The impact of loop diathermy on management of early invasive cervical cancer

Abstract

Large loop excision of the transformation zone (LLETZ) allows complete histologic assessment of cervical neoplasia. However, selective colposcopically directed punch biopsy followed by local ablation allows the possibility of inappropriate local ablation of early invasive lesions missed at punch biopsy. The onus of accurate diagnosis lies on the colposcopist. We have studied 1143 patients managed with loop diathermy and identified 35 invasive squamous carcinomas and 9 invasive adenocarcinomas. The data show that the cut-off for accurate colposcopic detection of invasive squamous lesions is not breach of the basement membrane but invasion up to a depth of 1 mm. On the other hand, colposcopy is an unreliable guide for the diagnosis of early adenocarcinoma. Diagnosis based on loop excision allows accurate, rational individualization of management for the unexpected diagnosis of colposcopically occult early invasive disease whilst retaining the logistic benefits of a 'see and treat' policy.

Role of Loop Electrosurgical Excision Procedure (LEEP) in the Management of Cervical Intraepithelial Neoplasia (CIN)

“…The submission of the entire specimen for histologic study increases the probability that unsuspected cancer will be detected and not ablated. In many large studies of LEEP, the unsuspected invasive cancer and highgrade glandular disease rate has been as high as 1% to 2% (12)(13)(14)(15) .…”

Microinvasive Carcinoma of the Cervix

“…19 Colposcopists sometimes suspect microinvasion if there is a sufficiently abnormal vascular pattern, but accurate colposcopic detection requires considerable skill and appears to be possible only when the depth of invasion exceeds 1 mm. 20,21 Prognostic factors in early cervical carcinoma include the depth of stromal invasion, the presence or absence of LVSI, the volume or lateral extent of the tumor, and the status of the excision margins. Analysis of these factors has led to the delineation of a category of patients who have minimal risk of lymph node metastasis or recurrence and who can be treated conservatively.…”

Controversial Topics in Abnormal Cervical Cytology: ???See and Treat???

“…Some have purported that the availability of a tissue specimen is an advantage of LEEP compared to ablative therapy because adenocarcinoma or invasive squamous carcinoma has been identified in a small percentage of LEEP specimens performed in the setting of cervical intraepithelial neoplasia. 2,6,[12][13][14]16,17 In a large study of 1000 women undergoing a single-visit approach, 9 (0.9%) of the LEEP specimens were found to have microinvasive or invasive carcinoma. 14 In another study of 206 patients undergoing single-visit large loop excision of the transformation zone (LLETZ), microinvasive carcinoma was detected in 1.4% of the women in the study.…”

“…6 Murdoch et al reported that in the evaluation of 1143 patients managed with loop diathermy (LEEP or LLETZ), 35 cases of invasive squamous carcinoma and 9 cases of invasive adenocarcinoma were identified for a total of 3.8% of patients found to have an invasive cancer. 17 The authors proposed that colposcopy was inherently inaccurate in the identification of early stage cervical cancer, and that this 1-step approach may decrease the number of false negative evaluations of abnormal Pap smears and have…”