Avoiding Checkmate: Planning the Next Move after HGSIL Pap Smear and Unsatisfactory Colposcopy

A 35 year old patient presents with a high grade squamous intraepithelial lesion (HGSIL) Pap smear. There is an unsatisfactory colposcopy; the transformation zone was not sampled.  The biopsy shows slight atypia. What’s your next move?

A recent post on OBGYN.net’s professional forum asked this very question to determine what treatment strategy her colleagues might pursue.  Although one poster suggested hysterectomy, the consensus was cone biopsy. What does current research say about the various methods?

In one study, researchers conducted consecutive follow-up among women undergoing loop electrosurgical excision procedure (LEEP) conization over a period of about three years. _¹ The researchers looked at 528 women who received LEEP conizations; the conizations were performed as a result of suspected or verified cervical dysplasia. They found cervical intraepithelial neoplasia (CIN)² or a higher degree of the cone specimen in cytology, punch biopsy and histopathology in 48.5%, 36.2% and 58.6%, respectively. In 16.8% of the cases, positive cone margins were found; the researchers noted significant risk for recurrent/residual disease among these patients.  Based on their findings, the researchers concluded that that an immediate colposcopically-guided LEEP conization after HSIL Pap smear was a safe and time saving strategy for such patients. However, they cautioned that clinicians should be aware of positive cone margins and the related risks for residual/recurrent disease.

While some situations indicate the use of the LEEP procedure, there are some situations that might benefit from cold-knife conization. In another study, researchers from Brazil conducted a retrospective study looking at conization specimens of women who received LEEP (N=102) or conization (N=245) as a result of HSIL.2 The researchers analyzed patient age, biopsy, compromised surgical margins in conization, and recurrence .They found frequency of invasion, non-compromised margins, and recurrence in were 7.7% versus 2.9%, 64.1% versus 48%, and 33.8% versus 24.1% in conization and LEEP, respectively. Within the first 5 years after the procedures, recurrence was found in 96.2% and 95.8% of women who underwent conization and LEEP, respectively.  Based on their findings, the researchers recommended the use of cold-knife conization in cases where the lesion is located deep in the cervical canal. 

Another option is the cone biopsy using a carbon dioxide laser. This method has also yielded positive outcomes. For instance, a recent study looked at 82 women with adenocarcinoma in situ of the cervix.³ Thirty-eight of the patients were treated with cold knife cone biopsy while 44 received treatment with laser cone biopsy. The researchers noted that laser excision did not compromise margin status or subsequent management. They only found one recurrence across both groups, which occurred after 8 years. The researchers concluded, “Laser cone biopsy is as effective as cold knife cone biopsy with no compromise of outcome for these patients.”

The case in question is still awaiting resolution, as insurance issues are preventing the patient to receive the cone biopsy. However, the poster agrees that this is the best option for her patient, and is hopeful for a positive outcome.

References:

1. Kjellberg L, Tavelin B. 'See and treat' regime by LEEP conisation is a safe and time saving procedure among women with cytological high-grade squamous intraepithelial lesion. Acta Obstet Gynecol Scand. 2007;86(9):1140-4.
2. Murta EF, Conti R, Rodovalho J, et al. Outcome after treatment of high-grade squamous intraepithelial lesions: relation between colposcopically directed biopsy, conization and cervical loop excision. Eur J Gynaecol Oncol. 2004;25(5):587-90.
3. Dalrymple C, Valmadre S, Cook A, et al. Cold knife versus laser cone biopsy for adenocarcinoma in situ of the cervix--a comparison of management and outcome. Int J Gynecol Cancer. 2008; 18(1):116-20.