Loop electrosurgical excision procedure for squamous intraepithelial lesions of the cervix: advantages and potential pitfalls

doi:10.1016/0029-7844(95)00453-X

Obstetrics & Gynecology

Volume 87, Issue 3, March 1996, Pages 332-337

https://doi.org/10.1016/0029-7844(95)00453-X Get rights and content

Objective:

To evaluate the advantages and pitfalls of the loop electrosurgical excision procedure as applied to the diagnosis and treatment of cervical cancer precursors.

Methods:

Loop electrosurgical excision procedure using local anesthesia and colposcopic guidance was performed in an outpatient clinical setting in 1189 consecutive patients referred for colposcopy for an abnormal Papanicolaou smear during a period of 4 years.

Results:

Of the 1189 patients, 915 (77%) were managed in one sitting with the “see and treat” approach, and in 274 patients endocervical curettage and cervical biopsies preceded loop electrosurgical excision procedure. One hundred nineteen (10%) patients were lost to follow-up. Twenty-one patients had either adenocarcinoma in situ (15) or microinvasive squamous cell carcinoma (six) in the loop electrosurgical excision procedure specimen, whereas the electroexcised specimens contained no lesional tissue in 166 (14%) patients. Cure (ie, disease-free at 6 months or longer) was observed in 92% of the 883 evaluable patients after a single treatment and 95% after a repeat loop electrosurgical excision procedure. High-grade squamous intraepithelial lesion was successfully treated with loop electrosurgical excision procedure in 287 (93%) of 309 patients. Complications, mainly intra- and postoperative bleeding, occurred in 7% of the patients. In most loop electrosurgical excision procedure—negative cases, the referral cytologic diagnosis or colposcopy and/or histology were false-positive on review, or the biopsies performed before loop electrosurgical excision procedure removed smaller areas of abnormal tissue.

Conclusions:

Loop electrosurgical excision procedure using the see and treat approach should be limited to cytologically and colposcopically unequivocal intraepithelial lesions, and depth of excision should be controlled by colposcopy using loop electrodes of appropriate size. In doubtful cases, particularly in the young patient, disease should be ascertained by expert histology and colposcopy before definite therapy. Loop electroexcision represents an attractive means of diagnosing and treating cervical cancer precursors.

References (25)

ShumskyAG et al.
Carcinoma of the cervix following conservative management of cervical intraepithelial neoplasia
Gynecol Oncol
(1994)
ChappatteOA et al.
Histologic differences between colposcopic-directed biopsy and loop excision of the transformation zone (LETZ): A cause for concern
Gynecol Oncol
(1991)
BigriggMA et al.
Colposcopic diagnosis and treatment of cervical dysplasia at a single clinic visit
Lancet
(1990)
KeijserKGG et al.
Diathermy loop excision in the management of cervical intraepithelial neoplasia: Diagnosis and treatment in one procedure
Am J Obstet Gynecol
(1992)
AlvarezRD et al.
Prospective randomized trial of LLETZ versus laser ablation in patients with cervical intraepithelial neoplasia
Gynecol Oncol
(1994)
BaggishMS
A comparison between laser excisional conization and laser vaporization for the treatment of cervical intraepithelial neoplasia
Am J Obstet Gynecol
(1986)
FerenczyA et al.
The effect of cervical loop electrosurgical excision procedure on subsequent pregnancy outcome: North-American experience
Am J Obstet Gynecol
(1995)
FerenczyA
Management of the patient with an abnormal Pap smear
TownsendDE et al.
Invasive cancer following outpatient evaluation and therapy for cervical disease
Obstet Gynecol
(1981)
AndersonMC
Invasive carcinoma of the cervix following local destructive treatment for cervical intraepithelial neoplasia
Br J Obstet Gynaecol
(1993)

PearsonSE et al.

Invasive cancer of the cervix after laser treatment

Br J Obstet Gynaecol

(1989)

Kruger-KjaerS et al.

