LLETZ Specimen Fragmentation: Impact on Diagnosis, Outcome, and Implications for Training

Abstract

Purpose This study was designed to assess fragmentation of Large loop excision of the transformation zone (LLETZ) specimens, its influence on short-term cytological outcome, and the risk factors for specimen fragmentation, as we well as trainee performance on clinical outcome. Method This retrospective study was performed at a cancer center. Women who underwent LLETZ for suspected high-grade cervical intra-epithelial neoplasia (CIN) over a 5-year period were included. Patients were identified through a regional database. Data were obtained from hospital and regional databases. Fisher's exact test was used.Results 75 % of all specimens were obtained intact. When the LLETZ specimen was intact, 89 % of smear tests were reported as negative, against 86 % when the specimen was fragmented. Fragmentation was significantly associated with high-grade smear results at 6 months. Trainee status was significantly related to specimen fragmentation. Conclusion Fragmentation of LLETZ specimens is associated with an increased likelihood of obtaining a highgrade smear at 6 months post treatment. Enhancing the colposcopy training may help improve clinical outcome.

Twenty-Year Experience with Large Loop Excision of the Transformation Zone at Sestre Milosrdnice University Hospital Centre

“…It should be considered that residual disease is more frequent in women with positive margin status 16,17 . Although LLETZ technique is superior in many ways to other excisional techniques, some reports claim that thermal artifacts and specimen fragmentation can have negative impact on histopathologic interpretation 18,19 . According to the National Health Service Cervical Screening Programme (NHS-CSP) standards from the United Kingdom, at least 80% of the specimens obtained by LLETZ technique should be in single form 20 .…”

The Role of Surgeonsʼ Colposcopic Experience in Obtaining Adequate Samples by Large Loop Excision of the Transformation Zone in Women of Reproductive Age

“…Adequate histological interpretation of the LLETZ specimen requires complete assessment of the margins. Literature data suggest that several patient and surgeon characteristics may influence sample adequacy [3]. Patient related factors include habitus, relaxation and vaginal compliance, age, parity, indication for the surgery and morphology and grade of the disease.…”

“…Messing et al [8] evaluated the specimens obtained by residents and found that 26.09 % of them had severe thermal artifacts precluding the evaluation for both the grade of dysplasia and the margins. Thermal artifacts are determined by the loop size, speed of cutting, electrical energy and tissue conductivity [3,8,17]. In cases of repeated excisions, artifacts are present on all sides of the specimens, except on the ectocervical surface [8].…”

“…Large loop excision of the transformation zone (LLETZ) is a commonly used technique for managing women with pathological changes on the uterine cervix, which has gained worldwide acceptance due to its numerous advantages [1][2][3][4]. Unlike ablative methods, LLETZ allows histological examination of the excised tissue [1][2][3][4]. However, LLETZ causes thermal damage of specimens [5], due to the use of electricity, which simultaneously cuts and coagulates the tissue [6].…”

“…LLETZ effectiveness and cure rates, adverse effects, complications, both short-term and long-term clinical outcomes and its influence on fertility have been widely investigated [1]. However, the risk factors for obtaining inadequate specimen and subsequent difficulties in histological interpretation, particularly in terms of surgeonsʼ skills and experience in colposcopy, are yet to be identified [3,9]. The aim of this study was to perform the quality assessment of LLETZ procedure in women of reproductive age, by investigating the colposcopic experience of the surgeons, and its influence on the presence, diagnostic significance and type of artifacts and their influence on histological interpretation and specimen adequacy.…”