- Email: [email protected]
Carbon dioxide laser surgery in treatment of condyloma
Carbon dioxide laser surgery in treatment of condyloma GEORGE A. HAHN, M.D. Philadelphia, Pennsylvania During the past few years there has been a marked increase in the occurrence of condyloma. A variety of treatment methods, including mental suggestion, local 5-ffuorouracil, podophyllum, electrosurgery, and cryotherapy, has been used with varying success. An experience in 47 patients, some of whom were pregnant, treated with the carbon dioxide laser is presented. The possible relationship to malignancy and tracheobronchial papiHomatosis in children is discussed. (AM. J. 0BSTET. GYNECOL. 141 :1000, 1981.)
GENERALLY, only five sexually transmissible diseases, gonorrhea, syphillis, chancroid, lymphogranuloma venereum, and granuloma inguinale, are reported to health departments. Other venereal diseases, such as genital herpes and trichomoniasis, have become more common. More recently, there has been a marked increase in the occurrence of condylomas in patients seen in the offices of physicians and gynecologic clinics. According to the Center for Disease Control, 1 venereal warts in women rank fourth in prevalence in patients seeking care in sexually transmissible disease clinics in this country. A well-known dermatoiogic cliche is that it is much easier to treat cancer of the skin than venereal warts. Evidence of the difficulties encountered in the management of patients with condyloma has been the multiplicity of treatments which have been used. Treatments ranging from mental suggestion, local applications of Fowler's solution, colchicine, formalin, cantharidin, acetic acid, nitric acid, and 5-fluorouracil have been tried. More recently, nonoxynol 9, ultrasound, cryomrgery, electrocoagulation, radiation, scalpel excision, and vaccination have been used. Despite its many shortcomings, including inconsistent results and toxicity, podophyllum has been the most frequently used medication for the control of condyloma acuminatum.
From the Section of Gynecologic Laser Therapy, Misericordia Division, Mercy Catholic Medical Center Southeastern P enPvsylvania.
of
Presented at the Second Combined Annual Meeting of the American GynecoloKit;al Society and American Association of Obstetricians and Gynecologists, Montreal, Quebec, Canada, May 20-23, 1981. Reprini requesis: Dr. George A. Hahn, lV1edical Tower Building, 255 South 17th St., Philadelphia, Pennsylvania 19103.
000
imrnunomerapy Poweli,2 in 1978, presented his experience m the management of 67 patients with condyloma who were treated with autogenous vaccine; he achieved 76% exceUent results. Difficulties in proper preparation of the autogenous vaccine and Food and Drug Administration regulations in regard to shipping the vaccine across state lines mitigate against the practicality of this method of treatment. Powell suggests its use, particularly in chronic, recurrent cases, and is continuing his use of this type of therapy. (Table l).
Pap!!!omatoeis In investigating the conditions associated with condyloma recurrent respiratory papiliomawsis is often encountered. More than IOO years ago, MacKenzie:1 described papiHomas as the most common benign tumor of the larynx. As a gynecologist, it was exciting to discover that there n1ight be a link betwee_n a viral gynecologic infection and a stubborn disabling condition principally occurring in the pediatric population. Strong, 4 Simpson," Cohen,'; and Quick 7 and their co-workers have investigated the treatment and etiology of papillomatosis in children. Quick postulated that the virus responsible for laryngeal papillomatosis is a strain of human papillomavirus different from that causing cutaneous warts but probably closely related to tht: strain causing condyloma acuminatum. Strong, 4 in his extensive study of papillomatosis, stresses that the condition is rarely, if ever, diagnosed in the newborn infant, but two thirds of the patients are under the age of 5 years when the disease is diagnosed and one third are between 16 and 50 years of age. Of 36 patients under the age of 5, 50% were born of mothers who had vaginal warts at the time of delivery. 0002-9378/81/241000+09$00.90/0© 1981 The C. V. Mosby Co.
LasHr surgery in treatment of condyloma
Volume I-ll 1\umber !\
1001
Fig. I. tow-power view of condyloma acuminatum showing an orderly benign growth of squamous epithelium with completelY normal cellular elements .
Fig. %. High-power view of condyloma acuminatum showing branching and interlocking papillae of contwctin· tissue stroma.
No history could be obtained from the mothers of nine adopted children. Four patients whose disease was diagnosed after the age of 20 volunteered a history of oral-genital contact with an infected partner. A few of the other 33 patients also acknowledged such a history. It would appear logical to assume that a reservoir of papillomatosis exists in condyloma acuminatum. Papillomatosis is characterized by multiple lesions and frequent recurrences , some as late as 25 years after apparent disappearance of all lesions. In some cases over 100 surgical procedures may be necessary to preserve voice, maintain airway, and preserve iife. Tucker 8 cited the case of an 8-year-old child who has had a multiplicity of surgical procedures over the past 4 years, recently with the carbon dioxide laser, and the papilloma process has extended deeper and deeper into the bronchial tree . Unless the characteristics of the disease change, the prospect for continuing life is poor.
Table I. Immunologic therapy
Epidemiologic study
ln a population-based epidemiologic study of 51 patients with pregnancies complicated by condyloma,
Rnull., No.
Excellent
Texas Other areas Survey
67 101 95
66
TOlal
263
193
~odified
51
76
I
Good
H :II 'I
H
I
None
2 14
10
26
from Powell, L. C. , Jr ."
during the period 1950 to 197~ . Chuang and associates9 noted no association between infant laryngeal papilloma and maternal condyloma (Tahle II) . Strong, 10 in an experience with more t.han 400 patients with papillomatosis, knows of no siblings with the disease. It is reasonable to assume that there is a relationship between maternal condyloma and papillomatosis, but mandatory ces
1002
Hahn Am.
Decem her I '1. l tJ~ I J. Obstet. Cmccol
Fig. 3. Verrucous carcinoma. Papillary configuration with solid nests of epithelial cells and wide base. Low-power view.
Fig. 4. High-power view of verrucous carcinoma shown in Fig. 3.
Because of dissatisfaction with the results of treatnent with podophyllum and other commonly used nethods, it was decided to use carbon dioxide laser mrgery in the management of patients with condyloma tcuminatum. Baggish, 11 • 12 Bellina and associates,l 3 and Hahn 14 • 1" 1ave described the general principles and mode of ac.ion of the carbon dioxide laser beam in gynecologic :onditions.
Carbon dioxide laser beam surgery
Carbon dioxide laser beam surgery performed with colposcopic guidance offers exceptional surgical precision with maximum preservation of normal tissues, virtual absence of pain in treating disease above the vaginal introitus, and rapid healing with minimal fibrosis. Most patients experience a marked decrease in condyloma-associated discomfort almost as soon as the procedure has been completed.
