex hospital in a year were 4349 and the deliveries at term gestation (37 +) were 4057. The total number of all preterm deliveries were 268 (6.16 %), 34 to 36+6 weeks were 198 (4.55 %) and less than 34 weeks were 70 (1.6 %). In 24 cases gestation was unknown. The total data collected were of 407 LLETZ treatment cases. The number of premature deliveries were 45 (11 %) as against background risk of 6.16%. Those who had term pregnancy prior to LLETZ were 15 out of these 45 cases, and the remaining had their first pregnancy after having LLETZ. Conclusion: LLETZ increases the chances of premature births.

Posttreatment monitoring by ASCL1/LHX8 methylation analysis in women with HIV treated for cervical intraepithelial neoplasia grade 2/3

Women with HIV (WWH) have an increased risk to develop recurrent cervical intraepithelial neoplasia grade 2/3 (rCIN2/3) after treatment compared with HIV-negative women. Therefore, appropriate posttreatment monitoring of WWH is important. This study evaluates the performance of ASCL1 and LHX8 methylation analysis as posttreatment monitoring test in WWH treated for CIN2/3, as alternative to cytology or human papillomavirus (HPV) as follow-up test. Prospective observational cohort study. WWH treated for CIN2/3 by large loop excision of the transformation zone (LLETZ) (n = 61) were invited for follow-up study visits at 1, 2.5 and 4 years after baseline. Baseline and follow-up cervical scrapes were tested for cytology, HPV and DNA methylation of ASCL1 and LHX8 genes. The performance of these strategies for the detection of rCIN2/3 was evaluated in the first follow-up cervical scrape. Thirteen (21.3%) rCIN2/3 lesions were detected within 4 years of follow-up. In women without rCIN2/3 in follow-up, methylation levels of ASCL1 and LHX8 decreased significantly after LLETZ treatment (P = 0.02 and 0.007, respectively). In women with rCIN2/3, methylation levels remained high after LLETZ treatment. The 4-year rCIN2/3 risk was 4.9% (95% CI: 0.6-16.5) for ASCL1/LHX8-negative women, 8.1% (95% CI: 1.7-21.9) for HPV-negative women and 7.7% (95% CI: 2.1-18.5) for cytology-negative women. A negative ASCL1/LHX8 methylation test in follow-up is associated with a low rCIN2/3 risk and could serve as an objective test of cure and well tolerated alternative for HPV and/or cytology screening in the posttreatment monitoring of WWH.

HPV self-sampling in the follow-up of women after treatment of cervical intra-epithelial neoplasia: A prospective study in a high-income country

Current follow-up strategy for women after large loop excision of the transformation zone (LLETZ) for cervical intra-epithelial neoplasia (CIN) is burdened by a low compliance. We evaluated the performance of home-based Human Papillomavirus (HPV) self-sampling (Self-HPV) after treatment for CIN with the aim to assess the (i) feasibility and (ii) follow-up compliance. This study took place at the Geneva University Hospitals between May 2016 and September 2020. Women aged 18 years or older, undergoing LLETZ for a biopsy-proven cervical intraepithelial neoplasia grade 1 or worse (CIN1 + ) were invited to participate. Agreement statistics, interpreted according to the scale of κ values, were calculated for Self-HPV and HPV performed by the physician (Dr-HPV). The samples were analyzed using GeneXpert and Cobas. Sample size was calculated to provide a 10% precision to estimate the kappa coefficient. A total of 127 women were included, with a median age of 35 years (interquartile range 30–41 years). There was a substantial agreement between Self-HPV and Dr-HPV using GeneXpert at 6 and 12 months, with a κ value of 0.63 (95%CI: 0.47–0.79) and 0.66 (95%CI: 0.50–0.82), respectively. Up to 9/10 (90%) women who did not come to their follow-up visit did not send their Self-HPV, either. In the follow-up after LLETZ treatment, home-based self-HPV is feasible, with substantial agreement between the two groups, however, concern remains regarding adherence to Self-HPV performance at home and loss to follow-up.The trial was registered on clinicaltrials.gov with the identifier NCT02780960.

