Association of preoperative cone biopsy with recurrences after radical hysterectomy.

OBJECTIVE: To evaluate association of preoperative cone biopsy with the probability of recurrent disease after radical hysterectomy for cervical cancer. METHODS: This is a retrospective single-center study. Patients with cervical cancer stage IA1 with LVSI to IIA2 and squamous, adenosquamous and adenocarcinoma subtype were included. Patients were analyzed for general characteristics and recurrence-free survival (RFS). RESULTS: In total, of 480 patients with cervical cancer, 183 patients met the inclusion criteria (117 with laparoscopic and 66 with open surgery). The median tumor diameter was 25.0 mm (range 4.6-70.0 mm) with 66 (36.2%) patients having tumors smaller than 2 cm. During median follow-up of 54.0 months (range 0-166.0 months), the RFS for the laparoscopic cohort was 93.2% and 87.5% at 3 and 4.5 years, and 79.3% for the open cohort after 3 and 4.5 years, respectively. In total, 17 (9.3%) patients developed recurrent disease, 9 (7.3%) after laparoscopic, and 8 (12.1%) after open surgery. No preoperative cone biopsy (OR 9.60, 95% CI 2.14-43.09) as well as tumor diameter > 2 cm (OR 5.39, 95% CI 1.20-24.25) were significantly associated with increased risk for recurrence. In multivariate analysis, only missing preoperative cone biopsy was significantly associated with increased risk for recurrence (OR 5.90, 95% CI 1.11-31.29) CONCLUSION: There appears to be a subgroup of patients (preoperative cone biopsy, tumor diameter < 2 cm) with excellent survival and low risk for recurrence after radical hysterectomy which might benefit from the advantages of laparoscopic surgery.

Excisional treatment comparison for in situ endocervical adenocarcinoma (EXCISE): A phase 2 pilot randomized controlled trial to compare histopathological margin status, specimen size and fragmentation after loop electrosurgical excision procedure and cold knife cone biopsy.

OBJECTIVE: Adenocarcinoma in situ (AIS) of the cervix is a precursor to cervical adenocarcinoma. When AIS is detected by cervical screening an excision biopsy is mandatory to exclude invasion. We aimed to compare margins status, specimen size and fragmentation after loop electrosurgical excision procedure (LEEP) and 'cold knife cone biopsy' (CKC). METHODS: The EXCISE Trial was an investigator-initiated, multicenter, open-label, parallel-group, phase 2, randomized study. Patients were enrolled at seven hospitals in Australia and New Zealand. We randomly assigned women aged ≥18 to ≤45 years with screen detected AIS to LEEP or CKC. Co-primary endpoints were margin status, specimen size and fragmentation. Analysis was by intention-to-treat. RESULTS: Between August 2, 2017 and September 6, 2019, 40 patients were randomly assigned 2:1 to LEEP or CKC. Margin status was evaluable in 36 cases. The proportion of patients with involved margins did not differ between groups. 25 of 26 LEEP and all 14 CKC biopsies were excised as single specimens (p = 1·00). There were no differences in specimen dimensions. Patients in the CKC group had more post-operative complications (64.3% compared to 15.4% for LEEP p = ·00). There were no differences in grade three complications (p = ·65). CONCLUSIONS: LEEP was not associated with a greater likelihood of positive margins, specimen fragmentation or smaller excision compared to CKC when performed according to a standardized protocol. However, the study was not powered to establish non-inferiority of LEEP and a definitive phase 3 trial to compare margin status and rates of treatment failure after LEEP and CKC is warranted.

A standardized simulation training program to type 1 loop electrosurgical excision of the transformation zone: a prospective observational study.

