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Treatment of cervical intraepithelial neoplasia with electrocautery: A report of 776 cases
Treatment of cervical intraepithelial neoplasia with electrocautery: A report of 776 cases Eric A. Deigan, M.D., J. A. Carmichael, M.D., C.M., I. D. Ohlke, R.N., and B.A.
J. Karchmar,
Kingston, Ontario, Canada From 1973 to 1984, 776 patients with cervical intraepithelial neoplasia were treated with outpatient electrocautery (hot cautery) without anesthesia. Of these, 726 (94%) were available for follow-up in 3 to 6 months. An initial cure rate with one treatment of 89% to 90% was achieved. Cure rates were similar for all degrees of dysplasia, including carcinoma in situ. There were no complications. All patients with failure of the initial treatment who returned for further outpatient management were eventually cured with use of electrocautery. Long-term follow-up rates ranged from 75% at 1 year to 46% at 5 years. There were few late recurrences, most of which were treated again (successfully) with electrocautery. Electrocautery produces cure rates similar to those for other forms of conservative management and may be the most cost-effective method of management of cervical intraepithelial neoplasia. (AM J OSSTET GVNECOL 1986;154:255-9.)
Key words: Cervical intraepithelial neoplasia, electrocautery, colposcopy Conservative treatment of cervical intraepithelial neoplasia is now the accepted method of management. The advantages of conservative management as opposed to surgical removal (cone biopsy or hysterectomy) are well recognized. Methods available are electrocautery (hot cautery), I., electrocoagulation diatherm," cryotherapy,' and laser surgery.' All modalities report similar high cure rates. Short and long-term recurrence rates, however, are seldom reported.'"" and therefore data on the degree of permanency of effect of the different modalities of treatment is still lacking. Electrocautery has been used for the treatment and prevention of cervical lesions, dysplastic and benign, for several decades. 7. H Despite its demonstrated ability to effectively reverse dysplastic cervical lesions, 1.2 it has largely been discarded in favor of the newer techniques of cryotherapy and the carbon dioxide laser. From its inception the colposcopy clinic at the Kingston General Hospital has favored and almost exclusively used electrocautery for the conservative management of cervical intraepithelial neoplasia. Results of our experience with electrocautery have been published before. 2 At that time, 426 patients treated with
From the Department of Obstetrics and Gynaecology, Queen's University. Supported in part by the Clare Nelson Fund. Presented at the Forty-first Annual Meeting of The Society of Obstetricians and Gynaecologists of Canada, jasper, Alberta, Canada, june 10-15, 1985. Reprint requests: J.A. Carmichael, M.D., Department of Obstetrics and Gynaecology, Queen's University, Kingston, Ontario, Canada K7L 3N6.
electrocautery were described. This study is an extension of this experience, both in number of patients and length of follow-up, making this one of the largest series of the treatment of cervical intraepithelial neoplasia so far reported. This report reviews our clinic's experience with electrocautery, presenting the results of treatment in terms of initial cure rates and follow-up, and compares these results with other modalities of treatment. Material and methods
Since its beginning in 1973 the colposcopy clinic has seen over 2500 patients referred for assessment of abnormal cervical cytologic conditions. The general organization and policies of the clinic have been previously reported.' All patients continue to be seen by a single staff member (J. A. C.) with the resident currently serving with the oncology service. Patients are treated only after completion of a satisfactory colposcapic examination including calposcopically directed biopsies. Electrocautery is performed in the colposcopy clinic without anesthesia. The instrument used was made by National Electric, Instrument Division, Engelhard Hanovia Inc., Long Island, New York, with a National cautery pistol tip No.6. The entire transformation zone is treated by destroying the tissue with a series of radial burns with the red-hot metal cautery tip. Infrequently a patient with a particularly large transformation zone is treated at two sittings. This procedure differs from and should not be confused with electrocoagulation diathermy, which requires grounding of the patient
255
256 Deigan et al.
February, 1986 Am J Obstet Gynecol
Table I. Initial cure rate with treatment of cervical intraepithelial neoplasia by electrocauterization, 1973-1984
Histologic findings
Total No. treated
Total No. followed
Mild Moderate Marked Carcinoma in situ
218 264 222 68
203 248 208 65
Total
772
724
Initial failures %
Initial cure rate (%)
24 23 21 5
11.8 9.3 10.1 7.7
88.2 90.7 89.9 92.3
73
10.1
89.9
No.'