Large loop excision of the transformation zone and preterm delivery over a decade in a major women’s hospital

The success of cervical screening relies on assessment and treatment of pre-malignant disease. Large loop excision of the transformation zone (LLETZ) has been the mainstay of treatment for cervical intraepithelial neoplasia (CIN). Preterm delivery (PTD) in subsequent pregnancy is a long-term complication of the intervention. To describe the characteristics of women who had LLETZ treatment(s) followed by PTD in the Rotunda Hospital over a 10-year period. The pathology and the obstetric databases were searched to identify women who had LLETZ followed by PTD from 1 January 2007-31 December 2016. Details including gestation at delivery, depth of LLETZ and grade of CIN were extracted. Exclusion criteria included multiple pregnancy, and deliveries due to current pregnancy indications. There were 97 women eligible for inclusion. Mean gestation at delivery was 33+2 weeks. CIN 1 was diagnosed in 16, CIN 2 in 24, CIN 3 in 53, and four were negative for CIN. No microinvasive or invasive disease was identified. The average depth of excision was 9.9mm, 11.4mm and 8.5mm for CIN 1, 2 and 3, respectively. The difference in depth between excisions with CIN 2 and 3 was significant (p = 0.019). Despite having a lower mean depth of excision, women with CIN 3 comprised the majority of those who experienced PTD, suggesting that factors other than mechanical weakness are implicated in PTD for these women. This is in keeping with recent suggestions that the common denominator in high grade CIN and PTD is an altered vaginal microbiome.

TOPical Imiquimod treatment of residual or recurrent cervical intraepithelial neoplasia (TOPIC-2 trial): a study protocol for a randomized controlled trial

BackgroundCervical dysplasia (cervical intraepithelial neoplasia (CIN)) is caused by Human Papillomavirus (HPV) and is most common in women of reproductive age. Current treatment of moderate to severe CIN is surgical. This procedure has potential complications, such as haemorrhage, infection and preterm birth in subsequent pregnancies. Moreover, 15% of women treated for high grade CIN develop residual/recurrent CIN or cervical cancer after surgical excision. Finally, 75–100% of patients with a residual and recurrent CIN 2–3 lesion are still HPV positive. They could possibly benefit from an alternative medical treatment, which aims to eliminate HPV.The primary study objective is to evaluate the effectivity of imiquimod 5% cream compared to treatment with Large Loop Excision of the Transformation Zone (LLETZ) for recurrent/residual CIN.Methods/designThis study is a multicentre, non-inferiority randomized single blinded study. The study population consists of female patients with histological proven residual/recurrent CIN after previous surgical treatment. Four hundred thirty-three patients will be included in the Netherlands. The first 35 patients will be included in a pilot study to prove non-futility.Included patients will be randomized to receive either 5% imiquimod cream or LLETZ treatment. Imiquimod will be inserted three times a week intravaginally for a period of 16 weeks using a vaginal applicator. Ten weeks after the end of imiquimod treatment a biopsy will be taken for treatment response. In case of progressive or stable disease a LLETZ will be performed. At 12 and 24 months after the start of treatment cytology will be taken for follow up. The LLETZ group will be treated according to the current guidelines. Throughout the study, HPV typing and quality of life will be tested.DiscussionRepeated LLETZ in women with residual/recurrent CIN lesions has complications. We would like to possibly offer alternative treatment in a selected group to avoid these risks. Moreover, we monitor treatment efficacy, side effects and long-term recurrence rates.Trial registrationMedical Ethical Committee approval number: NL 53792.078.15. Affiliation: Erasmus Medical Center.Registration number ClinicalTrials.gov: NCT02669459, date of registration: 27th January 2016.