PURPOSE: To evaluate a simulation-based standardized training program for type 1 loop electrosurgical excision procedure (LEEP) under direct colposcopic vision in postgraduate teaching. METHODS: Seventeen participants (five experienced and 12 novice surgeons) performed 170 simulated cervical excisional procedures. Each participant performed 10 type 1 (cone length between 8 and 10 mm) excisional procedures under direct colposcopic vision on a low-fidelity simulator. Length of specimen was measured after each excision allowing the surgeons a subsequent resection to ensure a cone length of more than 8 mm. Main outcome measures were cone length, specimen fragmentation, and a self-developed score (LEEP score), which allowed the simultaneous evaluation of both measured parameters. RESULTS: The precision of the excision showed statistically significant improvement in the novice group during the training procedures after five procedures [LEEP score 1.61 (SD 1.34) vs. 0.46 (SD 0.58); p = 0.023], while experts showed consistently high performance. Inexperienced surgeons performed more frequently cuts that were too deep than experienced surgeons (33/120, 27.5% vs. 4/50, 8%; p = 0.003). CONCLUSIONS: Low-fidelity simulation training seems to be an effective method for learning the accurate cone length for a type 1 excision for novice surgeons. As excessive excisions are related with high risk for premature delivery in subsequent pregnancies, in our opinion, LEEP should be practiced in simulation training, especially before performing in woman of reproductive age.

Management and long-term outcomes of women with adenocarcinoma in situ of the cervix: A retrospective study.

BACKGROUND: Adenocarcinoma in situ of cervix is increasingly managed by local excision rather than hysterectomy and this study will ascertain if conservative management by excision alone is adequate. AIMS: To evaluate the long-term outcomes of conservative management of adenocarcinoma in situ of cervix, particularly in relation to excisional margin status. MATERIALS AND METHODS: Retrospective analysis of women diagnosed with adenocarcinoma in situ and their management between 1992 and 2010 retrieved from the Victorian Cervical Cytology Registry, Australia. Failure of conservative treatment is defined by histologically proven adenocarcinoma in situ or adenocarcinoma at follow-up after negative excisional margins. RESULTS: adenocarcinoma in situ of the cervix was managed primarily with cold knife cone biopsy or loop electrosurgical excision of the cervix. Most excisions were in one piece (83.4%) with average depth of 16.1 mm and 21.9% had involved excisional margins. Women with adenocarcinoma in situ on any excisional margin were more likely to have residual or recurrent disease (28.7%) compared with negative excisional margins (4.3%). Residual adenocarcinoma in situ was twice as common if adenocarcinoma in situ was present at endocervical (29.6%) and stromal (23.1%) margins compared with an ectocervical margin (13.6%). Cancer incidence at follow-up was 2.3% for women with positive excisional margins compared to 1.3% with negative margins. CONCLUSIONS: Women with adenocarcinoma in situ of cervix can be managed with local excisional procedures, best in single pieces to provide the important information on excisional margins. Adenocarcinoma in situ at endocervical and stromal excisional margins needs re-excision or where appropriate, hysterectomy, while negative excisional margins have a low rate of recurrence and can be followed up with test of cure.

Post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin: a retrospective cohort study.

The aim of this study was to investigate whether patients with CIN 2/3 with different amount of distance to negative cone biopsy margin differ in terms of post-conization follow-up results. Cold-knife cone specimens with a negative surgical margin with a diagnosis of CIN-2/3 were selected. The minimum distance between the margin and lesion was categorised as less than 2 mm (Group-1), 2-5 mm (Group-2), or more than 5 mm (Group-3). There were no statistically significant differences between groups in terms of postoperative cone-biopsy results (p = .61). Furthermore, there were no statistically significant differences between groups in terms of cytology at 6 months and 12 months (p = .33 and p = .80, respectively). Results of the present study indicate that the amount of distance of lesion to cone biopsy margin seems to have no effect on follow-up results in patients with negative surgical margin.Impact StatementWhat is already known on this subject? Negative surgical margins on conization are associated with lower rates of lesion recurrence. Only the efficacy of volume and size of cone biopsy specimens have been analysed on lesion recurrence. However, there is no clear definition of the minimum distance of a negative margin during cone biopsy.What do the results of this study add? To the best of our knowledge, this is the first study describing the post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin. Patients who underwent surgical treatment with a wider cone biopsy margin and narrower cone biopsy margin demonstrated similar follow-up results.What are the implications of these findings for clinical practice and/or further research? The present study provides valuable information to guide physicians performing conizations with an appropriate amount of negative surgical margin. Future studies investigating the effect of different amount of distance to negative cone biopsy margin on gynaecologic and obstetrics complications such as stenosis, bleeding, and preterm labour, low birth weight, and perinatal mortality are needed to show the benefits of a narrower distance to negative cone biopsy margin.