and produces fulguration and coagulation of tissue by the passage of a high-frequency current through the tissue. The procedure is not free of discomfort, although the expression of discomfort varies widely from patient to patient. The pain is of two types: a crampy feeling (similar to menstrual cramps) and a sensation of burning in the vagina, which usually followed too prolonged an application of the cautery tip. The latter can largely be avoided by the use of frequent intermittent applications rather than a continuous technique. The occasional very anxious patient is given an analgesic agent one-half hour before cautery (e.g., 275 mgofnaproxen sodium). This may be of some value in preventing the crampy type of pain. Treatment, once initiated, was completed in all patients. All patients were advised to expect a brownish discharge beginning 1 week after the cautery and lasting for approximately 1 week. Antibiotics were not used, nor was any local care recommended. Intercourse was discouraged until the discharge subsided. The duration of treatment, even with the most anxious patient, was usually between 3 to 5 minutes. All patients so treated were asked to return to the colposcopy clinic for follow-up examination (cytologic study, repeat colposcopic examination, and biopsy where indicated) at 3 to 6 months. When findings of both cytologic and colposcopic examinations were negative, the patient was returned to the referring physician with the recommendation of routine follow-up, i.e., annual cytologic study. The colposcopy clinic follows all patients treated conservatively on an annual basis. Each patient's referring physician (gynecologist or family physician) is contacted on the anniversary date of the treatment to assure that appropriate follow-up has been done and to ascertain the result of this follow-up. Results
From May, 1973, to September, 1984, 776 patients were treated with electrocautery for cervical intraepithelial neoplasia. Four of these patients have been ex-
cluded from analysis: In three patients results of treatment could not be adequately assessed because a hysterectomy or cone biopsy was performed by the referring physician within 2 months of treatment, and in one patient treatment with electrocautery was considered incomplete, but spontaneous regression of the dysplastic changes occurred during the follow-up period without further treatment. Of the 772 remaining patients, 724 (94%) returned for initial follow-up assessment at 3 to 6 months. There were 73 failures of initial cautery treatment, defined as any persisting cytologic, colposcopic, or histologic evidence of dysplasia. This resulted in an initial failure rate of 10.1 %, or an initial cure rate of 89.9%. Fiftyseven patients had minor cytologic abnormalities on the first follow-up visit, which reverted to normal within 3 to 6 months without further treatment (transient mild dysplasia). These patients were not considered as treatment failures. Cure rates were similar for all degrees of dysplasia including carcinoma in situ, as is illustrated in Table I. Table II shows the outcome of the patients who had failure of the initial electrocautery treatment. Most of the patients who had persisting dysplastic changes following the initial cautery were retreated a second, or occasionally third, time with electrocautery. After the initial cautery one patient had persisting cytologic abnormalities associated with condyloma of the cervix and was eventually cured with podophyllum resin applications. Another patient has been retreated with electrocautery in another center. The remainder of the patients with failure of initial cautery and not treated with repeat cautery were either treated with cone biopsy (4 patients) or hysterectomy (4), were lost to follow-up (3), or are currently awaiting further evaluation and/ or treatment with electrocautery (2). There were two patients who did not return to our clinic for their follow-up assessment, but were subsequently treated elsewhere with cryotherapy because of mild cytologic abnormalities on examination 8 to 9 months after our treatment with electrocautery. The original histologic diagnosis in these patients had been of moderate and marked dysplasia. If these patients are included in the treatment failures, then the initial failure rate would be 10.3% (75 of 726). There were four patients who had recurrences diagnosed between 7 and 12 months after treatment, following an initial negative assessment at 3 to 6 months. If these patients are considered to have persistent disease rather than recurrences, then the initial failure rate increases to 791726, or 10.9%. All four of these patients were retreated successfully with electrocautery. There was only one occurrence of microinvasive cancer following treatment with electrocautery. The patient was treated with electrocautery with a histologic diagnosis of moderate dysplasia but did not return for
Electrocautery of cervical intraepithelial neoplasia
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257
Table II. Results of re-treatment Histologic findings
Mild Moderate Marked Carcinoma in situ Total
24 23 21 5 73
No. having second treatment
No. followed up after re-treatment
18 17 19 4 58
16 15 16 4 51