Psychosexual outcomes in women of reproductive age at more than two-years from excisional cervical treatment – a cross-sectional study

Purpose: To investigate the long-term psychosexual outcomes in women following excisional cervical treatment.Materials and methods: Women with cold-knife conization (CKC) or large loop excision of the transformation zone (LLETZ) treatment were interviewed after a follow-up colposcopy visit. Their demographics, treatment and psychosexual characteristics were recorded.Results: One hundred and forty six women with a mean age of 35.2 ± 5.4 years underwent either LLETZ (68.5%) or CKC (31.5%) treatment within 4.7 ± 2.7 years (range: 2–15) before the interview. 27.4% of women were less interested in sexual intercourse following treatment in comparison with their interest before. Those women with less interest in sexual intercourse after treatment had higher anxiety and depression scores and were more worried about disease progression. Women with post-treatment complications were at risk of less interest in sexual intercourse and of greater anxiety and depression. Women with abnormal smears at follow-up were at risk of greater anxiety. The type of treatment and grade of dysplasia did not affect their interest in sexual intercourse or the anxiety and depression scores.Conclusions: Approximately, one-third of women at more than two years post-treatment may suffer from less interest in sexual intercourse, have relatively greater anxiety and depression, and might still be concerned about the possibility of disease progression.

Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study.

To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia. This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded. We identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p=0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32weeks and 34weeks, respectively. We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.

Risk factors for HPV persistence and cytology anomalies at follow-up after treatment for cervical dysplasia.

To evaluate predictor factors of persistent cytologic dysplasia and/or high-risk human papillomavirus (hrHPV) infection at 6-month follow-up and at 3-5years during routine cervical smear testing. The present retrospective study included data from women treated for cervical dysplasia by large loop excision of the transformation zone (LLETZ) at Ipswich Hospital, UK, between January 1 and December 31, 2012. Age, parity, smoking, status of resection margins, and previous LLETZ treatment were evaluated by multivariate analyses. There were 192 patients included in the study. There was no association between age (relative risk [RR] 1.0, 95% confidence interval [CI] 0.80-1.23; P>0.99), smoking (RR 1.12, 95% CI 0.79-1.59; P=0.516), or parity (RR 1.10, 95% CI 0.88-1.38; P=0.382) and abnormal cytology and/or persistent hrHPV infection at 6months. There was an association between positive margins (RR 1.64, 95% CI 1.20-2.24; P=0.003), previous LLETZ (RR 3.48, 95% CI 1.69-7.15; P<0.001), and dyskaryosis and/or hrHPV infection at 6months. Only previous LLETZ treatment remained associated with abnormal cytology and persistent hrHPV infection at 3-5years (RR 6.37, 95% CI 3.56-11.3; P<0.001). Clinical factors, including age, smoking, treatment history, and status of surgical margins, could help to determine the risk of dysplasia recurrence and facilitate patient follow-up based on risk stratification.

TOPical Imiquimod treatment of high-grade Cervical intraepithelial neoplasia (TOPIC trial): study protocol for a randomized controlled trial.

BackgroundCervical intraepithelial neoplasia (CIN) is the premalignant condition of cervical cancer. Whereas not all high grade CIN lesions progress to cervical cancer, the natural history and risk of progression of individual lesions remain unpredictable. Therefore, high-grade CIN is currently treated by surgical excision: large loop excision of the transformation zone (LLETZ). This procedure has potential complications, such as acute haemorrhage, prolonged bleeding, infection and preterm birth in subsequent pregnancies. These complications could be prevented by development of a non-invasive treatment modality, such as topical imiquimod treatment.The primary study objective is to investigate the efficacy of topical imiquimod 5 % cream for the treatment of high-grade CIN and to develop a biomarker profile to predict clinical response to imiquimod treatment. Secondary study objectives are to assess treatment side-effects, disease recurrence and quality of life during and after different treatment modalities.Methods/designThe study design is a randomized controlled trial. One hundred forty women with a histological diagnosis of high-grade CIN (CIN 2–3) will be randomized into two arms: imiquimod treatment during 16 weeks (experimental arm) or immediate LLETZ (standard care arm). Treatment efficacy will be evaluated by colposcopy with diagnostic biopsies at 20 weeks for the experimental arm. Successful imiquimod treatment is defined as regression to CIN 1 or less, successful LLETZ treatment is defined as PAP 1 after 6 months. Disease recurrence will be evaluated by cytology at 6, 12 and 24 months after treatment. Side-effects will be evaluated using a standardized report form. Quality of life will be evaluated using validated questionnaires at baseline, 20 weeks and 1 year after treatment. Biomarkers, reflecting both host and viral factors in the pathophysiology of CIN, will be tested at baseline with the aim of developing a predictive biomarker profile for the clinical response to imiquimod treatment.DiscussionTreatment of high-grade CIN lesions with imiquimod in a selected patient population may diminish complications as a result of surgical intervention. More knowledge on treatment efficacy, side effects and long-term recurrence rates after treatment is necessary.Trial registrationEU Clinical Trials Register EU-CTR2013-001260-34. Registered 18 March 2013.Medical Ethical Committee approval number: NL44336.068.13 (Medical Ethical Committee Maastricht University Hospital, University of Maastricht).Affiliation: Maastricht University Hospital.Registration number ClinicalTrials.gov: NCT02329171.