Introduction of a learning model for type 1 loop excision of the transformation zone of the uterine cervix in undergraduate medical students: a prospective cohort study.

PURPOSE: We address the impact of applying loop electrosurgical excision procedure (LEEP) under direct colposcopic vision teaching to our undergraduates using a self-developed simulation model and a standardized assessment to evaluate the progress of learning. METHODS: The undergraduate teaching module was composed of a theoretical course on cervical dysplasia, colposcopy, electrosurgery and excisional procedures of the uterine cervix. This was followed by hands-on practical rounds. During the hands-on practice the students performed five "type 1" LEEP under direct colposcopic vision on the self-developed simulator. Based on specimen fragmentation and excision accuracy a score system was established. The students were asked to answer a course evaluation questionnaire. RESULTS: The accuracy of the excisions showed a statistically significant improvement during the five training procedures (excision depth 7.34 ± 1.60-8.54 ± 1.67 mm, p = 0.0041; deviation from target cone thickness 0.88 ± 1.16-0.13 ± 0.94 mm, p = 0.0116). The fragmentation of the conus decreased (2.57 ± 1.26-1.29 ± 0.60 pieces, p < 0.0001). All this led to a general improvement of the LEEP score (2.59 ± 1.93-0.84 ± 1.03, p = 0.001). The student's questionnaire revealed a subjective satisfaction and improvement of their knowledge in pathomechanism, diagnosis and therapy of cervical pathologies. CONCLUSION: Undergraduate surgical training, in cervical excisional procedure, is a successful method in improving the students' perception and management of cervical pathologies.

Risk of persistent or recurrent neoplasia in conservatively treated women with cervical adenocarcinoma in situ with negative histological margins.

INTRODUCTION: Conservative treatments including cold knife cone biopsy (CKC) or loop electrosurgical excision procedure (LEEP) are fertility-preserving alternatives to hysterectomy. The risks of persistent cervical neoplasia in women with negative surgical margins following conservative treatment of adenocarcinoma-in-situ (AIS) are uncertain. This study aims to investigate the risk of persistent or recurrent cervical neoplasia [AIS, adenocarcinoma and/or high-grade cervical squamous intraepithelial neoplasia (CIN)] and compliance with follow-up recommendations in conservatively treated women with AIS and negative histopathological margins. MATERIAL AND METHODS: A retrospective, population-based study of Western Australian women treated by CKC or LEEP for AIS between 2001 and 2012. Histopathology reports were reviewed for demographic information, treatment procedures and clinicopathological factors. Primary outcomes were the diagnosis of cervical neoplasia during follow-up (defined as <12 months) and surveillance (≥12 months) periods. RESULTS: The cohort comprised 360 women, with 175 (48.6%) initially treated by CKC and 185 (51.4%) treated by LEEP. The median patient age at time of excisional treatment was 30.0 years (range 18-64 years) and the median follow-up time was 3.9 years (range six months to 12.2 years). During the follow-up and surveillance periods, seven (1.9%) women were diagnosed with CIN 2/3, 10 (2.8%) with AIS, and one (0.3%) with cervical adenocarcinoma, despite their initial excision specimens having negative histological margins. CONCLUSION: In this study, there was a low but significant risk of persistent or recurrent cervical neoplasia in women who had initial conservative management of AIS with negative histopathological margins.

Large loop versus straight-wire excision of the transformation zone for treatment of cervical intraepithelial neoplasia: a randomised controlled trial of electrosurgical techniques.

OBJECTIVE: To compare two electrosurgical techniques, straight-wire excision of transformation zone (SWETZ) with large loop excision of transformation zone, as a cone procedure (LLETZ-cone), for the treatment of cervical intraepithelial neoplasia (CIN), when disease is present at the cervical canal. DESIGN: Randomised controlled trial. SETTING: Two public hospitals, one in Rio de Janeiro, Brazil and one in Dublin, Ireland. POPULATION: One hundred and three women with indication to treat CIN located at cervical canal. METHODS: Women were randomised to receive LLETZ-cone or SWETZ. OUTCOMES: Main outcome was the incidence of complete excision of disease at endocervical margin of the surgical specimen. Secondary outcomes were complete excision at ectocervical and stromal margins, time to complete the procedure, specimen fragmentation, blood loss and death after 1 year. RESULTS: Fifty-two women were allocated to LLETZ-cone and 51 to SWETZ. Ten women were lost for main outcome because of damaged specimens. Forty-two women in the LLETZ-cone group had free endocervical margin versus 43 women in the SWETZ group (relative risk 1.04, 95% confidence interval [95% CI] 0.87-1.25; P = 0.64). For secondary outcomes related to margins, we observed a relative risk of 1.15 (95% CI 0.95-1.39; P = 0.15) for ectocervical free margin. For free stromal margin, the relative risk was 1.07 (95% CI 0.89-1.29; P = 0.47). No death was observed. CONCLUSIONS: This study was inconclusive; SWETZ and LLETZ-cone were equally effective to treat endocervical disease, with no difference in protecting against margin involvement. Higher, but not severe, blood loss and longer surgical time were observed in the SWETZ group.