Adenocarcinoma of the uterine cervix: The epidemiology of an increasing problem

Epidemiol Rev

(1993)

Cited by (75)

Management of Cervical Dysplasia Using Office Loop Electrosurgical Excision Procedure
2021, Primary Care - Clinics in Office Practice
Safety, efficacy, and immunogenicity of VGX-3100, a therapeutic synthetic DNA vaccine targeting human papillomavirus 16 and 18 E6 and E7 proteins for cervical intraepithelial neoplasia 2/3: A randomised, double-blind, placebo-controlled phase 2b trial
2015, The Lancet
Citation Excerpt :
Finally, using a non-surgical treatment approach for CIN2/3 with less effectiveness than what has been reported for surgical resection might raise the concern that microinvasive cancers will develop. However, the frequency of microinvasive cancers identified in resection specimens was consistent with published data; occult, microinvasive carcinoma is a diagnosis typically made at therapeutic conisation, not colposcopy or biopsy.35,36 Our results are bona fide proof-of-principle for this therapeutic approach.
Despite preventive vaccines for oncogenic human papillomaviruses (HPVs), cervical intraepithelial neoplasia (CIN) is common, and current treatments are ablative and can lead to long-term reproductive morbidity. We assessed whether VGX-3100, synthetic plasmids targeting HPV-16 and HPV-18 E6 and E7 proteins, delivered by electroporation, would cause histopathological regression in women with CIN2/3.
Efficacy, safety, and immunogenicity of VGX-3100 were assessed in CIN2/3 associated with HPV-16 and HPV-18, in a randomised, double-blind, placebo-controlled phase 2b study. Patients from 36 academic and private gynaecology practices in seven countries were randomised (3:1) to receive 6 mg VGX-3100 or placebo (1 mL), given intramuscularly at 0, 4, and 12 weeks. Randomisation was stratified by age (<25 vs ≥25 years) and CIN2 versus CIN3 by computer-generated allocation sequence (block size 4). Funder and site personnel, participants, and pathologists were masked to treatment. The primary efficacy endpoint was regression to CIN1 or normal pathology 36 weeks after the first dose. Per-protocol and modified intention-to-treat analyses were based on patients receiving three doses without protocol violations, and on patients receiving at least one dose, respectively. The safety population included all patients who received at least one dose. The trial is registered at ClinicalTrials.gov (number NCT01304524) and EudraCT (number 2012-001334-33).
Between Oct 19, 2011, and July 30, 2013, 167 patients received either VGX-3100 (n=125) or placebo (n=42). In the per-protocol analysis 53 (49·5%) of 107 VGX-3100 recipients and 11 (30·6%) of 36 placebo recipients had histopathological regression (percentage point difference 19·0 [95% CI 1·4–36·6]; p=0·034). In the modified intention-to-treat analysis 55 (48·2%) of 114 VGX-3100 recipients and 12 (30·0%) of 40 placebo recipients had histopathological regression (percentage point difference 18·2 [95% CI 1·3–34·4]; p=0·034). Injection-site reactions occurred in most patients, but only erythema was significantly more common in the VGX-3100 group (98/125, 78·4%) than in the placebo group (24/42, 57·1%; percentage point difference 21·3 [95% CI 5·3–37·8]; p=0·007).
VGX-3100 is the first therapeutic vaccine to show efficacy against CIN2/3 associated with HPV-16 and HPV-18. VGX-3100 could present a non-surgical therapeutic option for CIN2/3, changing the treatment outlook for this common disease.
Inovio Pharmaceuticals.
Colposcopy: A Global Perspective. Introduction of the New IFCPC Colposcopy Terminology.
2013, Obstetrics and Gynecology Clinics of North America
Citation Excerpt :
So-called cone biopsy, using a cold knife, is the most common treatment of women with an abnormal smear in much of France and Germany and is often performed without any preliminary colposcopic examination and may be undertaken by a general surgeon rather than a gynecologist or colposcopist. In the United Kingdom, Australian, and Canadian practices large loop excision of the TZ (large loop excision of the transformation zone [LLETZ]),14 which became loop electrosurgical excision procedure (loop electrosurgical excision procedure [LEEP])15 on its introduction to the United States, is the usual treatment choice for women for whom treatment is indicated, and the procedure would usually be performed in the outpatient clinic as part of a thorough colposcopic examination, sometimes at the first or assessment visit. Hysterectomy is also widely used as the primary treatment of CIN despite the associated increased morbidity and without any benefit to the patient.
Endometrial, Ovarian, and Cervical Cancer