Does the number of tissue fragments removed from the cervix with excisional treatment for CIN pathology affect the completeness of excision and cytology recurrence at follow-up? An observational cohort study

The objective of our study was to determine whether removing multiple pieces of cervical tissue during large loop excision of the transformation zone (LLETZ) reduced the margin positivity of excision and cytology recurrence rates at follow-up. We conducted an observational cohort study and identified 462 women having had a single LLETZ treatment for cervical intraepithelial neoplasia (CIN) over a two-year period. Women with previous cervical treatment, cervical cancer on the excised tissue or missing follow-up data were excluded. Multiple regression analysis showed that removal of cervical tissue in multiple pieces did not offer any benefit in removing more disease and less recurrence rates. When multiple pieces were taken there was a four-fold increased risk for inconclusive excision margins as reported by the histopathologist. Removal of multiple pieces led to significantly more tissue being removed which may expose the patient to an increased risk of preterm delivery in a future pregnancy.

Endocervical Crypt Involvement by CIN2-3 as a Predictor of Cytology Recurrence After Excisional Cervical Treatment.

The primary objective was to determine whether endocervical crypt involvement (ECI) by cervical intraepithelial neoplasia (CIN) on the excised cervical tissue after large loop excision of the transformation zone (LLETZ) represents a predictor of cytology recurrence. Secondary objective was to identify the ability of a pretreatment cervical punch biopsy to predict cytology recurrence. This was a case series study conducted in an NHS hospital. Women with LLETZ treatment performed over a 2-year period (2010-2011) were identified through our colposcopy database. Women with previous cervical treatment, cervical cancer on cone histopathology, or missing follow-up data were excluded. A group of 526 eligible women was identified over the study period. Crypt involvement was not a predictor of recurrence in the total sample. However, in the subgroup of women with CIN2-3 on pretreatment punch biopsy and with ECI on cone specimen in comparison to those without ECI, we identified an increased risk for overall cytology recurrence (HR, 3.1; 95% CI, 1.04-9.28; P = 0.043) and a trend for increased risk of high-grade cytology recurrence (HR, 4.62; 95% CI, 0.84-25.28; P = 0.07). A pretreatment punch biopsy showing crypt involvement by CIN2-3 was indicative of women at risk for abnormal cytology after excision. In women with CIN2-3 on pretreatment punch biopsy and ECI on excised tissue, the high-grade cytology recurrence was significantly reduced if more than 1.9 cm of cervix was removed. It seems that the presence of crypt involvement on the excised cervix in the subgroup of women with CIN2-3 on pretreatment punch biopsy is predictive of cytology recurrence.

Patients' perceptions of colposcopy pain.

This study aimed to examine the sensory descriptors used by women undergoing their first ever colposcopy examination as part of cervical cancer screening. Immediately following colposcopy, women were asked to provide detailed information about the sensory, affective, evaluative and intensity properties of the colposcopy examination using a validated, standardised questionnaire. Overall, 160 colposcopy patients with different management options were assessed [53 women underwent diagnostic colposcopy only, 76 had colposcopy plus punch biopsy, 31 women had colposcopy plus see-and-treat large loop excision of the transformation zone (LLETZ) treatment]. The results demonstrated that women report greater pain intensity with more intensive management options, such that women who have punch biopsy or LLETZ treatment report significantly more pain than women who have diagnostic colposcopy. In addition, with increasing intensity of treatment, the number of qualitative sensory and pain descriptors increase. This information can usefully be incorporated into colposcopy information leaflets, to ensure the sensory and affective experience of colposcopy is fully explained to women prior to attending. Expanding the preparatory information that women receive may serve to reduce anxiety, pain and distress associated with colposcopy.

