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Does histological incomplete excision of cervical intraepithelial neoplasia following large excision of transformation zone increase recurrence rates? A six year cytological follow up
772 CORRESPONDENCE
concerning the colposcopic features of those women who returned with abnormal smears. 75 (23%) of the women had incomplete excision. All women apparently underwent outpatient large loop excision of the transformation zone using standard treatment protocols. It would be of interest to know what the standard protocols were, with particular reference to the size of the loop used. For example, what proportion of the women had large loops used as opposed to medium-sized loops? Was the intention to excise completely the abnormality using excision alone or was a combination of excision and ablation performed? If so, was there any difference in outcome between these groups?
C. W. E. Redman Women and Childrens' Division, Department of Obstetrics and Gynaecology, City General, Stoke-on-Trent, UK PII: S03 06-5456(00)0015 9-5
Sir, We read the above mentioned study with interest. We agree with the authors' argument that recurrence of CIN is increased if the excision is incomplete. However, we disagree with the blanket statement that ªcytology and colposcopy should be used for follow up for every case of incomplete excisionº; and the available literature does not support this. Studies have been divided in their opinion as to the best method of follow up; ®rstly, because of the dif®culty in differentiating dysplastic acetowhite epithelium from immature squamous metaplasis at colposcopy. This gives high rates of false positive results leading to unnecessary cervical biopsy and its attendant morbidity 1. Secondly, reliance on cytology only for follow up has been shown to improve ef®ciency without placing any additional burden on the available resources 2. There is excellent data to suggest that incomplete excision in the presence of high grade disease or endocervical gland involvement is most likely to be associated with residual disease and increased recurrence 3,4. Intensive surveillance should, therefore, be directed to this group of women only.
References 1. Lopes A, Mor-Yosef S, Pearon St, et al. Is routine colposcopic assessment necessary following laser ablation of cervical intraepithelial neoplasis? Br J Obstet Gynaecol 1990;97:175±177. 2. Murdoch JB, Morgan PR, Lopes A, et al. Histological incomplete excision of cervical intraepithelial neoplasia after large loop excision of the transformation zone merits careful follow up, not treatment. Br J Obstet Gynaecol 1992;99:990±993. 3. Livasy CA, Maygarden SJ, Rajaratnam CT, Novotny DB. Predictors of recurrent dysplasis after a cervical loop electroautery excision procedure for CIN-3: a study of margin, endocervical gland, and quadrant involvement. Mod Pathol 1999;12(3):233±238. 4. Hulman G, Pickles CJ, Gie CA, et al. Frequency of cervical intraepithelial neoplasia following large loop excision of the transformation zone. J Clin Pathol 1998;51:375±377.
S. Das & K. A. J. Chin Department of Obstetrics and Gynaecology, Stafford General Hospital, Stafford, UK PII: S03 06-5456(00)0016 0-1
Sir, S. P. Dobbs and co-authors 1 are to be congratulated for having con®rmed that residual or recurrent cervical intra-epithelial neoplasia (CIN) when treated by large loop excision of the transformation zone is seen more frequently following histological incomplete excision. However, we are unsure how they conclude that colposcopic follow-up should be performed in this group of women. Their study was a retrospective review of women who were followed up by cytological assessment alone. No data were presented of women who were followed up by colposcopy and so no comment can be made concerning the advantages of this method of follow-up. Furthermore, to our knowledge, there is no conclusive evidence showing increased detection rates of residual or recurrent CIN by the use of colposcopy in this setting. In women whose CIN was incompletely excised at the endocervical margin (37 of 75 cases, 49%), it is hard to believe that a colposcopic examination might be of any value by itself or in addition to cytology. A discussion of the value of brush smears in this group of women, however, would have been of interest. If the authors believe there is value in performing colposcopic follow-up of these women, would this identify women with residual or recurrent CIN which is not detected cytologically; or does colposcopy identify recurrent CIN sooner than by cytological assessment alone? It is not possible from their study to establish whether CIN is missed by cytology alone. Furthermore, there is no evidence that earlier detection of CIN improves the outcome in this group of women. In their case series, two women developed invasive cancer of the cervix during the study period, both stage Ial, of which neither was identi®ed `incidentally'. Both cases were identi®ed cytologically, following which both women were referred for further investigation and diagnosis followed by simple hysterectomy. Both of these cases could have been adequately treated by loop cone biopsy were fertility an issue. A further twelve cases were seen to have residual or recurrent CIN (3 low-grade and 9 high-grade), all of whom were also detected cytologically and referred for further investigation, and treatment, presumably by large loop excision of the transformation zone. This paper, supports the value of cytological follow-up in these women, and provides no information on the value of colposcopy.
References 1. Dobbs SP, Asmussen T, Nunns D, Hollingworth J, Brown LJR, Ireland D. Does histological incomplete excision of cervical intraepithelial neoplasia following large loop excision of transformation zone increase recurrence rates? A six year cytological follow up. Br J Obstet Gynaecol 2000;107:1298±1301.