Volume HI :\lumber H
La~:er
surgery in treatment of condyloma
Fig. 6. Operative specimen of verrucous seen in Fig. 5.
carcinom~
1003
of \·ulva
Table II. Results at Mayo Clinic, 1950 to 1978
Fig. 5. Clinical appearance of verrucous carcinoma of the vulva.
A Coherent Radiation System 400 carbon dioxide laser coupled with a Zeiss OPMI operating microscope (colposcope) was used in this study. Material
forty-nine patients with a diagnosis of condyloma acuminatum were referred for treatment from January, 1978, to January, 1981. The ages ranged from 15 to 71. The patients were referred from my own office, or were referred to me by other gynecologists because of the diagnosis, or were referred from the outpatient departments of the Misericordia and Fitzgerald Mercy Hospitals. Eighty-two percent of the patients had been treated repeatedly in a variety of fashions and were referred because of failure of previous therapy. The few patients who had not received prior therapy were referred in the latter part of this study. In addition to the usual abdominal, pelvic, rectal, and breast examination, smears and cultures were done when indicated and toluidine blue staining was occasionally used. Acetic acid was applied locally prior
Total patients Pregnancies Intrauterine pregnancies Live births Papilloma virus
:)00
54 .'il
42 ()
Modified from Chuang, T.-Y., Ilstrup. D. M., Perrv. H. 0 .. et a!.9
to colposcopy, and all patients had representative pieces of tissue taken for biopsy. Ordinariiy the Kevorkian punch biopsy forceps was used. but occa.sionally additionai tissue was removed for examination by means of the laser beam with the tissue held under tension by long Allis clamps. Despite the fact that most of the patients had prior treatment, prior biopsies, and prior examination by trained gynecologists, a number of diagnoses were considered. Differential diagnosis. Suppurative hydroadenitis appeared alone or in combination with condyloma. Pap..lomatosis of the genital area was not seen in this series. Condyloma latum and molluscum contagiosum did not occur in this group of patients. HoweV<·r. the giant condyloma of Buschke-Lowenstein 16 is undoubtedly represented in this referred group of patients as is verrucous carcinoma and there was one instance of rather
1004 Hahn
Decemht_'l i ;, , I ~--1 :-; I .'\m . .J. Ohstet. l; \'IH'n>l
Fig. 7. Condyloma acuminatum-moderate disease.
Fig. 8. Condyloma acuminatum-extensive disease.
typical invasive squamous cell carcinoma. Partridge and co-workers 17 have recently published a study on verrucous lesions of the female genitals; they stressed the difficulties inherent in differentiating verrucous carcinoma from giant condyloma with malignant changes and emphasized that large biopsies including adequate stroma are essential for diagnosis, and they further stated that local podophyllum and radiation therapy are inadequate for control.
be rare in verrucous carcinoma, groin dissection wa ~ deemed clinically indicated in this patient. Figs. 5 and 6 are photographs of the external genitals of a 71-year-old patient who had prior podophyllum therapy and electrosurgical treatment f(Jr apparent condyloma (histologically proved) . Biopsies taken in the gynecologic laser facility disclosed typical invasive squamous cell carcinoma, and a one-stage bilateral groin dissection and a radical vulvectomy were performed. Fig. 6 shows the appearance of the surgical speomen . The patient with verrucous carcinoma and the patient with squamous cell carcinoma are not inciuded in the group of patients treated with carbon dioxide surgical laser. The 47 patients in whom laser therapy was used comprised 15 teenagers, 22 women in their 20s, five in their 30s, and five who were more than 40 years old (one of whom was 71 years of age). Prior treatments. Thirty-seven patients had been treated with applications of podophyllum ; 32 had been treated more than once, with some having this type of medication used eight times. Four of the group had had cryotherapy and seven had electrosurgery; over half had had repeated e!ectrosurgical attempts. Clinical classification. Early in the investigation it became evident that some sort of clinical staging would be helpfuL In this study there were no patients who
Results Histologic appearance of condyloma. Figs. l and 2 demonstrate the characteristic appearance of condylomata. Fig. 1 shows an orderly benign growth of squamous epithelium with completely normal cellular elements. Fig. 2 at a higher power, dearly shows the typical branching and interlocking papillae of connective tissue stroma. Figs. 3 and 4 depict the histologic appearance of verrucous vulvar carcinoma. These photographs were taken from tissues removed from a 49-year-old patient who had had three prior electrosurgical operations for removal of histologically diagnosed condyloma. A papillary configuration is shown but is represented by solid nests of epithelia! cells and a very wide base. This case was managed by a radical vulvectomy and bilateral groin dissection. No neoplastic changes were found in the lymph nodes. Although lymphatic spread is thought to
Volume J.tl 1\ umber K
only had a few· limited or isolated w·arty ~powths. Seven patients were classified as having moderate disease (Fig. 7); 25 had extensive disease (Fig. 8), \Vhere perineum. perianal, vulvovaginal, and often cervical disease \vas evident but spread out in a fairly thin pattern. Fifteen were classified as having massive disease (Fig. 9). with bulky, thick, firm involvement evident. Some of these patients might be considered in the category of Buschke-Lowenstein giant condyloma. Thirteen patients had cervical condyloma. Associated conditions. There was an interesting array of associated conditions. Six had insulin-dependent diabetes and five were in varying stages of pregnancv. Three patients had been treated for invasive malignancv. and one of these had had radical surgery 3 vears previously for an invasive carcinoma of the cervix. One HI-year-old patient had had radiation 10 years previously and chemotherapy for lymphatic leukemia. A 71-year-old patient had had surgical and radiation therapy for carcinoma of the breast with metastases and was receiving chemotherapy when the condvloma developed. She subsequently died of the breast malignancy. In only one patient was a history of maternal diethylstilbestrol ingestion obtained. As a sidelight, one 17-year-old patient was unable to read or write, and several teenagers seemed pleased about their multiple sexual partners. With the bulky lesions and some of the flatter, more extensive lesions, treatment of the entire area at one session did not seem desirable. This was true in 12 patients. However, two patients, one pregnant, were found to be free of clinical evidence of disease when they were to be scheduled for further therapy. Seven required relatively minimal laser surgery and one patient had a definite reinfection over a year after primary laser surgery. Technique. Laser surgery was carried out at power densities ranging from 300 to 7 50 W /sq em/sec. In the first group of patients treated, the lower power densities and an intermittent beam of short duration were used. As experience with the modality increased, higher power densities were used and greater reliance was placed on continuous beam surgery. No anesthesia was required for cervical and vaginal condyloma. Two patients required general anesthesia for massive disease, iocal in filtration with i '7c lidocaine was used in ali others. Postoperative care. Strict instructions are given in reganl to local hygiene and the avoidance of sexual relations. Daily sitz baths are suggested, and the use of a hair dryer in the genital area has proved most helpfuL In the early part of this study sulfonamide creams were applied locally. Now no creams are prescribed,
Laser surgery in treatment of condyloma
1005
Fig. 9. Condvloma acuminatum-massi,·e disease.