Follow-up strategies after treatment (large loop excision of the transformation zone (LLETZ)) for cervical intraepithelial neoplasia (CIN): Impact of human papillomavirus (HPV) test

Development of cancer of the cervix is a multi-step process as before cervical cancer develops, cervical cells undergo changes and become abnormal. These abnormalities are called cervical intraepithelial neoplasia (CIN) and are associated with increased risk of subsequent invasive cancer of the cervix. Oncogenic high-risk human papillomavirus (hrHPV), the causative agent of cervical cancer and its precursor lesions, is present in up to one-third of women following large loop excision of the transformation zone (LLETZ) treatment and is associated with increased risk of residual disease and disease recurrence.HPV testing may serve as a surveillance tool for identifying women at higher risk of recurrence. High-risk human papillomavirus testing will enable us to identify women at increased risk of residual or recurrent CIN and therefore will allow us to offer closer surveillance and early treatment, when indicated. • To evaluate the effectiveness and safety of hrHPV testing after large loop excision of the transformation zone (LLETZ) treatment• To determine optimal follow-up management strategies following LLETZ treatment according to hrHPV status We searched the Cochrane Gynacological Cancer Review Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed and PsycINFO up to August 2013. We searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and we contacted experts in the field. We searched for randomised control trials (RCTs) that compared follow-up management strategies following LLETZ treatment for CIN. Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No trials were found; therefore no data were analysed. The search identified 813 references on MEDLINE, 418 on EMBASE, 22 on CINAHL, 666 on PubMed, 291 on PsycINFO and 145 on CENTRAL. When all references were imported into EndNote and duplications were removed, 1348 references remained. Initial screening of titles and abstracts of these references revealed that 42 references were potentially eligible for this review. After reading the full-text versions, we identified no relevant trials comparing hrHPV and cytology testing versus cytology testing alone for detecting residual or recurrent disease during follow-up to LLETZ treatment of adult women with CIN.We found no evidence on the effects of hrHPV and cytology testing on residual or recurrent CIN2 or higher lesions, anxiety and psychosexual morbidity outcomes in women undergoing colposcopy and treatment for CIN. We found no evidence from RCTs to inform decisions about the best surveillance strategy for women following treatment for CIN. A prognostic systematic review is needed to investigate the risk of developing recurrent cervical intraepithelial neoplasia 2+ (CIN2+) in women with a positive hrHPV test after large loop excision of the transformation zone (LLETZ) treatment.

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.

Multiple levels on LLETZ biopsies do not contribute to patient management

Cervical large loop excision of the transformation zone (LLETZ) specimens are performed both to treat and to diagnose or exclude cervical pre-neoplasia. Examination of these specimens forms a significant part of the routine histological work load of the pathologist, yet histological confirmation of squamous intraepithelial lesion (SIL) or completeness of excision, does not alter the treatment of SIL. When the LLETZ procedure is done, the treatment is complete, the dysplasia having been subject to excision as well as diathermy during the procedure. In this study, records of 1139 women who underwent LLETZ treatment for SIL were examined. The grade of SIL present and the margin status were extracted from histology reports and linked to post-LLETZ follow-up cytology and histology, for a period of 2 years. SIL recurrence in women with high grade (HG-SIL), low grade SIL (LG-SIL) and normal LLETZ biopsy results was not significantly different. There was no significant difference between the recurrence rates of HG-SIL and LG-SIL with SIL at margins compared to SIL clear of margins. Pathologists spend significant time examining multiple levels of LLETZ biopsies, grading SIL, determining margins and trying to find SIL in 'normal' LLETZ biopsies. None of this affects the subsequent follow-up. The most useful data the pathologist can provide is whether invasion is present or not. Pathological effort should be directed to examining multiple levels of those with HG-SIL to find invasion, rather than spending time looking at multiple levels of normal or LG-SIL LLETZ biopsies.