follow-up until 8 months later, at which time diagnosis of persistent disease was made. She did not return again to the clinic, but after an additional 5 months a vaginal hysterectomy was performed because of uterine prolapse. Histologic examination of the cervix revealed dysplasia and carcinoma in situ as well as one small discrete focus of microinvasion of < 1.0 mm in the depth of an endocervical gland. We are unaware of any other occurrence of invasive cancer following our treatment with electrocautery. Of the seven patients who experienced failure of the second treatment with electrocautery, four underwent a third treatment, and three patients had a cone biopsy. All four patients who had a third treatment were cured, having normal cytologic and colposcopic findings on follow-up. Thus all patients who continued to return to the colposcopy clinic for outpatient management were eventually cured with use of electrocautery. Favorable long-term follow-up rates have been achieved. Table III shows the number of patients who were followed at various time intervals. Follow-up rates were similar for all degrees of dysplasia, although there was a consistently higher follow-up rate of patients with carcinoma in situ (Table IV). Recurrences were defined as any cytologic, colposcopic, or histologic evidence of dysplasia (other than a transient mild cytologic abnormality) occurring more than 6 months after cautery. Among the 463 patients followed for 1 year, there were four recurrences (0.9%), occurring between 7 and 12 months. These might be considered as failures of primary treatment rather than recurrences, as previously mentioned. There were three recurrences in 267 patients at 2 years (1.1 %) and four recurrences in 148 patients at 3 years (2.7%). There have been no late recurrences after 3 years, although there has now been follow-up of some patients for more than 8 years after treatment. All but two of the patients with recurrences had both negative cytologic and negative colposcopic examinations following their initial treatment. The other two patients did not return to the clinic until the time of their recurrence, although they both had negative cytologic examinations, which were performed elsewhere in the intervening time interval. Table V outlines details regarding the patients with recurrences. Eight of the 11 patients with recurrences more than
No. cured
No. having third treatment
No. cured
16 13
I
I
II
3
3
4 44
4
4
Table III. Length and percentage of follow-up Length of follow-up (mo)
3-6 12 24 36 48
>60
772 622 415 265 173 109
No. followed up
Percent followed up
726 465 268
94.0 74.8 64.6 55.8 52.0 45.9
148
90 50
6 months after treatment returned to the colposcopy clinic for management and were treated successfully with repeat electrocautery. One patient was treated by hysterectomy; one patient has been re-treated but has not yet returned for follow-up, and the remaining patient has not yet returned to the colposcopy clinic for management. Treatment with electrocautery was free of significant complications. Several patients reported a persistent mild bleeding for up to 2 to 3 weeks after surgery. This bleeding always eventually ceased, and from our early experience it was found unrewarding to try to deal with this problem by repeat cautery of the bleeding areas. No patient required hospitalization, blood transfusion, or sutures to the cervix. The complication of cervical stenosis was not seen although two or three patients had synechiae between anterior and posterior lips of the cervix, which were either broken down or disregarded.
Comment This study demonstrates a cure rate of 89% to 90% with a single treatment of electrocauterization (hot cautery) in the treatment of cervical intraepithelial neoplasia. All patients with failure of the initial treatment who continued in the program of outpatient management with electrocautery were cured with a second or rarely a third treatment. This compares favorably with results obtained with the other modalities of conservative treatment.3-5. 9-14 There was no difference in the success of treatment with electrocautery for the different degrees of dysplasia, including carcinoma in situ. This is in contrast to results for cryotherapy, where some series have found a considerably higher failure rate in the treatment of marked dysplasia and carcinoma in situ,'· 9. 10
258
Deigan et al.
February, 1986 Am J Obstet Gynecol
Table IV. Follow-up by severity of disease Patients followed up at each time interoal
1 year
3-6 months Severity of disease
n
Mild Moderate Marked Carcinoma in situ
203/218 249/264 209/222 65/68
n
/ % 93 94 94 96
/
1291171 167/221 1261176 43/54
2 years
%
n
75 76
65/105 1031157 771119 23/34
72 80
3 years
r %
62 66 65 68
n
4 years
/%
36170 59/99 35170 18/26
51 60 50 69
n
23/46 33/64 17/39 17/24
/
5 years
%
n
50 52 44 71
10/24 20/43 11125 9117
/
% 42 47 44 53
Table V. Recurrences and outcome
Case No.
Time from first treatment to diagnosis of recurrence
Severity of diseases Initial
IRecurrence
Retreatment with cautery
Result of re-treatment
Mild Mild Moderate Mild
Yes Yes
Cure Cure
Moderate Marked Mild Moderate
Yes Yes Yes Yes
Cure Cure Cure Cure
Moderate Marked
Yes
Not known
3 yr
Mild
No
3 yr 3 yr 3 yr
Moderate Mild Moderate Mild Marked Moderate
1616 1112
7 mo 7 mo
1374 1660 238 1308
8 mo 11 mo 2 yr 2 yr
1646
2 yr
1201 546 846 404
Moderate Mild Mild Moderate
Mild
Yes Yes No
Cure Cure
Comment
Cytologic study done elsewhere negative at 3 months; first follow-up visit in clinic at 7 months Mild dysplasia on cytologic study but biopsy negative Mild and moderate dysplasia on cytologic study, but biopsy negative; re-treatment; follow-up negative Cytologic study done elsewhere negative at 11 and 21 months; first follow-up in clinic at 2 yr showed marked dysplasia; re-treatment November, 1984; patient has not returned for follow-up Recurrence diagnosed elsewhere on cytologic study; patient has not returned to clinic for evaluation Mild dysplasia on cytologic study but biopsy negative Normal examination in clinic at 1 year; subsequent cytologic study (done elsewhere) showed moderate dysplasia at 3 years and marked and carcinoma in situ at 5 years; hysterectomy at 5 years; carcinoma in situ
Table VI. Disposition of all new patients, January 1, 1984, to June 30,1984 No.