Raj Naik, Alberto de Barros Lopes & John Monaghan Northern Gynaeocological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK PII: S0 306-5456(00 )00 161-3
The relationship between increased folate stetabolism and the increased requirement for folate in pregnancy Sir, The article by Higgins et al. 1 presents de®nitive data that con®rms the previous ®ndings of this prestigious research group, that folate catabolites are increased in the third trimester of pregnancy. Their ®ndings make a signi®cant contribution to the scien-
concerning the colposcopic features of those women who returned with abnormal smears. 75 (23%) of the women had incomplete excision. All women apparently underwent outpatient large loop excision of the transformation zone using standard treatment protocols. It would be of interest to know what the standard protocols were, with particular reference to the size of the loop used. For example, what proportion of the women had large loops used as opposed to medium-sized loops? Was the intention to excise completely the abnormality using excision alone or was a combination of excision and ablation performed? If so, was there any difference in outcome between these groups?
C. W. E. Redman Women and Childrens' Division, Department of Obstetrics and Gynaecology, City General, Stoke-on-Trent, UK PII: S03 06-5456(00)0015 9-5
Sir, We read the above mentioned study with interest. We agree with the authors' argument that recurrence of CIN is increased if the excision is incomplete. However, we disagree with the blanket statement that ªcytology and colposcopy should be used for follow up for every case of incomplete excisionº; and the available literature does not support this. Studies have been divided in their opinion as to the best method of follow up; ®rstly, because of the dif®culty in differentiating dysplastic acetowhite epithelium from immature squamous metaplasis at colposcopy. This gives high rates of false positive results leading to unnecessary cervical biopsy and its attendant morbidity 1. Secondly, reliance on cytology only for follow up has been shown to improve ef®ciency without placing any additional burden on the available resources 2. There is excellent data to suggest that incomplete excision in the presence of high grade disease or endocervical gland involvement is most likely to be associated with residual disease and increased recurrence 3,4. Intensive surveillance should, therefore, be directed to this group of women only.
References 1. Lopes A, Mor-Yosef S, Pearon St, et al. Is routine colposcopic assessment necessary following laser ablation of cervical intraepithelial neoplasis? Br J Obstet Gynaecol 1990;97:175±177. 2. Murdoch JB, Morgan PR, Lopes A, et al. Histological incomplete excision of cervical intraepithelial neoplasia after large loop excision of the transformation zone merits careful follow up, not treatment. Br J Obstet Gynaecol 1992;99:990±993. 3. Livasy CA, Maygarden SJ, Rajaratnam CT, Novotny DB. Predictors of recurrent dysplasis after a cervical loop electroautery excision procedure for CIN-3: a study of margin, endocervical gland, and quadrant involvement. Mod Pathol 1999;12(3):233±238. 4. Hulman G, Pickles CJ, Gie CA, et al. Frequency of cervical intraepithelial neoplasia following large loop excision of the transformation zone. J Clin Pathol 1998;51:375±377.
S. Das & K. A. J. Chin Department of Obstetrics and Gynaecology, Stafford General Hospital, Stafford, UK PII: S03 06-5456(00)0016 0-1
Sir, S. P. Dobbs and co-authors 1 are to be congratulated for having con®rmed that residual or recurrent cervical intra-epithelial neoplasia (CIN) when treated by large loop excision of the transformation zone is seen more frequently following histological incomplete excision. However, we are unsure how they conclude that colposcopic follow-up should be performed in this group of women. Their study was a retrospective review of women who were followed up by cytological assessment alone. No data were presented of women who were followed up by colposcopy and so no comment can be made concerning the advantages of this method of follow-up. Furthermore, to our knowledge, there is no conclusive evidence showing increased detection rates of residual or recurrent CIN by the use of colposcopy in this setting. In women whose CIN was incompletely excised at the endocervical margin (37 of 75 cases, 49%), it is hard to believe that a colposcopic examination might be of any value by itself or in addition to cytology. A discussion of the value of brush smears in this group of women, however, would have been of interest. If the authors believe there is value in performing colposcopic follow-up of these women, would this identify women with residual or recurrent CIN which is not detected cytologically; or does colposcopy identify recurrent CIN sooner than by cytological assessment alone? It is not possible from their study to establish whether CIN is missed by cytology alone. Furthermore, there is no evidence that earlier detection of CIN improves the outcome in this group of women. In their case series, two women developed invasive cancer of the cervix during the study period, both stage Ial, of which neither was identi®ed `incidentally'. Both cases were identi®ed cytologically, following which both women were referred for further investigation and diagnosis followed by simple hysterectomy. Both of these cases could have been adequately treated by loop cone biopsy were fertility an issue. A further twelve cases were seen to have residual or recurrent CIN (3 low-grade and 9 high-grade), all of whom were also detected cytologically and referred for further investigation, and treatment, presumably by large loop excision of the transformation zone. This paper, supports the value of cytological follow-up in these women, and provides no information on the value of colposcopy.
References 1. Dobbs SP, Asmussen T, Nunns D, Hollingworth J, Brown LJR, Ireland D. Does histological incomplete excision of cervical intraepithelial neoplasia following large loop excision of transformation zone increase recurrence rates? A six year cytological follow up. Br J Obstet Gynaecol 2000;107:1298±1301.
Raj Naik, Alberto de Barros Lopes & John Monaghan Northern Gynaeocological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK PII: S0 306-5456(00 )00 161-3
The relationship between increased folate stetabolism and the increased requirement for folate in pregnancy Sir, The article by Higgins et al. 1 presents de®nitive data that con®rms the previous ®ndings of this prestigious research group, that folate catabolites are increased in the third trimester of pregnancy. Their ®ndings make a signi®cant contribution to the scien-