but local applications of honey are sometimes suggested. It is necessary that associated ceninwaginal infection be treated appropriatdv. This rna\ include the prescribing of specific drugs to control Chlamvdia or Trichomonas infestation. Follow-up is cnmplete in 46 of the ·17 patients. Depending on the extent of treatment, the patient is seen at I to :) weeks after treatment and at decreasing intervals thereafter. Complications. Possible complications include edema, bleeding, pain. infection. and scar formation. No bothersome complications have occurred. \Vith the higher power densities that are now being used, it is anticipated that .a higher complication rate may ensue. Safety. The beam should not strike rdlt-ctive surfaces since it could damage adjacent tissues. When the beam is used in the vagina, nonreflective instruments may be used or the instruments may be covered by moist gauze. The eyes of the operator are protected by the lens of the colposcope and others in thf' room may wear eyeglasses. lnHammable anesthetic or antiseptic agents or othe1· Hammable materials should not be used and any cloth that may he struck bv the beam should be thoroughly wet. Treatment principles. It is essential that a proper and exact diagnosis be made, even if it entails repeated
1006 Hahn
biopsies. The treatment must be carried out with adequate power density so that proper depth of destruction be achieved. When advisable, the treatment should be staged. The associated cervical and vaginal infection must be adequately managed. The male sexual partner(s) must be thoroughly examined and properly treated. Diabetes, when present, must be controlled. C'..enital hygiene should be improved. Repeated bouts of condyloma may be associated with altered immunity caused by oral contraceptives, which may have to be discontinued.
Comment Prior to the advent of the laser, most patients were treated with podophyllum with a pattern of repeated
December 1.1. l!l.~l Am.J. Obstet. C\'newl
recurrences. Some patients required electrosurger~ nr cryotherapy with inconsistent results and often marked scarring. Immunotherapy, when available, mav h<· beneficial in certain chronic recurrent cases. Interferon shows great promise in the treatment of papillomatosis and other viral infections but is in very limited supply. Carbon dioxide laser surgery, with its precision under colposcopic guidance, preservation of normal tissue. probable viral destruction, minimal scarring. verv minimal blood loss, and rapid healing, has proved to be the most satisfactory procedure for the control of condyloma acuminatum. The rapid return to normal life not only reduces medical costs but also reduces social inconvenience.
REFERENCES I. U.S. Department Health, Education, and Welfare: Morbid. Mortal. Weekly Rep. 28:Feb. 16, 1979. 2. Powell, L. C., Jr.: Condyloma accuminata: Recent advances in development, carcinogenesis and treatment, Clin. Obstet. Gynecol. 21:1061, 1978. 3. MacKenzie, M.: Diseases of the Pharynx, Larynx and Trachea, New York, 1880, William Wood and Company. p. 226. 4. Strong, M.S., Vaughn, C. W., Healy, G. B., Cooperland, S. R., and Clements, M.A. C. P.: Recurrent respiratory papillomatosis management with the carbon dioxide laser, Am. Otol85:508, 1976. 5. Simpson, G. T., Healy, G. B., McGill, T., and Strong, M. S.: Benign tumors and lesions of the larynx in children: Surgical excision by carbon dioxide laser, Am. Otol. 88:479, 1979. 6. Cohen, S. R., Geller, K. A., Seltzer, S., and Thompson, J. vV.: Papilloma of the larynx and tracheobronchial tree in children-A retrospective study, Am. Otol. 89:497, 1980. 7. Quick, C. A., Faras, A., and Krzysek, R.: The etiology of laryngeal papillomatosis, Laryngoscope 88:1789, 1978. 8. Tucker, J.: Personal communication, March, 1981. 9. Chuang, T.-Y., Ilstrup, D. M .. Perry, H. 0., and Kurland,
Discussion DR. RICHARD MATTINGLY, Milwaukee, Wisconsin. The near-epidemic infection rate of condyloma acuminatum in recent years demands an equally aggressive therapeutic approach to the problem. In conjunction with herpes Type II genital infections, the acuminate wart, caused by a DNA human papillomavirus, has changed the clinical picture of female venereal disease. No longer will a brief course of antibiotics eradicate most of the venereal diseases. Instead, the herpesvirus hibernates in the ganglia of peripheral nerves and causes frequent clinical exacerbations. The wart virus infects the nucleus of epithelial cells, causing them to divide rapidly and to form papillae or large, coalesced verrucous lesions. Recently, Reid and associates 1 have demonstrated a noncondylomatous variety of the wart
IO. II. 12. 13.
14. 15. 16. 17.
L. T.: Lack of unfavorable outcome from 51 pregnandes complicated by condyloma acuminatum, presented at the Thirty-ninth Annual Meeting of the American Academy of Dermatology, December 6-11, 1980. Strong, M.S.: Personal communication, March 17, 1981. Baggish, M. S.: Complications associated with carbon dioxide laser surgery in gynecology. AM. J. 0BSTET. GYNECOL. 139:568, 1981. Baggish, M.S.: Carbon dioxide laser treatment for condylomata acuminata venereal infections, Obstet. Gyn.ecol. 55:711, 1980. Bellina, J. H., Voros, J. I., and Kruppel, J.: Carbon dioxide micro-surgery in gynecology, in Kaplan, l ., editor: Laser surgery, Jerusalem, 1978, vol. 2, Jerusalem Academic Press. Hahn, G. A.: The carbon dioxide laser in gynecology, Philadelphia Med. 74:344. 1978. Hahn, G. A.: Gynecologic surgery with the carbon dioxide laser, KPR Infor/Media Corp., 1978. Buschke, A., and Lowenstein, L.: Uber Carcinomahnliche Condvlomata Acuminata, Klin Wochenschr4: 1726, 1925. Partridge, E C., and Murad, T., Shingleton, H. M .. Austin, J. M. and Hatch, K. D.: Verrucous lesions of the female genitalia, AM.J. 0BSTET. Gr.'iECOL. 137:412; 1980.