%
Electrocautery for cervical intraepithelial neoplasia Cone biopsy for inadequate colposcopic examination Cervical intraepithelial neoplasia present; returned to referring gynecologist (in another center); treatment by electrocautery recommended Hysterectomy (for other benign disease) Cervical intraepithelial neoplasia in pregnancy; did not return after delivery Refused colposcopic examination, biopsy, or treatment Invasive cancer of the cervix Vaginal intraepithelial neoplasia; treated with laser Vulvar intraepithelial neoplasia; laser treatment or vulvectomy Electrocautery for benign cervical disease (e.g., condyloma without dysplasia, cervicitis) No evidence of dysplasia; no treatment required
100 6 9
49.3 3.0 4.4
2 5
1.0 2.5
5
2.5
4 2 4
2.0 1.0 2.0
25
12.3
Total
203
Diagnosis and treatment
although this has been refuted by other studies. II. 12 Interestingly, most of our recurrences had an initial diagnosis of mild or moderate dysplasia. Only two of the 11 patients with recurrences more than 6 months
/
41
20.2 100
after treatment had an initial diagnosis of marked dysplasia, and there have been no recurrences in those patients treated for carcinoma in situ. In the first 2 to 3 years, only 3% of the first 200
Volume 154 Number 2
patients seen in the clinic were treated with electrocautery, since the clinic served primarily as a diagnostic center, with patients being sent back to the referring physician for treatment. In 1976 and 1977 conservative treatment (by electrocautery) was performed in the clinic more often, with 16% of the next 300 patients being so treated, although conservative treatment was still being reserved for those patients desiring to preserve their fertility. Since then, as confidence grew in the ability to cure these lesions with electrocautery, all patients who were appropriate candidates for conservative management were recommended for treatment with electrocautery. Currently, 45% to 55% of patients referred are eventually treated with outpatient electrocautery in the clinic. Most of the remaining patients seen in the clinic are found not to have cervical intraepithelial neoplasia. The eventual disposition of all new patients seen in the clinic in the first 6 months of 1984 is listed in Table VI and demonstrates the almost universal use of electrocautery for dysplasia and carcinoma in situ of the cervix. Acquiring good long-term follow-up is difficult because the patient population tends to be young and itinerant, but it is important, since the natural history of cervical intraepithelial dysplasia can extend over several years. I. 13 Our long-term follow-up shows that late recurrences, while uncommon, may still occur several years after successful treatment, confirming this need for long-term follow-up. However, in most patients electrocautery appears able to effect a permanent reversal of the premalignant changes. Reports on the other modalities of conservative management indicate that a small percentage of patients have complications that we have not seen from treatment with electrocautery. Significant bleeding complications have been reported in from O%U to 2.3%16 to 5.6%3 of patients treated with laser vaporization, and complications of hemorrhage, infection, and cervical stenosis have been reported in up to 3% treated with electrocoagulation diathermy." Complications of significant bleeding or pelvic infection are occasionally reported following cryotherapy.6. II General or regional anesthesia is not required for electrocautery, although it usually is for adequate treatment with electrocoagulation diathermy' and for some patients undergoing laser vaporization procedures.' Recently a review comparing cryotherapy and the carbon dioxide laser for the treatment of cervical intraepithelial neoplasia found that, while the two methods had similar effectiveness, cryotherapy was considerably less expensive in both capital and maintenance costs and it was technically easier to perform. 11 The equipment required for electrocautery is less expensive
Electrocautery of cervical intraepithelial neoplasia
259
than either of these modalities. The cost of a machine for electrocautery is currently approximately $500 (U.S.), and maintenance costs are almost nonexistent. Special training in the use of the equipment is not required, as it is for laser surgery, 16 and the time required in treating with electrocautery is less than is generally reported for either laser surgeriO or cryotherapy. I I Electrocautery (hot cautery) is as effective in treating cervical intraepithelial neoplasia as the other methods available for conservative management. In addition to the advantages of lack of need for anesthesia, fewer significant complications, and ease of use, it is also the most cost-effective method of treatment available. REFERENCES I. Younge PA, Hertig AT, Armstrong D. A study of I:{5 cases of carcinoma in situ of the cervix at the Free Hospital for Women. AM J OBSTET GY:\ECOL 1949;58:867. 