excisional procedures for cin treatment haberal a. mdfile.trsgo.org/pdf/2018/kongre2018/101.pdf ·...
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Excisional Procedures forCIN Treatment
Haberal A. MD
Başkent University School of MedicineDepartment Obstetric and Gynecology
D I V I S I O N o f G Y N E C O L O G I C O N C O L O G Y
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Treatment Objectives
Providing cure for the patient
Destruction or Complete Excision of Transformation Zone
Minimal destruction of healthy tissues
Low morbidity
No over-tretment
Cost-effectiveness
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Treatment Objectives
85-95% cript involvement in CIN3
Depth < 2.9mm in 96% of cases
The most efficient depth is 3.8mm for cripts
The threshold for depth is 7mm for treatment
Guido R,Clinical Obstet Gynecol, 2014
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The Type of T-Zone
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Indications for Treatment
Unsatisfactory Colposcopy
Suspect of invasion
Suspect of glandular abnormalities
Discrepancy between cytology and histology
Involvement of endocervical channel(ECC+)
Recurrence after ablative therapy
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Excisional Procedures
LEEP (LLETZ)
Cold Knife Conization
Laser Conization
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• Loop
• Electrosurgical
• Excisional
• Procedure
LEEP
• Large Loop
• Excision of the
• Transformation
• Zone
LLETZ
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Routine LEEP
•Procedure forlesionslocalized in the ectocervix
LEEP Conization
•For lesionswithendocervicalinvolvement
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Contra-indications
• Hemorrhage Diathesis
• History of DES exposure
• <12 weeks followingdelivery
• Cervical abnormalities
• Heavy menses
• Severe cervicitis
• Patient with a pacemaker
Relative
•Pregnancy
• Invasivecancer
• Severe cervicalbleeding
Absolute
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Equipments
➢Loops of different sizes
➢Electrosurgical unit with high frequency
➢Nonconductive speculum preventing smoke
➢Knob Electrode
➢Solutions– Local anesthesics combined with vasopressin
• Lidocain 1%,10 units vasopresin in 30mL
– Monsel solution
– Lugol solution
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Technique
During LEEP, the power levels of the coteryshould be minimalized in order to
decrease thermal destruction and
for optimal pathological evaluation
Cutting 40W (35-55)
Coagulation50W (40-60)
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Technique
The procedure should be started from 2-5 mm periphery of thetransformation zone without touching the LOOP to the tissue
The ideal LEEP material should be 5-8mm of depth
The procedure should be planned for the inclusion of the entire lesion
The procedure should be performed in one single move
If the procedure is interrupted, the excision would have hitches and thethermal destruction would increase in the tissue
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Technique
• Post-procedurehemorrhage can be controlled with knobelectrode cautery orMonsel solution
• Fulguration (depth of 2-3mm)
• No need fortamponade generally
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Risk Factors for insufficient treatment
Large lesions involving 3 or 4 quadrents
High-grade lesions, particularly CIN3
Elderly women (postmenopausal)
• The TZ can not be always visualized
• The lesion may involve endocervix more often
• The risk of residue/recurrent disease increases if the surgical margins arepositive after 50 years of age
Incomplete excisional margins
Operative difficulties
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Advantages of LEEPShort learning curve, a simple procedure
It can be applied for all cases of CIN
Cost -effective and no need for general anesthesia generally
Complication rate is lower when compared to other procedures
A chance for diagnosis and treatment at the same time
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Problems associated with LEEP
Thermal destruction
Not to have the specimenas a single tissue
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Complications
Hemorrhage (4-6%)
Pain
Infection
Damage to the lateral vaginal wall
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Follow-up
The patient should be counselled about complications
Black or browny vaginal discharge for 2-4 weeks
No sexual intercourse for 4-6 weeks
Permeability of the endocervical channel and tissue healing occurs at 6 weeks
Cytologic follow-up shuld begin after the 6th month
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Cold - Knife Conization
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Technique
Anesthesia; local (paracervical, spinal, epidural, general
Cervix excised cone shape with cold knife
ECC performed
Cauterization prefered for bleeding
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ComplicationsBleeding (9.3-15%)
Cervical stenosis (1.0-3.2%)
Uterine perforation (0.4-1.9%)
Cervical insufficiency
Infection
Bladder ,rectum injuries
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Laser Conization
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Comparative analysis of transcervical resection and loop electrosurgical excision in the treatment of
high‐grade cervical intraepithelial neoplasia
➢2009-2015 years
➢N:647
– 292 (45.1%) TCRC
– 355 (54.9%) LEEP
➢Results;
– Margin positivities persistence , recurrence, intra-operative bleeding,less TCRC cases
– TCRC;is an altarnative to LEEP ,in HSIL
Chen M, İnt J of Gynecol&Obstet, 2018
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Comparative analysis of transcervical resection and loop electrosurgical excision in the treatment of
high‐grade cervical intraepithelial neoplasia
Chen M, İnt J of Gynecol&Obstet, 2018
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Risk of recurrence
Positive margins
Endocervical gland involvement
Multiple quadrants positivities
In elderly women
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Studies➢7RCT➢1Prospective cohort study➢12 Retrospective cohort study
Results➢Positive surgical margins, bleeding, cervical
stenosis ,similar in both techniques➢ In cold- knife conization excised tissue most
often larger
Jiang YM, OncoTargets and Therapy, 2016
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26 studies , N: 4062
Results
• Persistence and recurrence; LEEP/CKC (15.6 % vs 7.38%)
• LEEP; more rapid; 9.5 min, less intraoperativebleeding; 42.4ml, less duration of hospitalization;1.8 days
• LEEP is an accepted procedure in insufficentcolposcopic examination
El-Nashar S,J Low Genital Tract Dis, 2017
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Conclusion➢Excisional procedure does not affect fertility,
➢Type of excision may increase risk for pretermdelivery
➢Conization technique and configurationdepends on TZ
➢Whole TZ must be excised
➢Bleeding can be managed with localprocedures
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Santesso N, Int J Gynaecol Obstet, 2016
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Ayhan A,Eur J Obstet Gynecol& reprod Biol, 2016
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Ayhan A,Eur J Obstet Gynecol& reprod Biol, 2016