TREATMENT OPTIONS FOR THE MANAGEMENT OF PREINVASIVE CERVICAL LESIONS
Keywords:
cervical intraepithelial neoplasia, uterine cervix, treatmentAbstract
Background: To obtain a complete diagnosis of preinvasive cervical lesions, the results of cytology, col- poscopy and histological biopsy are needed. Low-grade lesions (LG-SIL, CIN 1) should be managed conservatively because such lesions can regress. Treatment is suggested if the abnormality persists for 2 years or if the lesion worsens in grade or size. High-grade lesions (HG-SIL, CIN 2 and 3) are managed by different treatment modalities. Ablative modalities include cryocautery, electrocoagulation diathermy and laser ablation. For ablative treat- ment only ectocervical lesions with entirely visible squamocolumnar junction visible are suitable. Small localized lesions of CIN 1 and 2 may be treated by cryocautery or electroco- agulation diathermy. Lesions entering the cervical canal cannot be destroyed with certainty. Laser destroys the tissue by evaporation and coagulation, and is useful if the dysplastic areas extend into the vaginal fornices. Excision modalities including loop diathermy excision, cold-knife conization, laser cone biopsy and hysterectomy provide specimens for histology. Loop diathermy excision is currently the most common treatment modality. Cold-knife conization is performed with a scalpel. The cone can be broad and shallow or narrow and deep, depending on the location and the size of the lesion. Laser cone biopsy is relatively costly and time-consuming. Histopathology aims to assess the nature of the lesion and to determine whether it has been removed completely.
Conclusions: Treatment of preinvasive lesions is not completely harmless for the patient. Complications include hemorrhage, cervical stenosis or incomplete excision. Hysterectomy should be con- sidered for a patient with CIN suffering from menorrhagia, uterine prolapse or leiomyomas as well as in cases of adenocarcinoma in situ, when the reproductive function has been completed.
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References
Rakar S. Surgical treatment of invasive cervical cancer. Tumori 2001; 87: S21.
RakarS,KovačičJ,ČavićM,ŠtolfaA,GergoletM.Cervicalcarci- noma in young women. Eur J Obstet Gynecol Reprod Biol 1994; 55: 19–20.
Kovačič J, Čavić M, Omahen A, Rakar S, Tomaževic T, Novak F. The treatment of invasive carcinoma of the cervix at the Depart- ment of Gynecology and Obstetrics in Ljubljana. Eur J Gynaecol Oncol 1980; 1: 65–71.
Čavić M, Rakar S, Tomažević T, Omahen A, Kovačič J. Results of surgical treatment of cervical carcinoma. Jugosl Ginekol Opstet 1978; 18: 131–9.
Uršič-VrščajM,RakarS,MožinaA,TakačI,BebarS,ŠubicZ,Kodrič T, Smrkolj Š. Clinical audit of patients with cervical cancer in Slovenia. Data analysis from 2003–2006. Eur J Gynaecol Oncol 2008; 29: 628–32.
Takač I, Uršič-Vrščaj M, Repše-Fokter A, Kodrič T, Rakar S, Možina A, Smrkolj Š, Primic-Žakelj M, Stržinar V, Vakselj A, Arko D. Clini- copathological characteristics of cervical cancer between 2003 and 2005, after the introduction of a national cancer screening program in Slovenia. Eur J Obstet Gynecol Reprod Biol 2008; 140: 82–9.
Smrkolj Š, Rakar S, Možina A, Eržen M. Evaluation of causes of increased incidence of cervical cancer in Slovenia. Eur J Obstet Gynecol Reprod Biol 2004; 117: 213–21.
Vrtačnik-Bokal E, Rakar S, Jančar N, Možina A, Poljak M. Role of human papillomavirus testing in reducing the number of surgi- cal treatments for precancerous cervical lesions. Eur J Gynaecol Oncol 2005; 26: 427–30.
VanHamontD,BekkersRL,MassugerLF,MelchersWJ.Detection, management, and follow-up of pre-malignant cervical lesions and the role for human papillomavirus. Rev Med Virol 2008; 18: 117–32.