An analysis of the outcomes of cervical cone biopsies performed in a low resource setting.

Following skills transfer to this low resource setting, we carried out a descriptive analysis of the outcomes of all cone biopsies performed for women with cervical intra-epithelial neoplasia 3 (CIN 3). We also compared two methods of cone biopsy. All the women had follow-up smear tests at 6 and 18 months. There were no cases of CIN 3 at follow-up. 80% had normal smears at 18 months and 20% had CIN 1. Compared with knife cone biopsy, women who had an electric knife (hand-held diathermy blade) cone biopsy had a significantly smaller volume of mean blood loss (55.5mls ± 15.9 vs 153.3ml ± 40, p < 0.001). With appropriate skills transfer, women with CIN 3 in a low resource setting can be effectively treated with conisation procedures. The diathermy knife is preferred to cold knife because of its associated low blood loss.

Non-radical surgery for small early-stage cervical cancer. Is it time?

OBJECTIVES: Non-radical surgery has been proposed in women with early-stage cervical cancer to reduce morbidity. Our objective was to evaluate the outcomes of women with early-stage cervical cancer treated with non-radical surgery. METHODS: Between March 1991 and July 2013, 51 women with early-stage cervical cancer underwent simple hysterectomy or cone biopsy. All patients had assessment of pelvic lymph nodes. Patient demographics, stage, perioperative complications, pathology findings and disease-free interval were collected prospectively. RESULTS: Twenty-six women had squamous cell carcinoma (SCC), 22 adenocarcinoma (AC) and 3 adenosquamous (AS) carcinoma. Thirty women were FIGO stage 1A1, 8 women IA2, and 13 women 1B1. Twenty-two (43%) and 29 (57%) women underwent simple hysterectomy and cone biopsy respectively. Median measurable tumor size was 10mm (range 2-11), and median depth of invasion was 2.0mm (range 0.1-12 mm). Lymphovascular space invasion (LVSI) was present in 18 women (35%). Surgical margins were negative in all women. Two women received adjuvant chemoradiation (one had deep stromal invasion with LVSI, and one had two micrometastases to pelvic nodes). Forty-nine women (96%) had their Foley catheter removed on the day of surgery or post-operative day 1. No intraoperative or postoperative complications occurred and the median blood loss was 100ml. Median follow-up was 21 months (range 1-112). None of the 51 women developed a recurrence during follow-up (95% CI: 0-6%). CONCLUSION: Non-radical surgery in appropriately selected early-stage cervical cancer patients results in a low complication rate and excellent oncologic outcomes. This approach seems to be a reasonable option in well-selected patients.

Surgery for early stage cervical cancer: how radical should it be?

OBJECTIVE: Less radical or non radical surgery for early-stage cervical cancer has been proposed to reduce morbidity while maintaining oncologic outcomes. Given that a standardized approach to conservative surgery is not yet available, we have summarized the literature on less radical surgery to better inform clinical practice. METHODS: MEDLINE R and MEDLINE in-process and non-indexed citations were searched from inception to April 14, 2013 to identify all English-language articles evaluating less-radical or non radical surgery for invasive cervical carcinoma. Articles including patients with squamous cell carcinoma, adenocarcinoma and adenosquamous carcinoma were included and a narrative review of the literature is presented. RESULTS: Radical surgery is associated with significant adverse effects in terms of urinary function, sexual function, and body image. Radical trachelectomy is an accepted fertility-sparing option, but still leads to morbidity from parametrectomy. The importance of the parametrectomy in patients with small early-stage tumors has been questioned recently, and many studies have found simple hysterectomy and simple trachelectomy can be safe in appropriately selected patients. Cone biopsy may be a fertility-sparing option in those patients with a very low risk of parametrial involvement. Neoadjuvant chemotherapy is also being investigated as a method to reduce the need for radical surgery. Sentinel lymph node biopsy is discussed as a method to reduce the morbidity while increasing the sensitivity of pelvic lymph node assessment in women with early cervical cancers. Finally, the treatment of early adenocarcinoma is addressed. CONCLUSIONS: It appears many women with early-stage cervical cancer can be treated less radically than has been done in the past. Large prospective trials are underway to further define candidates for less-radical surgery.