virus infection occurring frequently in the lower genital tract. These lesions require either complete excision or destruction of all infected cells if a cure is to be achieved. Herein lies the fallacv of conventional treatment of condyloma acuminatum that involves the lower genital tract. As has been emphasized by the essayist, a multiplicity of local treatment modalities have emerged in recent years in an attempt to control this contagious disease. Most methods fail because. the therapeutic agent or excisional method has not destroyed all of the virus-infected cells in the vulva, vagina, cervix, and, most important the penis. Unfortunately, these venereal warts will continue to recur unless both sexual partners are examined and treated. Dr. Hahn reports his initial experiences in the treatment of 47 patients with condyloma acuminatum by
Volume 141 ~umber 8
means of a Coherent Radiation Model 400 carbon dioxide laser. coupled with a Zeiss operating colposcope. Both systems, the carbon dioxide laser and the colposcope, require special clinical experience and technical skill if therapeutic success is to be achieved. However, the laser beam is not an innovation of recent origin. The Argon and Ruby lasers have been used in ear, nose, and throat surgery and ophthalmology since 1958, although these units produce a beam in a pulsatile manner and in the visible light spectrum. In contrast, the carbon dioxide laser, which was developed in 1967, achieves its energy through a beam of coherent light. This energy source is contained in a parallel beam of light with uniform wave length in the infrared spectrum. This beam can be focused with precision into a pinpoint source of intense energy. It produces its biologic effect on tissues by rapidly boiling the intracellular water at 100° C, which results in cellular explosion and evaporation. The particular advantage of the laser beam in the treatment of the acuminate wart is the fact that it destrovs the entire cell-nucleus, cytoplasm, and cell membrane-by evaporation. The depth of evaporation is controlled by the power density or energy concentration (watts per square centimeter per second) delivered to a specific area. At the present time, laser vaporization and excisional conization are the two major methods of use in this unit. The vaporization technique can be used as an office procedure while the excisional cone requires hospitalization and general anesthesia. The carbon dioxide laser is most frequently used in gynecology for the treatment of intraepithelial lesions of the cervix, vagina, and vulva. One of the more exciting uses which we have found for the carbon dioxide laser is in the vaporization of pelvic endometriosis lesions. Obviously, care must be taken to avoid trauma to adjacent retroperitoneal struc--tures, but the effects of this method of therapy are far more precise, with more complete removal of implants, than with other excisional or thermal techniques. Star!, from our clinic, was one of the very early investigators of the use of the carbon dioxide laser in the treatment of cervical and vaginal intraepithelial neoplasms.2 Among the first 50 patients treated, there was a 10% persistence rate of the lesions with a depth penetration of 1.5 to 2.0 mm. Currently, the depth of evaporation has been increased to 5 to 7 mm with an improvement in overall cure rates to 90% to 95%. Vaporization of vulvar condyloma was a natural extension of the use of the laser. Baggish3 has recently reported one of the first large series of vulvar and vaginal condylomas treated with the carbon dioxide laser. The precision of the laser beam afforded destruction of the lesions with minimal bleeding, rapid healing, and absence of scarring. This technique was particularly useful in the treatment of condyloma during pregnancy. A recurrence rate of 5.5% was much improved from that with previous methods of treatment. It would be im-
Laser surgery in treatment of condyloma
1007
portant to know how many of Dr. Hahn's 17 cases had persistent or recurrent disese. How many treatments were required for each patient particularly those with giant condyloma? What tissue depth did he use in his treatment? One of the major disadvantages of the laser evaporation technique is the loss of tissue for histologic study. Therefore, it is critical that multiple biopsies be taken prior to the laser treatment. This is particularly important for patients in the perimenopausal and postmenopausal age ranges where the venereal wart is rarely found bm the risk of verrucous carcinoma increases. Did the six patients in this study who were over the age of 41 have any alteration in the din ical behavior of these lesions and was there anv history of previous condyloma? \Vere there any complications of the laser treatment, such as bleeding or thermal burns? Finally. one has the uncomfortable feeling that the specialty is soon to have yet another exp<>nsive therapeutic tool offered to the gynecologist for the ambulatory treatment of various benign and noninvasive neoplasms of the lower genital tract. Thi~ will present some of the same problems as the current overabundance of colposcopes, cryocautery units, and ultrasound units. Surely, every gynecologist does not ha\'e sufficient cases to warrant the expense of purchasing a carbon dioxide laser, the cost of which must ultimately be borne by the patient. Since the technology of these units is changing rapidly, it would be prudent to regionalize the treatment of such lesions and avoid the needless duplication of equipment and expense that accompany any new method of therapy. While the future may bring many new applications for the carbon dioxide laser, one should not be misguided by the assumption that the high cost of a piece of t>
ment of cervical and vaginal neoplasia. GYNECOL.
AM.
J
0BSTET.
128:128, 19i7.
3. Baggish. M. S.: Carbon dioxide laser treatment for con· dvlornata acuminata venereal infections, Ob~tt~t. Gynecol. 55:711, 1980.
'
DR. EDWARD G. FRIEDRICH,jR., Gainesville, F'lorida. Dr. Hahn's paper is a very timely one, alerting us to a problem that each of us will have to deal with on a clinical basis in an increasing fashion over the next decade. However. before giving the laser credit for the cure rate. may I ask if it would be possible to develop a control group, treating it in identical fashion, by the
1008
l>ect'lllbcl 1.-,. 1~);1
Hahn Am.
same individual? I have no doubt that the enthusiasm of the investigator, the care taken in controlling vaginal infection, and the use of colposcopy to identify the lesions may have a great bearing on its success. Perhaps identical patients, treated with simple electrosurgery, may meet with equal success, and perhaps it is the professional care rather than the laser that is responsible for the cure rate. DR. ALFRED SHERMAN, Detroit, Michigan. Although we use the laser for neoplastic and other lesions, we do not often get a chance to use it for condyloma. In the last couple of years, we have been requested to treat some lesions, particularly with masses the size such as the one that Dr. Hahn showed, particularly with internal lesions, and often during the last 36 to 38 weeks of pregnancy. We have been amazed at the ease with which we can remove these and the ease with which the patient has subsequently been delivered vaginally fairiy comfortably because of the lack of associated, underlying therrnal burns or thermal injury to the tissue. I would like to ask Dr. Hahn one question, which has bothered us, as to how deep one has to go with these lesions, to the skin or below the skin, in order to adequately remove them. DR. HAHN (Closing). Dr. Mattingly, we have followup on 46 of 47 patients. The longest follow-up is from the end of 1977, so it would be 3Y2 years. The briefest follow-up has been since January. 1981, so we have a 5-month follow-up on the most recent case. There were 10 patients in whom further laser surgery was necessary. Hovvever, most of these cases \-\'ere early in the study. When we first started to use this
J.
Oh:-.tt-'1 (r\
tll't
!:i
method of treatment, not enough ptnver density wa.'used. I was not using the colposcope thoroughh enough. I was ignoring some seedlings and thinking maybe they would go away. Now I am using continuous-beam treatment almost throughout. I go lwneatlt the surface of the skin or vaginal mucosa and mt· higher power density. Before each patient is treated, a colposcopic examination is done, and after the patient has been treated. we again use the colposcope. Many times we detect small areas that were missed the first time. Therefore, some of the reasons that we have excellent results are use of the colposcope, which is essentially a microscope: use of the continuous beam to a greater depth. and reuse of the colposcope before we complete the session. One point that should be emphasized with regard to how the laser beam works is that the thermal energy is not transmitted as far or as deep as with electrosurgen or with cryotherapy. It only goes to possibly 800 p... We have controlled precision with this method, and this is
such satisfactory results. I am glad Dr. Mattingly asked about complications. We have had no untoward complications, such as bleeding, hemorrhage, or significant pain. There was no difference in the patients over 40 and under 40. In the classic description of condyloma, it is also mentioned that in the pregnant patient there mav be spontaneous regression. In treating only half of the lesions in nonpregnant or pregnant women, we have had two spontaneous regressions. I appreciate Dr. Friedrich's remarks, but actually the laser beam definitely played a role in the results.