2. Schuurmans SN, Ohlke ID, CarmichaelJA. Treatment of cervical intraepithelial neoplasia with electrocautery: report of 426 cases. AM .l OBsnT GY:\ECOl. 1984; 148:.')44. 3. Hollyock VE, Chanen W. Electrocoagulation diathermy for the treatment of cervical dysplasia and carcinoma in situ. Obstet Gynecol 1976;47:196. 4. Creasman WT, Hinshaw WM, Clarke-Pearson DL. Cryosurgery in the management of cervical intraepithelial n~o plasia. Obstet Gynecol 1984;63: 14.'). .'). Wright CV, Davies E, Riopelle MA. Laser surgery for cervical intraepithelial neoplasia: principles and results. A~IJ OflSHT GY!\ECOL 1983;145:181. 6. Hemmingsson E, Stendahl U, Stenson S. Cryosurgical treatment of cervical intraepithelial neoplasia with f()llo\\up of five to eight years. A\I .l OBSTH GY:\ECOl. 1981; 139:144. 7. Hunner GL. The treatment of leuco'rrhea with the actual cautery. .lAMA 1906;46: 191. 8. Pemberton FA, Smith GVS. The early diagnosis and prevention of carcinoma of the cervix: a clinical pathologic study of borderline cases treated at the Free Hospital for Women. A:I1 J OBSTET GY:-.IECOl. 1929; 17: 165. 9. Ostergard DR. Cryosurgical treatment of cervical intraepithelial neoplasia. Obstet Gynecol 1980;56:231. 10. Wright VC, Davies EM. The conservative management of cervical intraepithelial neoplasia: the use of cryosurgery and the carbon dioxide laser. Br J Obstet Gynaecol 1981 ;88:683. II. Popkin DR, Scali V, Ahmed M:>J. Cryosurgerv for the treatment of cervical intraepithelial neoplasia. A\1 JOB. STET GYNECOL 1978;130:551. 12. Benedet JL, Nickerson KG, Anderson GH. Cryotherapy in the treatment of cervical intraepithelial neoplasia. Obstet Gynecol 1981;58:725. 13. Popkin DR. Treatment of cervical intraepithelialneoplasia with the carbon dioxide laser. A\I J OI\Sn:T GnECOl. 1983; 145: 177. 14. Wetchler SJ. Treatment of cervical intraepithelialneoplasia with the CO, laser: laser versus cryotherapy-a review of effectiveness and cost. Obstet Gynecol Surv 1984: 39:469. 15. Kolstad P, Klem V. Long-term follow-up of 1121 cases of carcinoma in situ. Obstet Gynecol 1976;48: 125. 16. Baggish MS. Complications associated with carbon dioxide laser surgery in gynecology. A\1 J OBSTE"I GY:\ECOI. 1981;139:568.
J. Karchmar,
Kingston, Ontario, Canada From 1973 to 1984, 776 patients with cervical intraepithelial neoplasia were treated with outpatient electrocautery (hot cautery) without anesthesia. Of these, 726 (94%) were available for follow-up in 3 to 6 months. An initial cure rate with one treatment of 89% to 90% was achieved. Cure rates were similar for all degrees of dysplasia, including carcinoma in situ. There were no complications. All patients with failure of the initial treatment who returned for further outpatient management were eventually cured with use of electrocautery. Long-term follow-up rates ranged from 75% at 1 year to 46% at 5 years. There were few late recurrences, most of which were treated again (successfully) with electrocautery. Electrocautery produces cure rates similar to those for other forms of conservative management and may be the most cost-effective method of management of cervical intraepithelial neoplasia. (AM J OSSTET GVNECOL 1986;154:255-9.)
Key words: Cervical intraepithelial neoplasia, electrocautery, colposcopy Conservative treatment of cervical intraepithelial neoplasia is now the accepted method of management. The advantages of conservative management as opposed to surgical removal (cone biopsy or hysterectomy) are well recognized. Methods available are electrocautery (hot cautery), I., electrocoagulation diatherm," cryotherapy,' and laser surgery.' All modalities report similar high cure rates. Short and long-term recurrence rates, however, are seldom reported.'"" and therefore data on the degree of permanency of effect of the different modalities of treatment is still lacking. Electrocautery has been used for the treatment and prevention of cervical lesions, dysplastic and benign, for several decades. 7. H Despite its demonstrated ability to effectively reverse dysplastic cervical lesions, 1.2 it has largely been discarded in favor of the newer techniques of cryotherapy and the carbon dioxide laser. From its inception the colposcopy clinic at the Kingston General Hospital has favored and almost exclusively used electrocautery for the conservative management of cervical intraepithelial neoplasia. Results of our experience with electrocautery have been published before. 2 At that time, 426 patients treated with
From the Department of Obstetrics and Gynaecology, Queen's University. Supported in part by the Clare Nelson Fund. Presented at the Forty-first Annual Meeting of The Society of Obstetricians and Gynaecologists of Canada, jasper, Alberta, Canada, june 10-15, 1985. Reprint requests: J.A. Carmichael, M.D., Department of Obstetrics and Gynaecology, Queen's University, Kingston, Ontario, Canada K7L 3N6.