Is Endocervical Glandular Involvement Related to The Depth of Cone Biopsy?

Introduction. This study aimed to determine whether endocervical glandular involvement by squamous intraepithelial lesion would differ with respect to the depth of the excised specimen and analyze the related factors that may define endocervical glandular involvement among cases treated with cone biopsy. Methods. Between April 2016 and December 2018, women who underwent colposcopy and excisional procedures in the department of gynecologic oncology were retrospectively investigated. Patients with multiple specimens, or whose specimen depths were not measured, and a negative/unknown HPV status were excluded from the study. Also, patients with no dysplasia or microinvasive/invasive cancer in the final pathology report and those who had not undergone endocervical curettage during colposcopy were excluded. HPV genotypes, degree of dysplasia, surgical margin status, and specimen depth were documented from medical records. Further, the association of these factors with endocervical glandular involvement was evaluated. Results: A total of 321 patients who fulfilled the criteria were included in the study, with a mean age of 41.9 years. In total, 101 patients (31.5%) had endocervical glandular involvement. The mean excised specimen depth was 17.04 mm; 17.9 and 16.7 mm for the positive and negative glandular involvement groups, respectively (p = .13). The mean ages were 42.7 and 41.6 years for these groups, respectively (p = .32). There was no association between the HPV genotypes and glandular involvement. Conclusions: Endocervical glandular involvement is not associated with the depth of the excised specimen. A deeper cone biopsy may not necessarily enable a more effective treatment of the disease.

Use of an Arabin pessary to prevent preterm birth in pregnancy complicated by a short cervix after cervical conization for cervical adenocarcinoma with residual disease: A case report and literature review.

Surgical conization of the cervix for cervical cancer increases the risk of preterm birth in subsequent pregnancies. The ideal intervention to prevent preterm births in women with cervical insufficiency resulting from conization is not known. When histological margins of the cone biopsy are suspected to have residual malignancy, surveillance and oncological management during a concurrent pregnancy can be challenging. This case outlines the management of a pregnancy complicated by a short cervix secondary to conization for adenocarcinoma of cervix, with margins suspected to be not clear of disease. The patient had progressive shortening of the cervix despite vaginal progesterone, but maintained a cervical length of 16 mm following Arabin pessary insertion. She delivered a healthy neonate at 34 + 3 weeks of gestation (105 days following pessary insertion). The cervical pessary in combination with vaginal progesterone may be safe and effective in preventing preterm birth in a pregnancy with possible residual cervical cancer and a short cervix.

Modified method of cervical conization with hybrid use of a cold knife and an electric knife for high-grade squamous intraepithelial lesions.

OBJECTIVE: To evaluate the feasibility and surgical outcome of the modified method of cervical conization with hybrid use of a cold knife and an electric knife. METHODS: A retrospective analysis of cervical conization for high-grade squamous intraepithelial lesions was performed between January 2020 and December 2020. Traditional cold knife conization and modified conization were used. The clinical characteristics and surgical outcomes were compared between these methods. RESULTS: Ninety-two patients with high-grade squamous intraepithelial lesions were included. Traditional conization was performed in 46 patients, and the modified method was used in 46 patients. There were no differences in clinical characteristics, such as age, menopausal status, and conization height, between the methods. Intraoperative blood loss with the modified method was significantly lower than that with traditional conization (27.6 ± 4.7 vs 51.3 ± 18.3 mL). Postoperative vaginal bleeding requiring emergent measures, such as prolonged gauze compression, sutures, or electrocautery, was significantly less with the modified method than with traditional conization (4.3% vs 17.4%). A median follow-up of 10.2 months showed no significant difference in persistence or recurrence between the methods. CONCLUSIONS: The modified method of cervical conization with hybrid use of cold and electric knives may be a good alternative to traditional cold knife conization.

