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Dr. Patricia Yarberry Allen is a collaborative physician. Her patients, she believes, will be her best partners in providing diagnostic information?as long as they are asked the right questions.?She also believes in consulting with the best medical minds on issues that require specialization or unique clinical experience. Today, to evaluate the potential treatments for cervical dysplasia, grade 3, she calls on the expertise of three physicians who specialize in gynecologic oncology.
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Dear Dr. Pat:
I am 39 years old. I have been diagnosed with cervical dysplasia grade 3, High Risk HPV. Pathology results from the LEEP procedure showed inconclusive results for cells outside the margin. Should I have a hysterectomy or the cold knife cone procedure? My doctor is really pushing for the ?hysterectomy (but will leave my ovaries in place), but I am in limbo about what procedure to do. I really don?t want to have a hysterectomy.
Thanks for your help.
Vicky
Dear Vicky:
This is such a timely?question.?New recommendations to screen women less frequently with Pap smears?may result in more cases of delayed diagnoses of severe cervical dysplasia, carcinoma in situ, and invasive cervical cancer so it is important for patients to be informed of their choices for diagnosis and treatment.
The problem with the frequently used LEEP procedure that uses an electrocautery loop to excise?a?segment of the cervix is that the margins of the tissue?are often not easy for the pathologist to?evaluate, because the cautery that is used to excise the abnormal tissue destroys cells. Certainly you have a problem that requires a definitive diagnosis.
I have asked three gynecologic cancer surgeons to give us their approach to your clinical problem. I think you will be reassured by their thoughtful responses, and also reassured that in?the specialty of gynecology we do have guidelines for the evaluation of most clinical problems.
Thank you so much for sending in your question.
????????????????????????????????????????????????????????????????????????????????????????????? Dr. Pat Allen
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?Dr. Kevin Holcomb Responds:
Kevin M. Holcomb, M.D., is a board-certified Gynecological Oncologist at the New York Hospital?Weill Cornell Medical Center.
Dear Vicky:
CIN III, or ?cervical carcinoma in-situ,? is a severe precancerous change in the cervix caused by a persistent infection with high-risk Human Papilloma Virus. It is usually diagnosed following a colposcopy and directed biopsy as workup for an abnormal Pap smear. Most patients have no symptoms.
There are multiple treatment options for this lesion, including some that remove the abnormal cells? (?excisional techniques?) and others that destroy the abnormal cells? (?destructive techniques?). The choice of treatment is based on the location of the abnormal cells in the cervix and the patient?s plans for future pregnancy.
The LEEP cone biopsy (LEEP stands for Loop Electrocautery Excision Procedure) is a type of excisional technique. It plays two purposes?the first, diagnostic and the second, therapeutic. The LEEP cone biopsy mentioned in this case showed only CIN III with no evidence of invasive cancer. This is reassuring. However, the fact that the margins of the biopsy specimen were positive for precancerous cells means that the possibility of invasive cancer has not been definitively ruled out.
Some studies suggest that performing the cone biopsy with a knife (the traditional ?cold-knife cone biopsy?) leads to a more accurate assessment of the surgical margins. If there is sufficient cervix left after the LEEP procedure, I would strongly recommend that you undergo a cold-knife cone biopsy of the cervix.
If negative margins are achieved and no invasive cancer is found, this would be adequate treatment for your CIN III. If invasive cancer is found, a more radical type of hysterectomy would be appropriate. In my practice, hysterectomy has a limited role in the treatment of cervical pre-cancer. It is usually reserved for patients who have undergone numerous prior cone biopsies with subsequent recurrences of pre-cancer or in a patient with positive surgical margins on a cone biopsy and insufficient residual cervical tissue to perform another excisional procedure.
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Dr. Monica Prasad Hayes Responds:
Monica Prasad Hayes, M.D., is an Assistant Professor in the Department of Obstetrics, Gynecology, and Reproductive Science at the Mount Sinai School of Medicine.
Dear Vicky:
Cervical dysplasia 3, also known as cervical intraepithelial neoplasia III (CIN III), is considered a pre-cancer. Since the pathology from your LEEP procedure shows a question of abnormal cells at the margin, or cut edge, of the biopsy, there may still be residual abnormal cells present in the cervix. In order to remove all the abnormal cells, a cold knife cone procedure is a perfectly appropriate approach to this situation, and, in my opinion, would be the preferred next step.
This procedure would be potentially curative if no residual dysplasia is found or if there is residual dysplasia and it is removed completely with negative margins as determined by the pathologist. In addition, the procedure is diagnostic and can point to a potentially more severe finding if early invasion is found (i.e. an early cervical cancer), in which case you should then be referred to a gynecologic oncologist for further management.