electrocautery were described. This study is an extension of this experience, both in number of patients and length of follow-up, making this one of the largest series of the treatment of cervical intraepithelial neoplasia so far reported. This report reviews our clinic's experience with electrocautery, presenting the results of treatment in terms of initial cure rates and follow-up, and compares these results with other modalities of treatment. Material and methods
Since its beginning in 1973 the colposcopy clinic has seen over 2500 patients referred for assessment of abnormal cervical cytologic conditions. The general organization and policies of the clinic have been previously reported.' All patients continue to be seen by a single staff member (J. A. C.) with the resident currently serving with the oncology service. Patients are treated only after completion of a satisfactory colposcapic examination including calposcopically directed biopsies. Electrocautery is performed in the colposcopy clinic without anesthesia. The instrument used was made by National Electric, Instrument Division, Engelhard Hanovia Inc., Long Island, New York, with a National cautery pistol tip No.6. The entire transformation zone is treated by destroying the tissue with a series of radial burns with the red-hot metal cautery tip. Infrequently a patient with a particularly large transformation zone is treated at two sittings. This procedure differs from and should not be confused with electrocoagulation diathermy, which requires grounding of the patient
255
256 Deigan et al.
February, 1986 Am J Obstet Gynecol
Table I. Initial cure rate with treatment of cervical intraepithelial neoplasia by electrocauterization, 1973-1984
Histologic findings
Total No. treated
Total No. followed
Mild Moderate Marked Carcinoma in situ
218 264 222 68
203 248 208 65
Total
772
724
Initial failures %
Initial cure rate (%)
24 23 21 5
11.8 9.3 10.1 7.7
88.2 90.7 89.9 92.3
73
10.1
89.9
No.'
and produces fulguration and coagulation of tissue by the passage of a high-frequency current through the tissue. The procedure is not free of discomfort, although the expression of discomfort varies widely from patient to patient. The pain is of two types: a crampy feeling (similar to menstrual cramps) and a sensation of burning in the vagina, which usually followed too prolonged an application of the cautery tip. The latter can largely be avoided by the use of frequent intermittent applications rather than a continuous technique. The occasional very anxious patient is given an analgesic agent one-half hour before cautery (e.g., 275 mgofnaproxen sodium). This may be of some value in preventing the crampy type of pain. Treatment, once initiated, was completed in all patients. All patients were advised to expect a brownish discharge beginning 1 week after the cautery and lasting for approximately 1 week. Antibiotics were not used, nor was any local care recommended. Intercourse was discouraged until the discharge subsided. The duration of treatment, even with the most anxious patient, was usually between 3 to 5 minutes. All patients so treated were asked to return to the colposcopy clinic for follow-up examination (cytologic study, repeat colposcopic examination, and biopsy where indicated) at 3 to 6 months. When findings of both cytologic and colposcopic examinations were negative, the patient was returned to the referring physician with the recommendation of routine follow-up, i.e., annual cytologic study. The colposcopy clinic follows all patients treated conservatively on an annual basis. Each patient's referring physician (gynecologist or family physician) is contacted on the anniversary date of the treatment to assure that appropriate follow-up has been done and to ascertain the result of this follow-up. Results
From May, 1973, to September, 1984, 776 patients were treated with electrocautery for cervical intraepithelial neoplasia. Four of these patients have been ex-
cluded from analysis: In three patients results of treatment could not be adequately assessed because a hysterectomy or cone biopsy was performed by the referring physician within 2 months of treatment, and in one patient treatment with electrocautery was considered incomplete, but spontaneous regression of the dysplastic changes occurred during the follow-up period without further treatment. Of the 772 remaining patients, 724 (94%) returned for initial follow-up assessment at 3 to 6 months. There were 73 failures of initial cautery treatment, defined as any persisting cytologic, colposcopic, or histologic evidence of dysplasia. This resulted in an initial failure rate of 10.1 %, or an initial cure rate of 89.9%. Fiftyseven patients had minor cytologic abnormalities on the first follow-up visit, which reverted to normal within 3 to 6 months without further treatment (transient mild dysplasia). These patients were not considered as treatment failures. Cure rates were similar for all degrees of dysplasia including carcinoma in situ, as is illustrated in Table I. Table II shows the outcome of the patients who had failure of the initial electrocautery treatment. Most of the patients who had persisting dysplastic changes following the initial cautery were retreated a second, or occasionally third, time with electrocautery. After the initial cautery one patient had persisting cytologic abnormalities associated with condyloma of the cervix and was eventually cured with podophyllum resin applications. Another patient has been retreated with electrocautery in another center. The remainder of the patients with failure of initial cautery and not treated with repeat cautery were either treated with cone biopsy (4 patients) or hysterectomy (4), were lost to follow-up (3), or are currently awaiting further evaluation