The Loop Electrosurgical Excision Procedure and Cone Conundrum: The Role of Cumulative Excised Depth in Predicting Preterm Birth.

Objective The objective was to determine factors associated with spontaneous preterm birth at less than 37 weeks in a cohort of patients who underwent a loop electrosurgical excision procedure (LEEP) or cone prior to pregnancy. Study Design This was a nested case-control study within a cohort of patients who underwent at least one LEEP or cone and had care for the next singleton pregnancy at either of two institutions between 1994 and 2014. Cases had spontaneous preterm birth at less than 37 weeks. Exposures included potential risk factors for preterm birth such as cumulative depth of excised cervix and time since excision. Reverse stepwise selection was used to identify the covariates for multivariable logistic regression. Results A total of 134 patients were included. Eighteen (13%) had a spontaneous preterm birth at less than 37 weeks. Median second-trimester cervical lengths were similar between those who delivered preterm and term (3.9-cm preterm and 3.6-cm term, p = 0.69). Patients who delivered preterm had a significantly greater median total excised depth of cervix (1.2 vs. 0.8 cm, p = 0.04). After adjustment for confounders, total excised depth remained significantly associated with preterm birth (adjusted odds ratio [aOR] = 2.2, 95% confidence interval [CI]: 1.3-3.8). Conclusion Total excised depth should be considered in addition to cervical length screening when managing subsequent pregnancies. Key Points A history of a LEEP or cone excision has been associated with spontaneous preterm birth.A two-fold increase in spontaneous preterm birth was seen per cumulative centimeter excised.There was no difference in second-trimester cervical length between the term and preterm groups.

Endocervical adenocarcinoma in situ-from Papanicolaou test to hysterectomy: a series of 74 cases.

INTRODUCTION: Endocervical adenocarcinoma in situ (AIS) is not always identified on cervical Papanicolaou (Pap) test cytology because the Pap test has relatively low sensitivity for the diagnosis endocervical glandular lesions. We performed a retrospective study to determine the relative sensitivity of different diagnostic approaches, including Pap tests, cervical biopsy and/or endocervical curettage, loop electrosurgical excision procedure (LEEP), and hysterectomy specimens. METHODS: Cases of endocervical AIS diagnosed from August 2005 to January 2019 were retrieved from our institution's pathology databases, and their clinicopathologic features were reviewed. RESULTS: A total of 74 patients with endocervical AIS with or without concurrent squamous intraepithelial lesions or cervical neoplasms were identified. Their mean age at diagnosis was 39.9 years. More than one half of the cases of AIS were not detected from screening Pap tests but were diagnosed during histologic examination of cervical biopsy or endocervical curettage, LEEP, or cone biopsy specimens (~66%). Only a few patients had had a definitive diagnosis of AIS from the Pap tests (10.8%). Other abnormal glandular cytology included atypical glandular cells, not otherwise specified (16.2%), atypical glandular cells favoring neoplasia (5.4%), and atypical glandular cells suspicious for malignancy (1.3%). Abnormal squamous cytology was common in the study population (54%), with high-grade squamous intraepithelial lesion the most common finding (30%). AIS was diagnosed in 31 of 42 cervical biopsies or curettages, with 16 cases an incidental finding and 15 cases confirming previous abnormal glandular cytology. In addition, AIS was identified in 51 of 53 LEEPs. Approximately 41.5% of those undergoing LEEP had a previous diagnosis of AIS, and 54.7% of the cases were incidental findings. More than one half of the AIS cases harbored significant concurrent cervical lesions, including 26.7% with high-grade squamous intraepithelial lesion, 5.7% with low-grade squamous intraepithelial lesion, 1.9% with invasive squamous cell carcinoma, 20.9% with invasive adenocarcinoma, and 6.7% with microinvasive adenocarcinoma. CONCLUSIONS: Our results have demonstrated that the ability to detect AIS with routine screening Pap testing or biopsy/curettage has variable efficacy depending on the screening methods. Given the relatively low combined sensitivity of Pap testing and biopsy/endocervical curettage in the diagnosis of AIS, all LEEPs and cervical cone biopsies performed for squamous cell abnormalities should be thoroughly evaluated for glandular lesions.

