Efficacy of Large Loop Excision of the Transformation Zone for Cervical Intraepithelial Neoplasia

EDITORIAL COMMENT": We wish to draw this paper to the attention of readers because it provides confirmation of other reports in the literature suggestive that laser or electrocoagulation diathermy of the cervix may be inappropriate in the treatment of patients found to have cervical intraepithelial carcinoma following colposcopically‐directed punch biopsy. It also emphasizes the disparity that can be seen between colposcopic and biopsy findings, reinforcing the need for formal histology before undertaking treatment. The question is what is the best method of treatment. The technique of large loop excision of the transformation zone appears to be cheaper and quicker and can also be performed under local analgesia as an outpatient procedure which are important advantages. The fact that histological diagnosis can be made on the excised tissue is important and this paper confirms the reports of Bonardi and colleagues (A) that patients with microinvasive carcinoma of the cervix may otherwise be undiagnosed. It may be emphasized that no oncologist recommends the management of known microinvasive carcinoma of the cervix with local ablation although such patients may be treated by cone biopsy where there is a further opportunity for precise histological diagnosis and the formulation of a revised plan for definitive therapy in the light of the findings. This and similar papers suggest that we require more information in larger series but it seems reasonable to recommend that ablation of the cervix, especially in patients with cervical intraepithelial neoplasia grade HI is inappropriate. One possible disadvantage of this new method for excising the transformation zone in patients with cervical intraepithelial neoplasia is that its simplicity may encourage the performance of the procedure when it is not necessary. We require more information of the complications associated with the technique and the proportion of patients with CIN II and CIN III in whom microinvasive carcinoma of the cervix may be overlooked unless an adequate‐sized biopsy of the cervix is available for careful histological examination. We do not know whether the finding of microinvasive foci in LLETZ biopsies is clinically significant and whether there is any difference in cure rates between this and ablative treatment. A much larger sample of patients in a trial setting comparing cure and complication rates would be needed to answer this question. A. Bonardi R, Cecchini S, Grazzini G, Ciatto S. Loop electrosurgical excision procedure of the transformation zone and colposcopically directed punch biopsy in the diagnosis of cervical lesions. Obstet Gynecol 1992; 80: 1020–1022. Summary: This study showed the efficacy of large loop excision of the transformation zone (LLETZ) in the management of cervical intraepithelial neoplasia (CIN). Eighty‐three women with abnormal cervical cytology were recruited. Colposcopic examination and directed punch biopsy were performed and the women had LLETZ therapy as an outpatient procedure. There were 2 cases of microinvasive cervical carcinoma that were missed by directed punch biopsy, the diagnosis being made after the patients underwent LLETZ treatment. There was a large disparity in the histological analysis between directed punch biopsy and LLETZ specimen. This disparity would not have been detected if the women were treated by ablative methods. In women with cervical dysplasia, LLETZ procedure is preferred as the whole excised lesion can be examined histologically and diagnostic error is reduced.