It is important to know that in select cases of early invasive cervical cancer, for those women who wish to maintain future fertility options there are treatments that can preserve the uterus and do not have to result in hysterectomy.? There are women, however, for whom it is appropriate to treat CIN III with a hysterectomy, such as when the cervix is too short to have a cone biopsy performed safely.
In your case, it sounds as if your doctor feels it is safe to perform the cold knife cone biopsy, and so I would recommend that as the next step for you?particularly if you are undecided about having a hysterectomy at this time.
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Dr. Elizabeth Poynor Responds:
Elizabeth Poynor, M.D., Ph.D., a member of the WVFC Medical Advisory Board, is a practicing gynecologic oncologist and pelvic surgeon in private practice in New York City. ?She is an Attending Surgeon at Lenox Hill Hospital in New York City
?The management of precancerous changes in the cervix is highly individualized. Options for management are determined by: age, desire for future childbearing, preferences for surgical approaches, and personal health history, along with pathologic factors such as the degree and amount of dysplasia. A LEEP (loop electrosurgical excision procedure) is a large cervical biopsy which is used to not only to remove abnormal cells of the cervix, but also to ensure that no invasive cancer is present.
When abnormal cells reach the line of excision, or are present in an endocervical curettage (ECC?a sampling of cervical cells above the LEEP) the margin of the LEEP is called ?positive.? When LEEP margins are positive, there is a higher likelihood that abnormal cells are left behind in the cervix, when compared to when the margins are negative. The risk of residual disease (abnormal cells that are left behind in the cervix after the LEEP) is reported to be as high as 25 percent when LEEP margins are positive, as opposed to 11 percent with negative margins. For many women, however, these higher rates of residual disease translate into much lower rates of recurrent disease, and thus follow-up and observation may also be appropriate in selected instances.
Dysplasias of the cervix are extremely prevalent and their appropriate management are key to cervical cancer prevention, therefore well-researched guidelines have been established. NCCN (National Comprehensive Cancer Network) guidelines are highly researched guidelines established by thought leaders in their respective fields. When we look at the NCCN guidelines for positive LEEP margins after a diagnosis of high-grade dysplasia, three management options exist for women. Options include:
? observation,
? repeat excisional procedure such as a repeat LEEP or conization of the cervix,
? hysterectomy
For some selected women with a positive margin who have not completed childbearing, observation may be reasonable. For women in which the ECC is positive for abnormal cells or in which an invasive cancer is suspected or a concern, a repeat excisional procedure should be discussed. Excisional procedures may include: repeat LEEP, conization (either cold knife or laser) of the cervix, and hysterectomy. The post LEEP geometry of the cervix may preclude a repeat LEEP, or even a conization of the cervix if a large amount of the cervix has been removed with the LEEP and it is now flush with the vagina.
I would encourage our questioner to further review with her physician why he/she so strongly recommends a hysterectomy and why he/she would not recommend a conization of the cervix.? I would encourage any woman to get a formal second opinion with complete record review, if she is not comfortable with a surgical recommendation.?A conization, if able to be performed, may be acceptable, and may be even preferable, in order to assure that an invasive cancer is not undertreated with a simple hysterectomy. However, the above information should serve as a source of points for review only, as any recommendation can only be made with a through review of records.
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Kevin Holcomb, M.D., is Associate Attending Obstetrician and Gynecologist at NewYork-Presbyterian Hospital and Associate Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College. He received his M.D. degree from New York Medical College.
Dr. Monica Prasad Hayes is a board certified Gynecologic Oncologist who practices gynecologic oncology and gynecologic surgery, including robotic and minimally invasive surgery. She obtained her medical degree from SUNY Upstate Medical University at Syracuse and completed her residency in Obstetrics & Gynecology at the New York?Presbyterian Hospital/Weill Cornell Medical Center. She then went on to complete a research fellowship in the Department of Surgery at Memorial Sloan-Kettering Cancer Center, focusing on the molecular genetics of endometrial cancer. She subsequently completed a clinical fellowship in Gynecologic Oncology at the Mount Sinai Medical Center, where she continues to practice today.
A member of the WVFC Medical Advisory Board, Dr. Elizabeth Poynor is a practicing gynecologic oncologist and pelvic surgeon, with a Ph.D. in cell biology and genetics. Her private practice in New York focuses on cancer diagnosis, prevention and treatment. ?She is an Attending Surgeon at Lenox Hill Hospital.
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