Overview of fertility sparing treatments for cervical cancer.

Until the late 1980s, the mainstay of treatment for cervical cancer has been either hysterectomy or radiotherapy. From the mid to late 1990s, surgical treatments have been focussed more on sparing fertility by preserving the corpus of the womb with trachelectomy or even conserving part of the cervical stroma with a cone biopsy. In carefully selected cases, less radical treatment that preserves the uterus has been considered safe. However, these approaches can be associated with specific operative and obstetric complications such as stitch ulceration, cervical stenosis, late miscarriage, and premature labour. Most guidelines agree that the management of such patients should be centralised in a unit with specialist gynaecological oncology, radiology, and histopathology services supported by specialist cancer nurses.

Labor Complicated by Cervical Stenosis Following a Laser Cone Biopsy.

A 34-year-old lady, with three previous spontaneous vaginal deliveries, presented in labor at 37 + 0 weeks' gestation. Following the birth of her third child, she underwent a laser cone biopsy for cervical intraepithelial neoplasia (CIN) 3. Despite sustained regular contractions and augmentation with Syntocinon, progressive cervical dilatation beyond 1 cm failed to occur in this multiparous lady. A delayed diagnosis of cervical stenosis was made. She eventually underwent a cesarean section where her internal cervical os was found to be thin and fibrotic. This case describes an uncommon occurrence of cervical stenosis presenting in labor and seeks to increase awareness of this condition so as to allow preemptive counselling of similar patients, early recognition in a labor with poor progress and a swift, better-informed decision to deliver via an emergency cesarean section. We review the existing literature on cervical stenosis following cervical conization and analyze the various definitions available.

Morbidity after local excision of the transformation zone for cervical intra-epithelial neoplasia and early cervical cancer.

The awareness that cervical intra-epithelial neoplasia (CIN) treatment increases the risk of preterm birth has led to major changes in clinical practice. Women with CIN have a higher baseline risk of prematurity but local treatment further increases this risk. The risk further increases with increasing cone length and multiplies for repeat excisions; it is unclear whether small cones confer any additional risk to CIN alone. There is no evidence to suggest that fertility is affected by local treatment, although this increases the risk of mid-trimester loss. Caution should prevail when deciding to treat women with CIN of reproductive age. If treatment is offered, this should be conducted effectively to optimise the clearance of disease and minimise the risk of recurrence. Colposcopists should alert women undergoing treatment that this may increase the risk of preterm birth and that they may be offered interventions when pregnant. The cone length should be clearly documented and used as a risk stratifier.

200 years of diagnosis and treatment of cervical precancer.

OBJECTIVES: The history of the diagnosis and treatment of cervical precancer is fragmentary. Findings in the English-speaking and German-speaking areas vary considerably. We aim to describe the history of clinical advances in diagnosis and treatment of cervical precancer and identify areas where further work is required. STUDY DESIGN: We conducted a search of PubMed and Google Scholar. Full article texts were reviewed. Reference lists were screened for additional articles and books. 9 basic articles in German and 13 basic articles in books were identified. RESULTS: The first images of the ectocervix were published by H. Lebert (1812-1879) in the middle of the nineteenth century. R. Meyer's (1864-1947) theory of erosions, which dominated cervical pathology in the nineteenth century, was later refuted in studies by C. A. Ruge (1846-1926) and J. Veit (1852-1917). In 1908 W. Schauenstein (1870-1943) recognized the step-by-step development of cervical cancer. H. Hinselmann (1884-1959) replaced the purely histopathological approach previously with the use of colposcopy. All conization methods applied today can be traced back to amputation of the ectocervix as first indicated by J. Marion Sims (1813-1883) in 1861. In 1928 M. N. Hyams was the first to describe an excision method that employed electrodiathermy. The method of cold knife conization is based on a publication by J.W. Scott from 1957. The final breakthrough to effective electrodiathermy was achieved with the publications of W. Prendiville. CONCLUSIONS: This paper is a step toward a better understanding of what we think and do today based on past findings of colposcopists and gynecopathologists.