Excisional Procedures forCIN Treatment

Haberal A. MD

Başkent University School of MedicineDepartment Obstetric and Gynecology

D I V I S I O N o f G Y N E C O L O G I C O N C O L O G Y

Treatment Objectives

Providing cure for the patient

Destruction or Complete Excision of Transformation Zone

Minimal destruction of healthy tissues

Low morbidity

No over-tretment

Cost-effectiveness

Treatment Objectives

85-95% cript involvement in CIN3

Depth < 2.9mm in 96% of cases

The most efficient depth is 3.8mm for cripts

The threshold for depth is 7mm for treatment

Guido R,Clinical Obstet Gynecol, 2014

The Type of T-Zone

Indications for Treatment

Unsatisfactory Colposcopy

Suspect of invasion

Suspect of glandular abnormalities

Discrepancy between cytology and histology

Involvement of endocervical channel(ECC+)

Recurrence after ablative therapy

Excisional Procedures

LEEP (LLETZ)

Cold Knife Conization

Laser Conization

• Loop

• Electrosurgical

• Excisional

• Procedure

LEEP

• Large Loop

• Excision of the

• Transformation

• Zone

LLETZ

Routine LEEP

•Procedure forlesionslocalized in the ectocervix

LEEP Conization

•For lesionswithendocervicalinvolvement

Contra-indications

• Hemorrhage Diathesis

• History of DES exposure

• <12 weeks followingdelivery

• Cervical abnormalities

• Heavy menses

• Severe cervicitis

• Patient with a pacemaker

Relative

•Pregnancy

• Invasivecancer

• Severe cervicalbleeding

Absolute

Equipments

➢Loops of different sizes

➢Electrosurgical unit with high frequency

➢Nonconductive speculum preventing smoke

➢Knob Electrode

➢Solutions– Local anesthesics combined with vasopressin

• Lidocain 1%,10 units vasopresin in 30mL

– Monsel solution

– Lugol solution

Technique

During LEEP, the power levels of the coteryshould be minimalized in order to

decrease thermal destruction and

for optimal pathological evaluation

Cutting 40W (35-55)

Coagulation50W (40-60)

Technique

The procedure should be started from 2-5 mm periphery of thetransformation zone without touching the LOOP to the tissue

The ideal LEEP material should be 5-8mm of depth

The procedure should be planned for the inclusion of the entire lesion

The procedure should be performed in one single move

If the procedure is interrupted, the excision would have hitches and thethermal destruction would increase in the tissue

Technique

• Post-procedurehemorrhage can be controlled with knobelectrode cautery orMonsel solution

• Fulguration (depth of 2-3mm)

• No need fortamponade generally

Risk Factors for insufficient treatment

Large lesions involving 3 or 4 quadrents

High-grade lesions, particularly CIN3

Elderly women (postmenopausal)

• The TZ can not be always visualized

• The lesion may involve endocervix more often

• The risk of residue/recurrent disease increases if the surgical margins arepositive after 50 years of age

Incomplete excisional margins

Operative difficulties

Advantages of LEEPShort learning curve, a simple procedure

It can be applied for all cases of CIN

Cost -effective and no need for general anesthesia generally

Complication rate is lower when compared to other procedures

A chance for diagnosis and treatment at the same time

Problems associated with LEEP

Thermal destruction

Not to have the specimenas a single tissue

Complications

Hemorrhage (4-6%)

Pain

Infection

Damage to the lateral vaginal wall

Follow-up

The patient should be counselled about complications

Black or browny vaginal discharge for 2-4 weeks

No sexual intercourse for 4-6 weeks

Permeability of the endocervical channel and tissue healing occurs at 6 weeks

Cytologic follow-up shuld begin after the 6th month

Cold - Knife Conization

Technique

Anesthesia; local (paracervical, spinal, epidural, general

Cervix excised cone shape with cold knife

ECC performed

Cauterization prefered for bleeding

ComplicationsBleeding (9.3-15%)

Cervical stenosis (1.0-3.2%)

Uterine perforation (0.4-1.9%)

Cervical insufficiency

Infection

Bladder ,rectum injuries

Laser Conization

Comparative analysis of transcervical resection and loop electrosurgical excision in the treatment of

high‐grade cervical intraepithelial neoplasia

➢2009-2015 years

➢N:647

– 292 (45.1%) TCRC

– 355 (54.9%) LEEP

➢Results;

– Margin positivities persistence , recurrence, intra-operative bleeding,less TCRC cases

– TCRC;is an altarnative to LEEP ,in HSIL

Chen M, İnt J of Gynecol&Obstet, 2018

Comparative analysis of transcervical resection and loop electrosurgical excision in the treatment of

high‐grade cervical intraepithelial neoplasia

Chen M, İnt J of Gynecol&Obstet, 2018

Risk of recurrence

Positive margins

Endocervical gland involvement

Multiple quadrants positivities

In elderly women

Studies➢7RCT➢1Prospective cohort study➢12 Retrospective cohort study

Results➢Positive surgical margins, bleeding, cervical

stenosis ,similar in both techniques➢ In cold- knife conization excised tissue most

often larger

Jiang YM, OncoTargets and Therapy, 2016

26 studies , N: 4062

Results

• Persistence and recurrence; LEEP/CKC (15.6 % vs 7.38%)

• LEEP; more rapid; 9.5 min, less intraoperativebleeding; 42.4ml, less duration of hospitalization;1.8 days

• LEEP is an accepted procedure in insufficentcolposcopic examination

El-Nashar S,J Low Genital Tract Dis, 2017

Conclusion➢Excisional procedure does not affect fertility,

➢Type of excision may increase risk for pretermdelivery

➢Conization technique and configurationdepends on TZ

➢Whole TZ must be excised

➢Bleeding can be managed with localprocedures

Thank you for your attention…

Santesso N, Int J Gynaecol Obstet, 2016

Ayhan A,Eur J Obstet Gynecol& reprod Biol, 2016

Ayhan A,Eur J Obstet Gynecol& reprod Biol, 2016