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Use of Endocervical Brushing after Cervical Electrical Loop Excision as Predictor of Residual Disease
Valor del cepillado de canal endocervical remanente durante LLETZ como predictor de enfermedad residual
Jorge Ojeda-Ortiza, Rebeca Muñoz-Molinaa, Francisco De la Rosa Bayónb, Beatriz Sereno Gómezc, Martha Guevara Cruzd
a Departamento de Colposcopia, Hospital General de Pachuca, Secretaría de Salud, Hidalgo, México. Supported by the Hospital General de Pachuca, Secretaría de Salud, Hidalgo, México.
b Departamento de Patología, Hospital General de Pachuca, Secretaría de Salud, Hidalgo, México. Supported by the Hospital General de Pachuca, Secretaría de Salud, Hidalgo, México.
c Academia Mexicana de Cito-patología, México. Supported by the Hospital General de Pachuca, Secretaría de Salud, Hidalgo, México.
d Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, DF. Supported by the Hospital General de Pachuca, Secretaría de Salud, Hidalgo, México.
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">The contributions of the authors were as follows&#58; JO&#58; conception&#44; design&#44; and supervision of the study&#59; RM&#58; general design&#44; medical examination&#44; manuscript preparation&#44; and data interpretation&#59; FJDB&#58; Pathologist to study the biopsies&#59; BS&#58; contributed to the experimental design&#59; MG&#58; general design&#44; statistical analysis&#44; and manuscript preparation&#46; All authors agreed on the final version of the manuscript&#46; Authors had no conflict of interest&#46; </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ INTRODUCTION </span></p><p class="elsevierStylePara">Electrical excision of cervical lesions was first used in the nineteenth century&#46; Hunner &#40;1906&#41; was the first reporting the use of therapeutic electrocauterization&#46;<span class="elsevierStyleSup">1</span> Rene Cartier in 1981 adapted a small loop electrode using low voltage and in 1989 Walter Prendiville for the first time introduced radio frequencies to perform the excision of the cervical transformation zone using a large loop &#40;LLETZ&#41;&#46;<span class="elsevierStyleSup">2&#44;3</span> This technique has become widely used and offers the advantages of obtaining a large specimen for histopathological diagnosis&#44; it is well tolerated by patients when performed under local anesthesia on an outpatient basis&#44; has few complications and side effects&#44; and has a relatively low cost&#59;<span class="elsevierStyleSup">4</span> in addition&#44; it allows to correlate colposcopic impression with the histology&#44; and micro-invasion can be ruled-out&#46;<span class="elsevierStyleSup">5</span> Also&#44; fertility is preserved&#46; Disadvantages include post-treatment cervical stenosis&#44;<span class="elsevierStyleSup">6</span> infections&#44; bleeding&#44;<span class="elsevierStyleSup">7</span> and thermal damage of the margins that may preclude an adequate study of the margins&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara"> LLETZ is an effective treatment of cervical intraepithelial neoplasia &#40;CIN&#41; and thus avoids the progression to invasive carcinoma&#46; </p><p class="elsevierStylePara">The persistence or recurrence of CIN following LLETZ is related to several factors such as degree of the disease&#44;<span class="elsevierStyleSup">8</span> positive endocervical curettage&#44;9 diagnosis of positive margins of the specimen&#46;<span class="elsevierStyleSup">9-11</span> Ghaem-Maghami demonstrated that after incomplete resection&#44; the relative risk &#40;RR&#41; of having a recurrence of disease of any degree was 5&#46;47 &#40;confidence interval &#91;CI&#93; 95&#37; 4&#46;37-6&#46;83&#41;&#46;<span class="elsevierStyleSup">12</span> Tan et al&#46; report that only positive margins after LLETZ are an independent risk factor &#40;p &#60;0&#46;05&#44; odds ratio &#91;OR&#93; &#61; 4&#46;20&#41;<span class="elsevierStyleSup">13</span> and Livasy comments on the presence of involved endocervical glands as a factor&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara"> Chien-Hsing points out the usefulness of clinical indicators such as positive endocervical margins&#44; age over 50&#44; and disease in multiple quadrants as having a positive predictive value of 40&#37;&#44; 31&#46;4&#37; and 21&#46;9&#37;&#44; respectively&#46;<span class="elsevierStyleSup">15</span> The management of patients with residual lesions post LLETZ is still controversial&#46; Incomplete resection is ignored on many occasions when patients are followed&#46; Follow-up is also done by cytology&#44; a second loop excision&#44; and even hysterectomy&#46; There are no reports in the literature on endocervical brushing of the cervix immediately post LLETZ with histological study of the specimen <span class="elsevierStyleItalic">vs&#46;</span> endocervical brushing in cases with positive margins as a predictor of residual disease&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ OBJECTIVES </span></p><p class="elsevierStylePara">To study the concordance of positive predictive value of endocervical brushing performed immediately following LLETZ and histological results of cervical cones with positive