GENERALLY, only five sexually transmissible diseases, gonorrhea, syphillis, chancroid, lymphogranuloma venereum, and granuloma inguinale, are reported to health departments. Other venereal diseases, such as genital herpes and trichomoniasis, have become more common. More recently, there has been a marked increase in the occurrence of condylomas in patients seen in the offices of physicians and gynecologic clinics. According to the Center for Disease Control, 1 venereal warts in women rank fourth in prevalence in patients seeking care in sexually transmissible disease clinics in this country. A well-known dermatoiogic cliche is that it is much easier to treat cancer of the skin than venereal warts. Evidence of the difficulties encountered in the management of patients with condyloma has been the multiplicity of treatments which have been used. Treatments ranging from mental suggestion, local applications of Fowler's solution, colchicine, formalin, cantharidin, acetic acid, nitric acid, and 5-fluorouracil have been tried. More recently, nonoxynol 9, ultrasound, cryomrgery, electrocoagulation, radiation, scalpel excision, and vaccination have been used. Despite its many shortcomings, including inconsistent results and toxicity, podophyllum has been the most frequently used medication for the control of condyloma acuminatum.
From the Section of Gynecologic Laser Therapy, Misericordia Division, Mercy Catholic Medical Center Southeastern P enPvsylvania.
of
Presented at the Second Combined Annual Meeting of the American GynecoloKit;al Society and American Association of Obstetricians and Gynecologists, Montreal, Quebec, Canada, May 20-23, 1981. Reprini requesis: Dr. George A. Hahn, lV1edical Tower Building, 255 South 17th St., Philadelphia, Pennsylvania 19103.
000
imrnunomerapy Poweli,2 in 1978, presented his experience m the management of 67 patients with condyloma who were treated with autogenous vaccine; he achieved 76% exceUent results. Difficulties in proper preparation of the autogenous vaccine and Food and Drug Administration regulations in regard to shipping the vaccine across state lines mitigate against the practicality of this method of treatment. Powell suggests its use, particularly in chronic, recurrent cases, and is continuing his use of this type of therapy. (Table l).
Pap!!!omatoeis In investigating the conditions associated with condyloma recurrent respiratory papiliomawsis is often encountered. More than IOO years ago, MacKenzie:1 described papiHomas as the most common benign tumor of the larynx. As a gynecologist, it was exciting to discover that there n1ight be a link betwee_n a viral gynecologic infection and a stubborn disabling condition principally occurring in the pediatric population. Strong, 4 Simpson," Cohen,'; and Quick 7 and their co-workers have investigated the treatment and etiology of papillomatosis in children. Quick postulated that the virus responsible for laryngeal papillomatosis is a strain of human papillomavirus different from that causing cutaneous warts but probably closely related to tht: strain causing condyloma acuminatum. Strong, 4 in his extensive study of papillomatosis, stresses that the condition is rarely, if ever, diagnosed in the newborn infant, but two thirds of the patients are under the age of 5 years when the disease is diagnosed and one third are between 16 and 50 years of age. Of 36 patients under the age of 5, 50% were born of mothers who had vaginal warts at the time of delivery. 0002-9378/81/241000+09$00.90/0© 1981 The C. V. Mosby Co.
LasHr surgery in treatment of condyloma
Volume I-ll 1\umber !\
1001
Fig. I. tow-power view of condyloma acuminatum showing an orderly benign growth of squamous epithelium with completelY normal cellular elements .
Fig. %. High-power view of condyloma acuminatum showing branching and interlocking papillae of contwctin· tissue stroma.
No history could be obtained from the mothers of nine adopted children. Four patients whose disease was diagnosed after the age of 20 volunteered a history of oral-genital contact with an infected partner. A few of the other 33 patients also acknowledged such a history. It would appear logical to assume that a reservoir of papillomatosis exists in condyloma acuminatum. Papillomatosis is characterized by multiple lesions and frequent recurrences , some as late as 25 years after apparent disappearance of all lesions. In some cases over 100 surgical procedures may be necessary to preserve voice, maintain airway, and preserve iife. Tucker 8 cited the case of an 8-year-old child who has had a multiplicity of surgical procedures over the past 4 years, recently with the carbon dioxide laser, and the papilloma process has extended deeper and deeper into the bronchial tree . Unless the characteristics of the disease change, the prospect for continuing life is poor.
Table I. Immunologic therapy
Epidemiologic study
ln a population-based epidemiologic study of 51 patients with pregnancies complicated by condyloma,
Rnull., No.
Excellent
Texas Other areas Survey
67 101 95
66
TOlal
263
193
~odified
51
76
I
Good
H :II 'I
H
I
None
2 14
10
26
from Powell, L. C. , Jr ."
during the period 1950 to 197~ . Chuang and associates9 noted no association between infant laryngeal papilloma and maternal condyloma (Tahle II) . Strong, 10 in an experience with more t.han 400 patients with papillomatosis, knows of no siblings with the disease. It is reasonable to assume that there is a relationship between maternal condyloma and papillomatosis, but mandatory ces
1002
Hahn Am.
Decem her I '1. l tJ~ I J. Obstet. Cmccol
Fig. 3. Verrucous carcinoma. Papillary configuration with solid nests of epithelial cells and wide base. Low-power view.
Fig. 4. High-power view of verrucous carcinoma shown in Fig. 3.
Because of dissatisfaction with the results of treatnent with podophyllum and other commonly used nethods, it was decided to use carbon dioxide laser mrgery in the management of patients with condyloma tcuminatum. Baggish, 11 • 12 Bellina and associates,l 3 and Hahn 14 • 1" 1ave described the general principles and mode of ac.ion of the carbon dioxide laser beam in gynecologic :onditions.
Carbon dioxide laser beam surgery
Carbon dioxide laser beam surgery performed with colposcopic guidance offers exceptional surgical precision with maximum preservation of normal tissues, virtual absence of pain in treating disease above the vaginal introitus, and rapid healing with minimal fibrosis. Most patients experience a marked decrease in condyloma-associated discomfort almost as soon as the procedure has been completed.
Volume HI :\lumber H
La~:er
surgery in treatment of condyloma
Fig. 6. Operative specimen of verrucous seen in Fig. 5.
carcinom~
1003
of \·ulva
Table II. Results at Mayo Clinic, 1950 to 1978
Fig. 5. Clinical appearance of verrucous carcinoma of the vulva.