RouzierR.ManagementofCIN1.JGynecolObstetBiolReprod (Paris) 2008; 37 (Suppl 1): S114–20.
McCredie MR, Sharples KJ, Paul C, Baranyai J, Medley G, Jones RW, Skegg DC. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol 2008; 9: 425–34.
Deisinger D. Kazalci kakovosti pri zdravljenju prekanceroz materničnega vratu v Sloveniji. V: Možina A, ur. Zbornik prada- vanj 2. Slovenskega kongresa o cervikalni patologiji z mednaro- dno udeležbo in kolposkopskim tečajem, Portorož, 7. 3.–10. 3. 2007. Ljubljana: Združenje za ginekološko onkologijo, kolpos- kopijo in cervikalno patologijo, 2007: 150–4.
PrimicŽakeljM,BračkoM,HočevarM,Pompe-KirnV,StrojanP, Zadnik V, Zakotnik B, Žagar T. Incidenca raka v Sloveniji 2006. Ljubljana: Onkološki inštitut Ljubljana, Register raka Republike Slovenije, 2009: 40–7.
Uršič-Vrščaj M, Rakar S, Možina A, Kobal B, Takač I, Deisinger D. Smernice za celostno obravnavo žensk s predrakavimi spremem- bami materničnega vratu. Združenje za ginekološko onkologijo, kolposkopijo in cervikalno patologijo. Slovensko zdravniško društvo, Ljubljana 2006.
Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D; 2006 American Society for Colposcopy and Cervical Pathology-sponsored Consensus Conference. 2006 consensus guidelines for the management of women with cervical intra- epithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol 2007; 197: 340–5.
Luciani S, Gonzales M, Munoz S, Jeronimo J, Robles S. Effec- tiveness of cryotherapy treatment for cervical intraepithelial neoplasia. Int J Gynaecol Obstet 2008; 101: 172–7.
Nene BM, Hiremath PS, Kane S, Fayette JM, Shastri SS, Sankarana- rayanan R. Effectiveness, safety, and acceptability of cryotherapy by midwives for cervical intraepithelial neoplasia in Maharashtra, India. Int J Gynaecol Obstet 2008; 103: 232–6.
Zawislak A, Price JH, McClelland HR, Storey RG, Caughley L. Efficacy of cervical intrarepithelial neoplasia (CIN) treatment by cold coagulation. Ulster Med J 2003; 72: 10–5.
Chanen W. Electrocoagulation diathermy. Baillieres Clin Obstet Gynaecol 1995; 9: 157–72.
KimHS,ParkNH,ParkIA,ParkJH,ChungHH,KimJW,SongYS, Kang SB. Risk factors for recurrence of vaginal intraepithelial neoplasia in the vaginal vault after laser vaporization. Lasers Surg Med 2009; 41: 196–202.
Jančar N, Rakar S, Poljak M, Fujs K, Kocjan BJ, Vrtačnik-Bokal E. Efficiency of three surgical procedures in eliminating high-risk human papillomavirus infection in women with precancerous cervical lesions. Eur J Gynaecol Oncol 2006; 27: 239–42.
TakačI,ArkoD,GorišekB,KodričT.Loopdiathermyconization of the uterine cervix. Gynaecol Perinatol 1996; 5: 133–6.
Suwannarurk K, Bhamarapravati S, Thaweekul Y, Mairaing K, Poomtavorn Y, Pattaraarchachai J. The accuracy of cervical cancer and cervical intraepithelial neoplasia diagnosis with loop electrosurgical excisional procedure under colposcopic vision. J Gynecol Oncol 2009; 20: 35–8.
Rivoire WA, Monego HI, Dos Reis R, Binda MA, Magno V, Tavares EB, Hammes LS, Capp E, Edelweiss MI. Comparison of loop electrosurgical conization with one or two passes in high-grade cervical intraepithelial neoplasias. Gynecol Obstet Invest 2009; 67: 228–35.
Shin JW, Rho HS, Park CY. Factors influencing the choice be- tween cold knife conization and loop electrosurgical excisional procedure for the treatment of cervical intraepithelial neoplasia. J Obstet Gynaecol Res 2009; 35: 126–30.