endocervical margins&#44; as predictors of residual disease&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ METHODS </span></p><p class="elsevierStylePara">A prospective study including 1817 patients referred with abnormal cytology and treated by LEETZ was undertaken at the Colposcopy Clinic&#44; General Hospital of Pachuca&#44; Hidalgo&#44; Mexico&#46; </p><p class="elsevierStylePara">The Ethics and Research Committee from the same hospital approved the protocol&#59; informed consent was obtained from all patients&#46;</p><p class="elsevierStylePara">Demographic data included age&#44; educational level&#44; marital status&#59; reproductive data included number of pregnancies and children&#44; age at sexual debut&#44; number of sexual partners&#44; and method of contraception&#59; clinical data included previous cytological results&#44; index cytology&#44; Reid index&#44;<span class="elsevierStyleSup">16</span> and Campion&#39;s level&#46;17 </p><p class="elsevierStylePara">These 1877 patients underwent endocervical brushing of the remaining endocervical canal immediately after removing the specimen&#59; 344 patients had a high grade intraepithelial lesion on cytology&#44; histology&#44; and colposcopy&#46; In 62 patients margins were positive on histology and the endocervical brushing was also positive&#46; These 62 patients underwent a new treatment &#40;LEETZ or hysterectomy&#41; within 6 &#40;&#177; 2&#41; months&#46; </p><p class="elsevierStylePara"> All 1877 patients were referred to the Colposcopy Clinic due to an abnormal cytology&#46; On the first visit&#44; colposcopy was performed and recorded using the modified Reid Colposcopic Index&#46; Colposcopy-directed biopsies were obtained and sent for histo-pathological studies&#46; On a second visit&#44; a LLETZ was performed under local anesthesia&#46; Each specimen was marked at 12 o&#39;clock and reported by a single Pathologist&#46; A second expert pathologist reviewed all 62 cases blinded to the previous results&#46; An excellent concordance between both pathologists was reported &#40;kappa &#61; 0&#46;95&#41;&#46; All margins were considered acceptable for evaluation&#46; </p><p class="elsevierStylePara"> Statistical analysis was performed on SPSS for Windows &#40;version 10&#46;00&#59; SPSS Inc&#46; Chicago&#44; Ill&#46;&#41;&#46; Continuous variables were expressed as means and standard deviation&#59; dichotomy variables as frequencies and percentages&#46; To study group comparisons student&#180;s t test for independent samples &#46; A significant value was expressed using a two-tail p value &#60;0&#46;05&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ RESULTS </span></p><p class="elsevierStylePara">Mean age of the 344 patients with cytological and histological diagnosis of high grade intraepithelial lesion was 42&#46;2 &#177; 12&#46;5 years &#40;range 20 - 80&#41;&#46; The 62 cases with both positive endocervical margins and a positive cytobrush of the remaining canal had a second treatment&#58; 46 hysterectomies and 16 second LLETZ&#46; Findings showed 54 patients &#40;87&#37;&#41; had residual lesion on the second specimen and 8 &#40;13&#37;&#41; had a negative specimen &#40;p &#60;0&#46;05&#41; &#40;<span class="elsevierStyleBold">Figure 1</span>&#41;&#46; </p><p class="elsevierStylePara"><img src="305v10n05-90089426fig1.jpg" alt="Figure 1&#46; Results in 62 second specimens with both positive endocervical margins and endocervical brushing&#46; "></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Figure 1&#46; </span>Results in 62 second specimens with both positive endocervical margins and endocervical brushing&#46; </p><p class="elsevierStylePara">The length&#44; height and width of the cone were significantly different in patients with residual disease when compared with those from patients with negative margins and negative endocervical brushing &#40;<span class="elsevierStyleBold">Table 1</span>&#41;&#46; </p><p class="elsevierStylePara"><img src="305v10n05-90089426fig2.jpg" alt="Table 1&#46; Comparison of patients with negative margins and a positive histological report for residual lesion&#46;"></img></p><p class="elsevierStylePara">There were no significant differences in demographic data&#44; reproductive history&#44; and clinical data between the group of patients with residual disease and the one with both negative margins and endocervical brushing&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ DISCUSSION </span></p><p class="elsevierStylePara">When the presence of a positive endocervical cytobrush and endocervical margins positive in a cone &#40;LLETZ&#41; specimen were combined&#44; second specimens with residual lesion were obtained in 87&#37; of the cases&#44; i&#46;e&#46;&#44; such rate of positive specimens in the future may be predicted &#40;positive predictive value&#41;&#46; Residual lesion was seen in 8&#37; of the cases &#40;from 1817 LLETZ specimens&#41;&#46; No other studies comparing Mexican rates have been published&#59; however&#44; rates reported in the international literature are quite variable &#40;14&#37; - 31&#37;&#41;&#46;<span class="elsevierStyleSup">18-21</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ CONCLUSIONS </span></p><p class="elsevierStylePara">The