Electrofulguration for low-grade CIN lesions

By definition, electrofulguration (EF) refers to using spray coagulation to destroy living tissue in a controlled manner with electric sparks. Low-voltage, high-frequency alternating current set at coagulation power output mode is delivered via the sparks generated between a ball-shaped electrode and the tissue, in the absence of a steam envelope. This results in protein coagulation and cell vaporization, in which the depth and extent of tissue destruction and charring are considerably less severe than that produced by electrodesiccation. The latter technique is characterized by deep, poorly-controlled protein coagulation and dehydration of cells.¹

From a technical point of view, the ball electrode used in electrofulguration is placed very close to the lesion's epithelium, without actually touching it. In contrast, when electrodesiccating, the electrode is placed directly upon the epithelium-or in the case of radical electrocoagulation dia-thermy, deep needle-shaped electrodes are inserted into the stroma, and kept in place until tissue boiling develops.

The electrosurgical ablative technique of EF is making a comeback for treating low-grade cervical intraepithelial neoplasia (CIN) because of its effectiveness, ease of use, low cost, and minimal drawbacks. The loop electrosurgical excision procedure (LEEP) for treating CIN-even the grade 1 variant-quickly won worldwide acceptance, beginning in the mid-1990s.² But key concerns soon emerged, too: the potential for removing too much tissue, high rates of false-negative LEEP specimens, and the cost of the excisional procedure. Because electroablation carries none of these pitfalls, it's easy to see why this approach is being revisited.³ We have been using EF for the past 10 years, not only for persistent, exocervical grade 1 CINs, but also for low-and high-grade vaginal and vulvar intraepithelial neoplasia, as well as external anogenital condylomata.^3,4 Our goal here is to present our experience with EF, its adverse effects, and our treatment results for histologically verified low-grade CIN.

Our follow-up approach includes repeat cytology and colposcopy at 4 to 6 months; if both are negative, repeat cytology (either conventional or liquid-based) is performed at 12 months post-EF. We then follow the patient on a routine annual basis. Prospective clinical trials on a large number of women will be needed to gauge the value of HPV DNA testing versus combining cytology and colposcopy in monitoring patients who've undergone EF for low-grade CIN. HPV DNA testing after treatment of high-grade CIN has been shown to have very high negative predictive value for the absence of residual disease and very high sensitivity for its presence.⁷

Better than cryotherapy and CO₂ laser EF has several advantages over other ablative methods like cryotherapy and CO₂ laser vaporization. This is particularly true for practices that only have an ESU available for treating lower genital tract, HPV-related lesions. Unlike cryotherapy, EF is not associated with uterine cramps, and only 3% of women experience vasovagal-hypotensive episodes (vs. 20% with cryotherapy).^8,9 Whereas nearly 100% of patients treated with cryotherapy have watery discharge, this is seldom experienced by women treated with EF.

In fact, overall, the duration of EF is shorter and cure rates equal or exceed those experienced with cryotherapy. For example, in most practices, cryotherapy for a single quadrant lesion uses the freeze-thaw-freeze method that takes at least 9 to 10 minutes to perform. Combining this with the necessity for keeping the patient under observation for 10 to 15 minutes to manage delayed hypotensive symptoms makes cryosurgery considerably longer than EF. And for large CIN lesions, EF is significantly superior to cryotherapy, which requires overlapping of the cryo-ice balls, making the procedure time-consuming for the physician and painful for the patient. But that said, overall, the EF's advantages over cryotherapy are largely offset by the incremental cost for the local anesthesia EF requires. Indeed, the ESU may or may not be more expensive than a cryosurgical unit.

More versatile than cryosurgery, EF can be used with great success to treat vaginal and external anogenital lesions of all extent and distribution. Fewer return visits for managing adverse effects are needed after EF than for cryosurgery. The ball-shaped electrodes can be reused after appropriate cleaning using a sandpaper-type cleaning pad and steam sterilization for at least 50 consecutive fulguration procedures.

The cost of purchasing and maintaining a CO₂ laser unit and associated instruments is considerably greater than that of an ESU, and CO₂ laser vaporization, for all practical purposes, has been abandoned for treating CIN1.