A Coherent Radiation System 400 carbon dioxide laser coupled with a Zeiss OPMI operating microscope (colposcope) was used in this study. Material
forty-nine patients with a diagnosis of condyloma acuminatum were referred for treatment from January, 1978, to January, 1981. The ages ranged from 15 to 71. The patients were referred from my own office, or were referred to me by other gynecologists because of the diagnosis, or were referred from the outpatient departments of the Misericordia and Fitzgerald Mercy Hospitals. Eighty-two percent of the patients had been treated repeatedly in a variety of fashions and were referred because of failure of previous therapy. The few patients who had not received prior therapy were referred in the latter part of this study. In addition to the usual abdominal, pelvic, rectal, and breast examination, smears and cultures were done when indicated and toluidine blue staining was occasionally used. Acetic acid was applied locally prior
Total patients Pregnancies Intrauterine pregnancies Live births Papilloma virus
:)00
54 .'il
42 ()
Modified from Chuang, T.-Y., Ilstrup. D. M., Perrv. H. 0 .. et a!.9
to colposcopy, and all patients had representative pieces of tissue taken for biopsy. Ordinariiy the Kevorkian punch biopsy forceps was used. but occa.sionally additionai tissue was removed for examination by means of the laser beam with the tissue held under tension by long Allis clamps. Despite the fact that most of the patients had prior treatment, prior biopsies, and prior examination by trained gynecologists, a number of diagnoses were considered. Differential diagnosis. Suppurative hydroadenitis appeared alone or in combination with condyloma. Pap..lomatosis of the genital area was not seen in this series. Condyloma latum and molluscum contagiosum did not occur in this group of patients. HoweV<·r. the giant condyloma of Buschke-Lowenstein 16 is undoubtedly represented in this referred group of patients as is verrucous carcinoma and there was one instance of rather
1004 Hahn
Decemht_'l i ;, , I ~--1 :-; I .'\m . .J. Ohstet. l; \'IH'n>l
Fig. 7. Condyloma acuminatum-moderate disease.
Fig. 8. Condyloma acuminatum-extensive disease.
typical invasive squamous cell carcinoma. Partridge and co-workers 17 have recently published a study on verrucous lesions of the female genitals; they stressed the difficulties inherent in differentiating verrucous carcinoma from giant condyloma with malignant changes and emphasized that large biopsies including adequate stroma are essential for diagnosis, and they further stated that local podophyllum and radiation therapy are inadequate for control.
be rare in verrucous carcinoma, groin dissection wa ~ deemed clinically indicated in this patient. Figs. 5 and 6 are photographs of the external genitals of a 71-year-old patient who had prior podophyllum therapy and electrosurgical treatment f(Jr apparent condyloma (histologically proved) . Biopsies taken in the gynecologic laser facility disclosed typical invasive squamous cell carcinoma, and a one-stage bilateral groin dissection and a radical vulvectomy were performed. Fig. 6 shows the appearance of the surgical speomen . The patient with verrucous carcinoma and the patient with squamous cell carcinoma are not inciuded in the group of patients treated with carbon dioxide surgical laser. The 47 patients in whom laser therapy was used comprised 15 teenagers, 22 women in their 20s, five in their 30s, and five who were more than 40 years old (one of whom was 71 years of age). Prior treatments. Thirty-seven patients had been treated with applications of podophyllum ; 32 had been treated more than once, with some having this type of medication used eight times. Four of the group had had cryotherapy and seven had electrosurgery; over half had had repeated e!ectrosurgical attempts. Clinical classification. Early in the investigation it became evident that some sort of clinical staging would be helpfuL In this study there were no patients who
Results Histologic appearance of condyloma. Figs. l and 2 demonstrate the characteristic appearance of condylomata. Fig. 1 shows an orderly benign growth of squamous epithelium with completely normal cellular elements. Fig. 2 at a higher power, dearly shows the typical branching and interlocking papillae of connective tissue stroma. Figs. 3 and 4 depict the histologic appearance of verrucous vulvar carcinoma. These photographs were taken from tissues removed from a 49-year-old patient who had had three prior electrosurgical operations for removal of histologically diagnosed condyloma. A papillary configuration is shown but is represented by solid nests of epithelia! cells and a very wide base. This case was managed by a radical vulvectomy and bilateral groin dissection. No neoplastic changes were found in the lymph nodes. Although lymphatic spread is thought to
Volume J.tl 1\ umber K
only had a few· limited or isolated w·arty ~powths. Seven patients were classified as having moderate disease (Fig. 7); 25 had extensive disease (Fig. 8), \Vhere perineum. perianal, vulvovaginal, and often cervical disease \vas evident but spread out in a fairly thin pattern. Fifteen were classified as having massive disease (Fig. 9). with bulky, thick, firm involvement evident. Some of these patients might be considered in the category of Buschke-Lowenstein giant condyloma. Thirteen patients had cervical condyloma. Associated conditions. There was an interesting array of associated conditions. Six had insulin-dependent diabetes and five were in varying stages of pregnancv. Three patients had been treated for invasive malignancv. and one of these had had radical surgery 3 vears previously for an invasive carcinoma of the cervix. One HI-year-old patient had had radiation 10 years previously and chemotherapy for lymphatic leukemia. A 71-year-old patient had had surgical and radiation therapy for carcinoma of the breast with metastases and was receiving chemotherapy when the condvloma developed. She subsequently died of the breast malignancy. In only one patient was a history of maternal diethylstilbestrol ingestion obtained. As a sidelight, one 17-year-old patient was unable to read or write, and several teenagers seemed pleased about their multiple sexual partners. With the bulky lesions and some of the flatter, more extensive lesions, treatment of the entire area at one session did not seem desirable. This was true in 12 patients. However, two patients, one pregnant, were found to be free of clinical evidence of disease when they were to be scheduled for further therapy. Seven required relatively minimal laser surgery and one patient had a definite reinfection over a year after primary laser surgery. Technique. Laser surgery was carried out at power densities ranging from 300 to 7 50 W /sq em/sec. In the first group of patients treated, the lower power densities and an intermittent beam of short duration were used. As experience with the modality increased, higher power densities were used and greater reliance was placed on continuous beam surgery. No anesthesia was required for cervical and vaginal condyloma. Two patients required general anesthesia for massive disease, iocal in filtration with i '7c lidocaine was used in ali others. Postoperative care. Strict instructions are given in reganl to local hygiene and the avoidance of sexual relations. Daily sitz baths are suggested, and the use of a hair dryer in the genital area has proved most helpfuL In the early part of this study sulfonamide creams were applied locally. Now no creams are prescribed,
Laser surgery in treatment of condyloma
1005
Fig. 9. Condvloma acuminatum-massi,·e disease.