Kos L, Lukanovič A. Konizacija. V: Kos L, Lukanovič A. Tehnika vaginalne kirurgije. Ljubljana: Klinični center, Ginekološka klinika, 2000: 167–71.
Takač I, Gorišek B. Cold knife conization and loop excision for cervical intraepithelial neoplasia. Tumori 1999; 85: 243–6. 28. Konno R, Akahira J, Igarashi T, Yamakawa H, Sato S, Yajima A.
Conization of the cervix using harmonic scalpel. Tohoku J Exp
Med 1999; 189: 171–8. 29. Akahira J, Konno R, Moriya T, Yamakawa H, Igarashi T, Ito K,
Sato S, Yajima A. Conization by harmonic scalpel for cervical intraepithelial neoplasia: a clinicopathological study. Gynecol Obstet Invest 2000; 50: 264–8.
FambriniM,PennaC,PieralliA,FallaniMG,AnderssonKL,Lozza V, Scarselli G, Marchionni M. CO2 laser cylindrical excision or standard re-conization for persistent-recurrent high-grade cervi- cal intraepithelial neoplasia (HG-CIN) in women of fertile age. Anticancer Res 2008; 28: 3871–5.
González Bosquet E, Torres A, Busquets M, Esteva C, Mu oz- Almagro C, Lailla JM. Prognostic factors for the development of vaginal intraepithelial neoplasia. Eur J Gynaecol Oncol 2008; 29: 43–5.
Guzej Z, Lovšin B. Vpliv zdravljenja cervikalne intraepitelijske neoplazije na trajanje poznejše nosečnosti in pogostost prezgod- njega poroda v SLO – rezultati raziskave za obdobje 2003–2004. Onkologija 2007; 11: 63–5.
ArbynM,KyrgiouM,SimoensC,RaifuAO,KoliopoulosG,Martin- Hirsch P, Prendiville W, Paraskevaidis E. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ 2008; 337: a1284.
Bindas A, Novak-Antolič Ž. Porodniški izid po konzervativni terapiji intraepitelijskih ali zgodnjih invazivnih lezij materničnega vratu: pregled podatkov za Slovenijo od leta 2002 do 2005. Zdrav Vestn 2009; 78: 241–6.
Jakobsson M, Gissler M, Tiitinen A, Paavonen J, Tapper AM. Treatment for cervical intraepithelial neoplasia and subsequent IVF deliveries. Hum Reprod 2008; 23: 2252–5.
Sun XG, Ma SQ, Zhang JX, Wu M. Predictors and clinical sig- nificance of the positive cone margin in cervical intraepithelial neoplasia III patients. Chin Med J (Engl) 2009; 122: 367–72.
Melnikow J, McGahan C, Sawaya GF, Ehlen T, Coldman A. Cervi- cal intraepithelial neoplasia outcomes after treatment: long-term follow-up from the British Columbia Cohort Study. J Natl Cancer Inst 2009; 101: 721–8.
Ghaem-Maghami S, Sagi S, Majeed G, Soutter WP. Incomplete excision of cervical intraepithelial neoplasia and risk of treat- ment failure: a meta-analysis. Lancet Oncol 2007; 8: 985–93.
Kodrič T, Takač I, Arko D, Gorišek B. The role of cytology in follow-up after loop diathermy conization. Acta Cytol 1997; 41: 1210–11.
Takač I, Arko D, Gorišek B, Kodrič T. Spremljanje bolnic po konizaciji materničnega vratu z diatermijsko zanko. Zdrav Vestn 1997; 66: 571–3.
Takač I. Human papillomavirus infection in patients with residual or recurrent cervical intraepithelial neoplasia. Tumori 2008; 94: 83–6.
Uršič-Vrščaj M, Rakar S, Možina A, Takač I, Šubic Z , Kodrič T, Smrkolj Š. Clinical audit of patients with cervical cancer in Slovenia – data analysis for the year 2003. Eur J Gynaecol Oncol 2005; 26: 537–42.
Jakobsson M, Gissler M, Paavonen J, Tapper AM. Long-term mortality in women treated for cervical intraepithelial neoplasia. BJOG 2009; 116: 838–44.
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