2010, Current Clinical Medicine: Expert Consult Premium Edition - Enhanced Online Features and Print
The impact of human papillomavirus vaccination on cervical cancer prevention efforts
2009, Gynecologic Oncology
To review concepts, information, obstacles, and approaches to cervical cancer screening and prevention as vaccination against human papillomavirus (HPV) types 16 and 18 is adopted.
Expert forum, conducted September 12–13, 2008, hosted by the Society of Gynecologic Oncologists, including 56 experts in cervical cancer and titled Future Strategies of Cervical Cancer Prevention: What Do We Need to Do Now to Prepare?
The current approach to cervical cancer screening in the U.S. is limited by its opportunistic nature. If given to women before exposure, a vaccine against HPV 16,18 can decrease cervical cancer risk by up to 70%. The impact on abnormal cytology and cervical intraepithelial neoplasia (CIN) will be less but still substantial. As the prevalence of high-grade CIN falls, fewer women with positive screening tests will have truly preinvasive disease. To minimize harm from false positive tests in women who are at low risk for cancer because of early vaccination, later initiation of and longer intervals between screenings are ideal. However, the vaccine is less effective when administered after first intercourse, and delivering and documenting HPV vaccination to girls at optimal ages may prove difficult.
Until population-based data on the performance of cytology, HPV testing, and alternate screening or triage interventions become available, modifying current screening guidelines is premature. Current recommendations to initiate screening as late as age 21 and to screen less often than annually are appropriate for young women known to have been vaccinated before first intercourse.
A randomized trial of basing treatment on human papillomavirus and/or cytology results in low-grade cervical lesion triage
2008, American Journal of Obstetrics and Gynecology
Citation Excerpt :
The adverse effects of LEEP or laser miniconization, when performed as a low cone with the maximal height of 10 mm, are limited, consisting mostly of minor perioperative and postoperative vaginal bleeding and infections.16,20,21 Prolonged vaginal bleeding or stenosis of the cervical canal may occur,16 but stenosis is less likely to occur if diathermy at the new cervical os is omitted.22 The adverse effect on fertility and pregnancy outcome is dependent on the type of procedure and amount of tissue excised.23
This study was undertaken to compare management algorithms that base treatment with loop electrosurgical excision procedure on human papillomavirus and/or repeat Papanicolaou test smear results.
A randomized trial that referred 674 women with either atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions cytology results, detected in organized screening to treatment either (1) if they were positive in a repeat Papanicolaou test smear and/or a human papillomavirus test or (2) if they were positive in the repeat Papanicolaou test smear test only. Women who tested positive were treated, regardless of colposcopic findings.
There were 208 of 337 (62%) women who were treated in the human papillomavirus /Papanicolaou test smear group (187/337 because of HPV positivity) and 138 of 337 (41%) in the Papanicolaou test smear only group. Histopathologically diagnosed cervical intraepithelial neoplasia grade 2 or worse was found among 112 of 337 (33.2%) women in the human papillomavirus/Papanicolaou test smear group compared with 85 of 337 (25.2%) women in the Papanicolaou test smear only group (P < .05). Twenty-one women with cervical intraepithelial neoplasia 2+ had normal colposcopy.
For adequate cervical intraepithelial neoplasia 2+ sensitivity, the decision to use loop electrosurgical excision procedure needs to be based on human papillomavirus testing results and should not exclude women with normal colposcopy.

View all citing articles on Scopus

View full text

Loop electrosurgical excision procedure for squamous intraepithelial lesions of the cervix: advantages and potential pitfalls

Objective:

Methods:

Results:

Conclusions:

Gynecol Oncol

Gynecol Oncol

Lancet

Am J Obstet Gynecol

Gynecol Oncol

Am J Obstet Gynecol

Am J Obstet Gynecol

Management of the patient with an abnormal Pap smear

Invasive cancer following outpatient evaluation and therapy for cervical disease

Obstet Gynecol

Invasive carcinoma of the cervix following local destructive treatment for cervical intraepithelial neoplasia

Br J Obstet Gynaecol

Invasive cancer of the cervix after laser treatment

Br J Obstet Gynaecol

Adenocarcinoma of the uterine cervix: The epidemiology of an increasing problem

Epidemiol Rev