Diagnosis and treatment of cervical intraepithelial neoplasia in a single visit.

We evaluated the diagnostic and therapeutic efficacy of large loop excision of the transformation zone (LLETZ) performed in the first visit (see and treat policy) as compared to LLETZ treatment performed as an interval procedure. Data of 248 patients were analyzed of which 206 patients had LLETZ. Two thirds of the procedures were performed at the first visit. Of all the women who had the 'see and treat policy' 94.9% were diagnosed to have cervical intraepithelial neoplasia (CIN) on histology compared to 90.8% in the interval treatment group. A total of 3 (1.4%) patients were detected to have microinvasive carcinoma. There was no difference in the immediate postoperative complication rate, overtreatment rate and need of repeat treatment in both the groups. Single visit colposcopy and loop treatment is a safe and effective option for treatment of cervical epithelial abnormalities. The experience of the colposcopist is very important.

Treatment of cervical intraepithelial neoplasia in a prospective study comparing large-loop excision of the transformation zone, laser vaporization, and knife cone biopsy.

Our aim was to compare cervical intraepithelial neoplasia (CIN) treatment results in the use of large-loop excision of the transformation zone (LLETZ), laser vaporization, and cold-knife cone biopsy. We included in the study patients with CIN lesions diagnosed at the Hospital Universitario Materno-Infantil Vall d'Hebron and Hospital Clinic i Provincial de Barcelona, Barcelona, Spain, between March 1991 and March 1994. Patients with unsatisfactory colposcopy were excluded from the study. One hundred twenty-three patients were included in this study: 98 patients were compared for LLETZ treatment versus laser vaporization, and 69 CIN3 patients were compared for three treatments: LLETZ, laser vaporization, and knife cone biopsy. Patients were followed at 3-month intervals for at least 1 year. Follow-up included physical examination, cervical Papanicolaou (Pap) smear, cervical colposcopy, and a colposcopically guided biopsy when required. Treatment failure (persistence or recurrence) was defined by the presence of CIN confirmed histologically by a colposcopically guided biopsy. The mean age of patients was 34.1 years. The agreement between histology from the colposcopically guided biopsy and the surgical specimen was 60%, and the kappa coefficient was 40.7% (moderate agreement). Three cases of microinvasive carcinoma were diagnosed in patients whose initial diagnosis was CIN3 on colpobiopsy (4% of invasion in the initial CIN3 group of patients). In a comparison of LLETZ with laser treatment for all CIN grades, the unique independent prognostic factor for persistence-recurrence of the disease was the colposcopic size of the primary lesion (relative risk, 4.9; Cl, 1.33-18.45). We conclude that the LLETZ procedure for CIN treatment demonstrates an advantage over destructive methods for detection of occult microinvasive and invasive cancer. This process is a simple outpatient technique with the same failure as that of laser vaporization in all CIN grades. In the treatment of CIN3, cold-knife cone biopsy had better cure rates. Close follow-up is required in these patients, because of their risk of developing recurrent CIN or invasive carcinoma.

Efficacy of Large Loop Excision of the Transformation Zone for Cervical Intraepithelial Neoplasia

This study showed the efficacy of large loop excision of the transformation zone (LLETZ) in the management of cervical intraepithelial neoplasia (CIN). Eighty-three women with abnormal cervical cytology were recruited. Colposcopic examination and directed punch biopsy were performed and the women had LLETZ therapy as an outpatient procedure. There were 2 cases of microinvasive cervical carcinoma that were missed by directed punch biopsy, the diagnosis being made after the patients underwent LLETZ treatment. There was a large disparity in the histological analysis between directed punch biopsy and LLETZ specimen. This disparity would not have been detected if the women were treated by ablative methods. In women with cervical dysplasia, LLETZ procedure is preferred as the whole excised lesion can be examined histologically and diagnostic error is reduced.