Conclusions Electrofulguration is an easy-to-perform and good therapeutic alternative for biopsy-verified, persistent grade 1 CIN, including that involving all four quadrants of the exocervix. EF has low rates of adverse effects, offers for excellent cure rates, and is recommended for treating low-grade CIN lesions in practices where electrosurgery is already used for treating HPV-related lesions of the lower anogenital tract.

REFERENCES1. Wright TC Jr, Richart RM, Ferenczy A. Electrosurgery for HPV-related Diseases of the Lower Genital Tract: A Practical Handbook for Diagnosis and Treatment by Loop Electrosurgical Excision and Fulguration Procedures. New City, N.Y: Arthur Vision, Inc.; and Anjou, Quebec, Canada: BioVision, Inc; 1992.

2. Wright TC Jr, Gagnon S, Richart R, Ferenczy A. Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Obstet Gynecol. 1992;79:173-178.

3. Roy M-C, Mayrand M-H, Franco E, Ferenczy A. Electrofulguration for low-grade squamous intraepithelial lesions of the cervix (CIN1). J Lower Genital Tract Dis. 2004;8:10-15.

4. Ferenczy A, Wright TC Jr, Richart RM. Comparison of CO2 laser surgery and loop electrosurgical excision/fulguration procedure (LEEP) for the treatment of vulvar intraepithelial neoplasia (VIN). Int J Gynecol Cancer. 1994;4:22-28.

5. Ferenczy A, Choukroun D, Arseneau J. Loop electrosurgical excision procedure for squamous intraepithelial lesions of the cervix: advantages and potential pitfalls. Obstet Gynecol. 1996;87:332-337.

6. Richart RM, Sciarra JJ. Treatment of cervical dysplasia by outpatient electrocauterization. Am J Obstet Gynecol. 1968;101:200-2005.

7. Zielinski GD, Bais AG, Helmerhorst TJ, et al. HPV testing and monitoring of women after treatment of CIN3: review of the literature and meta-analysis. Obstet Gynecol Surv. 2004;59:543-553.

8. Benedet JL, Miller DM, Nickerson KG. Results of conservative management of cervical intraepithelial neoplasia. Obstet Gynecol. 1992;79:105-110.

9. Ferris D. Cryotherapy of the cervix. J Lower Genital Tract Dis. 1998;2:98-105.

Step-by-step guidelines for electrofulguration 1. Place the return pad electrode on the least hairy site-the patient's inner thigh.

2. Insert a coated speculum fitted with the fume evacuator tube and a latex condom (Figure A). The condom stretches the vaginal wall and prevents its inadvertent contact with the ball electrode.

3. Set your colposcope at low (4× or 7×) magnification.

4. Ascertain that epithelial lesions are present and determine the margins by using 5% acetic acid and iodine (Lugol's) solutions (Figure B).

5. Depending on size of lesion slowly infiltrate about 1.0 to 1.8 mL of 2% to 4% xylocaine solution in epinephrine in a concentration of 1:200,000, under the epithelium at four points, i.e., 12, 3, 6, and 9 o'clock, along the outer lesional margins.

(NOTE: Subepithelial infiltration elevates the epithelium at the injection site, whereas deeper injection of solution does not.)

6. Moisten the exocervical epithelium with either 5% acetic acid solution or saline to enhance the arcing of the electrical current.

8. Activate the fume evacuator.

9. Under colposcopic guidance, start EF by sweeping the electrode over the lesional epithelium and that of the 1.0-cm lesion-free margin in a relatively slow, continuous motion from top to bottom, just once.

11. A second round of EF may be performed; however, you must re-moisten the denuded surface with acetic acid solution or saline and the eschar will be more difficult to remove than after the first round of EF. The maximum stromal depth after two EF procedures is about 1.0 mm. Low-grade CIN seldom extends into underlying endocervical glands, but when it does, endocervical gland involvement does not exceed 0.2 to 0.3 mm. As a result, a 1 mm-deep stromal destruction is quite sufficient for low-grade CIN.

12. There's no need to apply Monsel's paste or intravaginal antibiotic cream after EF, and you can discharge a patient immediately after EF with written post-EF instructions. These tell her to refrain from sexual intercourse for 2 weeks and to call the office in case vaginal spotting lasts for more than 6 days, or immediately if she has active bleeding or severe pelvic pain and/or fever. A follow-up visit is required between 4 and 6 months after EF.