but local applications of honey are sometimes suggested. It is necessary that associated ceninwaginal infection be treated appropriatdv. This rna\ include the prescribing of specific drugs to control Chlamvdia or Trichomonas infestation. Follow-up is cnmplete in 46 of the ·17 patients. Depending on the extent of treatment, the patient is seen at I to :) weeks after treatment and at decreasing intervals thereafter. Complications. Possible complications include edema, bleeding, pain. infection. and scar formation. No bothersome complications have occurred. \Vith the higher power densities that are now being used, it is anticipated that .a higher complication rate may ensue. Safety. The beam should not strike rdlt-ctive surfaces since it could damage adjacent tissues. When the beam is used in the vagina, nonreflective instruments may be used or the instruments may be covered by moist gauze. The eyes of the operator are protected by the lens of the colposcope and others in thf' room may wear eyeglasses. lnHammable anesthetic or antiseptic agents or othe1· Hammable materials should not be used and any cloth that may he struck bv the beam should be thoroughly wet. Treatment principles. It is essential that a proper and exact diagnosis be made, even if it entails repeated
1006 Hahn
biopsies. The treatment must be carried out with adequate power density so that proper depth of destruction be achieved. When advisable, the treatment should be staged. The associated cervical and vaginal infection must be adequately managed. The male sexual partner(s) must be thoroughly examined and properly treated. Diabetes, when present, must be controlled. C'..enital hygiene should be improved. Repeated bouts of condyloma may be associated with altered immunity caused by oral contraceptives, which may have to be discontinued.
Comment Prior to the advent of the laser, most patients were treated with podophyllum with a pattern of repeated
December 1.1. l!l.~l Am.J. Obstet. C\'newl
recurrences. Some patients required electrosurger~ nr cryotherapy with inconsistent results and often marked scarring. Immunotherapy, when available, mav h<· beneficial in certain chronic recurrent cases. Interferon shows great promise in the treatment of papillomatosis and other viral infections but is in very limited supply. Carbon dioxide laser surgery, with its precision under colposcopic guidance, preservation of normal tissue. probable viral destruction, minimal scarring. verv minimal blood loss, and rapid healing, has proved to be the most satisfactory procedure for the control of condyloma acuminatum. The rapid return to normal life not only reduces medical costs but also reduces social inconvenience.
REFERENCES I. U.S. Department Health, Education, and Welfare: Morbid. Mortal. Weekly Rep. 28:Feb. 16, 1979. 2. Powell, L. C., Jr.: Condyloma accuminata: Recent advances in development, carcinogenesis and treatment, Clin. Obstet. Gynecol. 21:1061, 1978. 3. MacKenzie, M.: Diseases of the Pharynx, Larynx and Trachea, New York, 1880, William Wood and Company. p. 226. 4. Strong, M.S., Vaughn, C. W., Healy, G. B., Cooperland, S. R., and Clements, M.A. C. P.: Recurrent respiratory papillomatosis management with the carbon dioxide laser, Am. Otol85:508, 1976. 5. Simpson, G. T., Healy, G. B., McGill, T., and Strong, M. S.: Benign tumors and lesions of the larynx in children: Surgical excision by carbon dioxide laser, Am. Otol. 88:479, 1979. 6. Cohen, S. R., Geller, K. A., Seltzer, S., and Thompson, J. vV.: Papilloma of the larynx and tracheobronchial tree in children-A retrospective study, Am. Otol. 89:497, 1980. 7. Quick, C. A., Faras, A., and Krzysek, R.: The etiology of laryngeal papillomatosis, Laryngoscope 88:1789, 1978. 8. Tucker, J.: Personal communication, March, 1981. 9. Chuang, T.-Y., Ilstrup, D. M .. Perry, H. 0., and Kurland,
Discussion DR. RICHARD MATTINGLY, Milwaukee, Wisconsin. The near-epidemic infection rate of condyloma acuminatum in recent years demands an equally aggressive therapeutic approach to the problem. In conjunction with herpes Type II genital infections, the acuminate wart, caused by a DNA human papillomavirus, has changed the clinical picture of female venereal disease. No longer will a brief course of antibiotics eradicate most of the venereal diseases. Instead, the herpesvirus hibernates in the ganglia of peripheral nerves and causes frequent clinical exacerbations. The wart virus infects the nucleus of epithelial cells, causing them to divide rapidly and to form papillae or large, coalesced verrucous lesions. Recently, Reid and associates 1 have demonstrated a noncondylomatous variety of the wart
IO. II. 12. 13.
14. 15. 16. 17.
L. T.: Lack of unfavorable outcome from 51 pregnandes complicated by condyloma acuminatum, presented at the Thirty-ninth Annual Meeting of the American Academy of Dermatology, December 6-11, 1980. Strong, M.S.: Personal communication, March 17, 1981. Baggish, M. S.: Complications associated with carbon dioxide laser surgery in gynecology. AM. J. 0BSTET. GYNECOL. 139:568, 1981. Baggish, M.S.: Carbon dioxide laser treatment for condylomata acuminata venereal infections, Obstet. Gyn.ecol. 55:711, 1980. Bellina, J. H., Voros, J. I., and Kruppel, J.: Carbon dioxide micro-surgery in gynecology, in Kaplan, l ., editor: Laser surgery, Jerusalem, 1978, vol. 2, Jerusalem Academic Press. Hahn, G. A.: The carbon dioxide laser in gynecology, Philadelphia Med. 74:344. 1978. Hahn, G. A.: Gynecologic surgery with the carbon dioxide laser, KPR Infor/Media Corp., 1978. Buschke, A., and Lowenstein, L.: Uber Carcinomahnliche Condvlomata Acuminata, Klin Wochenschr4: 1726, 1925. Partridge, E C., and Murad, T., Shingleton, H. M .. Austin, J. M. and Hatch, K. D.: Verrucous lesions of the female genitalia, AM.J. 0BSTET. Gr.'iECOL. 137:412; 1980.