and/ or treatment with electrocautery (2). There were two patients who did not return to our clinic for their follow-up assessment, but were subsequently treated elsewhere with cryotherapy because of mild cytologic abnormalities on examination 8 to 9 months after our treatment with electrocautery. The original histologic diagnosis in these patients had been of moderate and marked dysplasia. If these patients are included in the treatment failures, then the initial failure rate would be 10.3% (75 of 726). There were four patients who had recurrences diagnosed between 7 and 12 months after treatment, following an initial negative assessment at 3 to 6 months. If these patients are considered to have persistent disease rather than recurrences, then the initial failure rate increases to 791726, or 10.9%. All four of these patients were retreated successfully with electrocautery. There was only one occurrence of microinvasive cancer following treatment with electrocautery. The patient was treated with electrocautery with a histologic diagnosis of moderate dysplasia but did not return for
Electrocautery of cervical intraepithelial neoplasia
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257
Table II. Results of re-treatment Histologic findings
Mild Moderate Marked Carcinoma in situ Total
24 23 21 5 73
No. having second treatment
No. followed up after re-treatment
18 17 19 4 58
16 15 16 4 51
follow-up until 8 months later, at which time diagnosis of persistent disease was made. She did not return again to the clinic, but after an additional 5 months a vaginal hysterectomy was performed because of uterine prolapse. Histologic examination of the cervix revealed dysplasia and carcinoma in situ as well as one small discrete focus of microinvasion of < 1.0 mm in the depth of an endocervical gland. We are unaware of any other occurrence of invasive cancer following our treatment with electrocautery. Of the seven patients who experienced failure of the second treatment with electrocautery, four underwent a third treatment, and three patients had a cone biopsy. All four patients who had a third treatment were cured, having normal cytologic and colposcopic findings on follow-up. Thus all patients who continued to return to the colposcopy clinic for outpatient management were eventually cured with use of electrocautery. Favorable long-term follow-up rates have been achieved. Table III shows the number of patients who were followed at various time intervals. Follow-up rates were similar for all degrees of dysplasia, although there was a consistently higher follow-up rate of patients with carcinoma in situ (Table IV). Recurrences were defined as any cytologic, colposcopic, or histologic evidence of dysplasia (other than a transient mild cytologic abnormality) occurring more than 6 months after cautery. Among the 463 patients followed for 1 year, there were four recurrences (0.9%), occurring between 7 and 12 months. These might be considered as failures of primary treatment rather than recurrences, as previously mentioned. There were three recurrences in 267 patients at 2 years (1.1 %) and four recurrences in 148 patients at 3 years (2.7%). There have been no late recurrences after 3 years, although there has now been follow-up of some patients for more than 8 years after treatment. All but two of the patients with recurrences had both negative cytologic and negative colposcopic examinations following their initial treatment. The other two patients did not return to the clinic until the time of their recurrence, although they both had negative cytologic examinations, which were performed elsewhere in the intervening time interval. Table V outlines details regarding the patients with recurrences. Eight of the 11 patients with recurrences more than
No. cured
No. having third treatment
No. cured
16 13
I
I
II
3
3
4 44
4
4
Table III. Length and percentage of follow-up Length of follow-up (mo)
3-6 12 24 36 48
>60
772 622 415 265 173 109
No. followed up
Percent followed up
726 465 268
94.0 74.8 64.6 55.8 52.0 45.9
148
90 50
6 months after treatment returned to the colposcopy clinic for management and were treated successfully with repeat electrocautery. One patient was treated by hysterectomy; one patient has been re-treated but has not yet returned for follow-up, and the remaining patient has not yet returned to the colposcopy clinic for management. Treatment with electrocautery was free of significant complications. Several patients reported a persistent mild bleeding for up to 2 to 3 weeks after surgery. This bleeding always eventually ceased, and from our early experience it was found unrewarding to try to deal with this problem by repeat cautery of the bleeding areas. No patient required hospitalization, blood transfusion, or sutures to the cervix. The complication of cervical stenosis was not seen although two or three patients had synechiae between anterior and posterior lips of the cervix, which were either broken down or disregarded.
Comment This study demonstrates a cure rate of 89% to 90% with a single treatment of electrocauterization (hot cautery) in the treatment of cervical intraepithelial neoplasia. All patients with failure of the initial treatment who continued in the program of outpatient management with electrocautery were cured with a second or rarely a third treatment. This compares favorably with results obtained with the other modalities of conservative treatment.3-5. 9-14 There was no difference in the success of treatment with electrocautery for the different degrees of dysplasia, including carcinoma in situ. This is in contrast to results for cryotherapy, where some series have found a considerably higher failure rate in the treatment of marked dysplasia and carcinoma in situ,'· 9. 10
258
Deigan et al.