positive predictive value of cone specimens with positive endocervical margins and concomitantly positive endocervical cytobrush of the proximal cervix is 87&#37;&#46; This knowledge may in the future allow choosing with reasonable certainty patients requiring a second treatment&#44; and offering better results in the treatment of residual disease when taking into account these elegibility factors&#46; </p><p class="elsevierStylePara"><span class="elsevierStyleBold">¿ ACKNOWLEDGMENT </span></p><p class="elsevierStylePara">To Fernando Guijon&#44; MD for his commentaries on the manuscript and help in the translation&#46; </p><hr></hr><p class="elsevierStylePara"><span class="elsevierStyleItalic">Corresponding Author</span>&#58; Jorge Ojeda-Ortiz&#46; <br></br> Departamento de Colpos-Departamento de Colposcopia&#44; Hospital General de Pachuca - Carretera Pachuca-Tulancingo S&#47;N Colonia Ciudad de los ni&#241;os&#46; Pachuca&#44; Hidalgo&#46; 42070&#44; M&#233;xico&#46; <br></br> Phone and Fax &#40;52&#41; 77 1718 2500&#46; <br></br><span class="elsevierStyleItalic">Email&#58;</span><a href="mailto&#58;jorgeojeda&#64;hotmail&#46;com" class="elsevierStyleCrossRefs">jorgeojeda&#64;hotmail&#46;com</a></p>"
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        "resumen" => "Objetivo&#58; Hay varios factores que determinan la persistencia o recurrencia de la neoplasia intraepitelial cervical despu&#233;s de una escisi&#243;n con asa grande de la zona de transformaci&#243;n &#40;LLETZ&#41;&#46; El presente estudio estima que el valor predictivo positivo del cepillado endocervical del canal cervical remanente inmediatamente despu&#233;s de retirar la muestra LLETZ&#44; como elemento predictivo de enfermedad residual&#46; M&#233;todos&#58; Estudio prospectivo&#44; llevado a cabo desde enero de 1990 hasta diciembre de 2006&#44; en el Hospital General de Pachuca&#44; Hidalgo&#44; M&#233;xico&#46; LLETZ se realiz&#243; en 1817 pacientes con un concomitante cepillado cervical para estudio citol&#243;gico&#46; 344 pacientes tuvieron lesiones intraepiteliales de alto grado en la citolog&#237;a&#44; histolog&#237;a y la colposcopia&#46; En 62 pacientes con diagn&#243;stico de lesiones intraepiteliales de alto grado tanto en LLETZ como en cytobrush&#44; se realiz&#243; un segundo tratamiento en 6 &#177; 2 meses&#44; ya fuese con LLETZ &#40;16 pacientes&#41; o histerectom&#237;a &#40;54 pacientes&#41;&#46; La evaluaci&#243;n histol&#243;gica fue realizada por dos pat&#243;logos&#44; cada uno desconoc&#237;a el diagn&#243;stico del otro pat&#243;logo &#40;cegado&#41;&#46; El an&#225;lisis estad&#237;stico se realiz&#243; mediante t-test y prueba de ji cuadrada con el programa SPSS v10&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#41;&#46; Resultados&#58; Tras el segundo tratamiento de 62 pacientes&#44; 87&#37; &#40;54 pacientes&#41; ten&#237;an una lesi&#243;n histol&#243;gica probada residual y 13&#37; &#40;8 pacientes&#41; no ten&#237;an enfermedad residual&#59; estos resultados tuvieron significaci&#243;n estad&#237;stica &#40;p &#60;0 05 conclusiones: cuando los márgenes endocervical y el cepillado cervical son positivos de forma concomitante existe un alto valor predictivo 87 tener la enfermedad residual según se muestra en segundo espécimen"
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        "resumen" => "Objective&#58; There are several factors which determine the persistence or recurrence of cervical intraepithelial neoplasia after a large-loop excision of the transformation zone &#40;LLETZ&#41;&#46; The current study estimates the positive predictive value of endocervical brushing of the remaining cervical canal immediately after removing the LLETZ specimen&#44; as a predictive element of a residual disease&#46; Methods&#58; Prospective study carried out from January 1990 to December 2006&#44; at General Hospital of Pachuca&#44; Hidalgo&#44; Mexico&#46; LLETZ was performed in 1817 patients undergoing concomitant cervical brushing for cytological study&#59; 344 patients had a high grade intraepithelial lesion on cytology&#44; histology&#44; and colposcopy&#46; In 62 patients with diagnosis of high grade intraepithelial lesion in both LLETZ and cytobrush&#44; a second treatment was performed within 6 &#177; 2 months either with LLETZ &#40;16 patients&#41; or hysterectomy &#40;54 patients&#41;&#46; Histological evaluation was performed by two pathologist&#44; each blinded to the diagnosis of a pathologist&#46; Statistical analyses were performed by t-test and2 test using SPSS v10&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#41;&#46; Results&#58; Following the second treatment performed in 62 patients&#44; 87&#37; &#40;54 patients&#41; had a histological proven residual lesion and 13&#37; &#40;8 patients&#41; had no residual disease&#59; these results had a statistical significance of p &#60;0 05 conclusions: when endocervical margins and cervical brushing are concomitantly positive there is a high predictive value 87 of having residual disease as demonstrated in second specimen"
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Article information
ISSN: 16659201
Original language: English
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