virus infection occurring frequently in the lower genital tract. These lesions require either complete excision or destruction of all infected cells if a cure is to be achieved. Herein lies the fallacv of conventional treatment of condyloma acuminatum that involves the lower genital tract. As has been emphasized by the essayist, a multiplicity of local treatment modalities have emerged in recent years in an attempt to control this contagious disease. Most methods fail because. the therapeutic agent or excisional method has not destroyed all of the virus-infected cells in the vulva, vagina, cervix, and, most important the penis. Unfortunately, these venereal warts will continue to recur unless both sexual partners are examined and treated. Dr. Hahn reports his initial experiences in the treatment of 47 patients with condyloma acuminatum by
Volume 141 ~umber 8
means of a Coherent Radiation Model 400 carbon dioxide laser. coupled with a Zeiss operating colposcope. Both systems, the carbon dioxide laser and the colposcope, require special clinical experience and technical skill if therapeutic success is to be achieved. However, the laser beam is not an innovation of recent origin. The Argon and Ruby lasers have been used in ear, nose, and throat surgery and ophthalmology since 1958, although these units produce a beam in a pulsatile manner and in the visible light spectrum. In contrast, the carbon dioxide laser, which was developed in 1967, achieves its energy through a beam of coherent light. This energy source is contained in a parallel beam of light with uniform wave length in the infrared spectrum. This beam can be focused with precision into a pinpoint source of intense energy. It produces its biologic effect on tissues by rapidly boiling the intracellular water at 100° C, which results in cellular explosion and evaporation. The particular advantage of the laser beam in the treatment of the acuminate wart is the fact that it destrovs the entire cell-nucleus, cytoplasm, and cell membrane-by evaporation. The depth of evaporation is controlled by the power density or energy concentration (watts per square centimeter per second) delivered to a specific area. At the present time, laser vaporization and excisional conization are the two major methods of use in this unit. The vaporization technique can be used as an office procedure while the excisional cone requires hospitalization and general anesthesia. The carbon dioxide laser is most frequently used in gynecology for the treatment of intraepithelial lesions of the cervix, vagina, and vulva. One of the more exciting uses which we have found for the carbon dioxide laser is in the vaporization of pelvic endometriosis lesions. Obviously, care must be taken to avoid trauma to adjacent retroperitoneal struc--tures, but the effects of this method of therapy are far more precise, with more complete removal of implants, than with other excisional or thermal techniques. Star!, from our clinic, was one of the very early investigators of the use of the carbon dioxide laser in the treatment of cervical and vaginal intraepithelial neoplasms.2 Among the first 50 patients treated, there was a 10% persistence rate of the lesions with a depth penetration of 1.5 to 2.0 mm. Currently, the depth of evaporation has been increased to 5 to 7 mm with an improvement in overall cure rates to 90% to 95%. Vaporization of vulvar condyloma was a natural extension of the use of the laser. Baggish3 has recently reported one of the first large series of vulvar and vaginal condylomas treated with the carbon dioxide laser. The precision of the laser beam afforded destruction of the lesions with minimal bleeding, rapid healing, and absence of scarring. This technique was particularly useful in the treatment of condyloma during pregnancy. A recurrence rate of 5.5% was much improved from that with previous methods of treatment. It would be im-
Laser surgery in treatment of condyloma
1007
portant to know how many of Dr. Hahn's 17 cases had persistent or recurrent disese. How many treatments were required for each patient particularly those with giant condyloma? What tissue depth did he use in his treatment? One of the major disadvantages of the laser evaporation technique is the loss of tissue for histologic study. Therefore, it is critical that multiple biopsies be taken prior to the laser treatment. This is particularly important for patients in the perimenopausal and postmenopausal age ranges where the venereal wart is rarely found bm the risk of verrucous carcinoma increases. Did the six patients in this study who were over the age of 41 have any alteration in the din ical behavior of these lesions and was there anv history of previous condyloma? \Vere there any complications of the laser treatment, such as bleeding or thermal burns? Finally. one has the uncomfortable feeling that the specialty is soon to have yet another exp<>nsive therapeutic tool offered to the gynecologist for the ambulatory treatment of various benign and noninvasive neoplasms of the lower genital tract. Thi~ will present some of the same problems as the current overabundance of colposcopes, cryocautery units, and ultrasound units. Surely, every gynecologist does not ha\'e sufficient cases to warrant the expense of purchasing a carbon dioxide laser, the cost of which must ultimately be borne by the patient. Since the technology of these units is changing rapidly, it would be prudent to regionalize the treatment of such lesions and avoid the needless duplication of equipment and expense that accompany any new method of therapy. While the future may bring many new applications for the carbon dioxide laser, one should not be misguided by the assumption that the high cost of a piece of t>
ment of cervical and vaginal neoplasia. GYNECOL.
AM.
J
0BSTET.
128:128, 19i7.
3. Baggish. M. S.: Carbon dioxide laser treatment for con· dvlornata acuminata venereal infections, Ob~tt~t. Gynecol. 55:711, 1980.
'
DR. EDWARD G. FRIEDRICH,jR., Gainesville, F'lorida. Dr. Hahn's paper is a very timely one, alerting us to a problem that each of us will have to deal with on a clinical basis in an increasing fashion over the next decade. However. before giving the laser credit for the cure rate. may I ask if it would be possible to develop a control group, treating it in identical fashion, by the
1008
l>ect'lllbcl 1.-,. 1~);1
Hahn Am.
same individual? I have no doubt that the enthusiasm of the investigator, the care taken in controlling vaginal infection, and the use of colposcopy to identify the lesions may have a great bearing on its success. Perhaps identical patients, treated with simple electrosurgery, may meet with equal success, and perhaps it is the professional care rather than the laser that is responsible for the cure rate. DR. ALFRED SHERMAN, Detroit, Michigan. Although we use the laser for neoplastic and other lesions, we do not often get a chance to use it for condyloma. In the last couple of years, we have been requested to treat some lesions, particularly with masses the size such as the one that Dr. Hahn showed, particularly with internal lesions, and often during the last 36 to 38 weeks of pregnancy. We have been amazed at the ease with which we can remove these and the ease with which the patient has subsequently been delivered vaginally fairiy comfortably because of the lack of associated, underlying therrnal burns or thermal injury to the tissue. I would like to ask Dr. Hahn one question, which has bothered us, as to how deep one has to go with these lesions, to the skin or below the skin, in order to adequately remove them. DR. HAHN (Closing). Dr. Mattingly, we have followup on 46 of 47 patients. The longest follow-up is from the end of 1977, so it would be 3Y2 years. The briefest follow-up has been since January. 1981, so we have a 5-month follow-up on the most recent case. There were 10 patients in whom further laser surgery was necessary. Hovvever, most of these cases \-\'ere early in the study. When we first started to use this
J.
Oh:-.tt-'1 (r\
tll't
!:i
method of treatment, not enough ptnver density wa.'used. I was not using the colposcope thoroughh enough. I was ignoring some seedlings and thinking maybe they would go away. Now I am using continuous-beam treatment almost throughout. I go lwneatlt the surface of the skin or vaginal mucosa and mt· higher power density. Before each patient is treated, a colposcopic examination is done, and after the patient has been treated. we again use the colposcope. Many times we detect small areas that were missed the first time. Therefore, some of the reasons that we have excellent results are use of the colposcope, which is essentially a microscope: use of the continuous beam to a greater depth. and reuse of the colposcope before we complete the session. One point that should be emphasized with regard to how the laser beam works is that the thermal energy is not transmitted as far or as deep as with electrosurgen or with cryotherapy. It only goes to possibly 800 p... We have controlled precision with this method, and this is
such satisfactory results. I am glad Dr. Mattingly asked about complications. We have had no untoward complications, such as bleeding, hemorrhage, or significant pain. There was no difference in the patients over 40 and under 40. In the classic description of condyloma, it is also mentioned that in the pregnant patient there mav be spontaneous regression. In treating only half of the lesions in nonpregnant or pregnant women, we have had two spontaneous regressions. I appreciate Dr. Friedrich's remarks, but actually the laser beam definitely played a role in the results.