February, 1986 Am J Obstet Gynecol
Table IV. Follow-up by severity of disease Patients followed up at each time interoal
1 year
3-6 months Severity of disease
n
Mild Moderate Marked Carcinoma in situ
203/218 249/264 209/222 65/68
n
/ % 93 94 94 96
/
1291171 167/221 1261176 43/54
2 years
%
n
75 76
65/105 1031157 771119 23/34
72 80
3 years
r %
62 66 65 68
n
4 years
/%
36170 59/99 35170 18/26
51 60 50 69
n
23/46 33/64 17/39 17/24
/
5 years
%
n
50 52 44 71
10/24 20/43 11125 9117
/
% 42 47 44 53
Table V. Recurrences and outcome
Case No.
Time from first treatment to diagnosis of recurrence
Severity of diseases Initial
IRecurrence
Retreatment with cautery
Result of re-treatment
Mild Mild Moderate Mild
Yes Yes
Cure Cure
Moderate Marked Mild Moderate
Yes Yes Yes Yes
Cure Cure Cure Cure
Moderate Marked
Yes
Not known
3 yr
Mild
No
3 yr 3 yr 3 yr
Moderate Mild Moderate Mild Marked Moderate
1616 1112
7 mo 7 mo
1374 1660 238 1308
8 mo 11 mo 2 yr 2 yr
1646
2 yr
1201 546 846 404
Moderate Mild Mild Moderate
Mild
Yes Yes No
Cure Cure
Comment
Cytologic study done elsewhere negative at 3 months; first follow-up visit in clinic at 7 months Mild dysplasia on cytologic study but biopsy negative Mild and moderate dysplasia on cytologic study, but biopsy negative; re-treatment; follow-up negative Cytologic study done elsewhere negative at 11 and 21 months; first follow-up in clinic at 2 yr showed marked dysplasia; re-treatment November, 1984; patient has not returned for follow-up Recurrence diagnosed elsewhere on cytologic study; patient has not returned to clinic for evaluation Mild dysplasia on cytologic study but biopsy negative Normal examination in clinic at 1 year; subsequent cytologic study (done elsewhere) showed moderate dysplasia at 3 years and marked and carcinoma in situ at 5 years; hysterectomy at 5 years; carcinoma in situ
Table VI. Disposition of all new patients, January 1, 1984, to June 30,1984 No.
%
Electrocautery for cervical intraepithelial neoplasia Cone biopsy for inadequate colposcopic examination Cervical intraepithelial neoplasia present; returned to referring gynecologist (in another center); treatment by electrocautery recommended Hysterectomy (for other benign disease) Cervical intraepithelial neoplasia in pregnancy; did not return after delivery Refused colposcopic examination, biopsy, or treatment Invasive cancer of the cervix Vaginal intraepithelial neoplasia; treated with laser Vulvar intraepithelial neoplasia; laser treatment or vulvectomy Electrocautery for benign cervical disease (e.g., condyloma without dysplasia, cervicitis) No evidence of dysplasia; no treatment required
100 6 9
49.3 3.0 4.4
2 5
1.0 2.5
5
2.5
4 2 4
2.0 1.0 2.0
25
12.3
Total
203
Diagnosis and treatment
although this has been refuted by other studies. II. 12 Interestingly, most of our recurrences had an initial diagnosis of mild or moderate dysplasia. Only two of the 11 patients with recurrences more than 6 months
/
41
20.2 100
after treatment had an initial diagnosis of marked dysplasia, and there have been no recurrences in those patients treated for carcinoma in situ. In the first 2 to 3 years, only 3% of the first 200
Volume 154 Number 2
patients seen in the clinic were treated with electrocautery, since the clinic served primarily as a diagnostic center, with patients being sent back to the referring physician for treatment. In 1976 and 1977 conservative treatment (by electrocautery) was performed in the clinic more often, with 16% of the next 300 patients being so treated, although conservative treatment was still being reserved for those patients desiring to preserve their fertility. Since then, as confidence grew in the ability to cure these lesions with electrocautery, all patients who were appropriate candidates for conservative management were recommended for treatment with electrocautery. Currently, 45% to 55% of patients referred are eventually treated with outpatient electrocautery in the clinic. Most of the remaining patients seen in the clinic are found not to have cervical intraepithelial neoplasia. The eventual disposition of all new patients seen in the clinic in the first 6 months of 1984 is listed in Table VI and demonstrates the almost universal use of electrocautery for dysplasia and carcinoma in situ of the cervix. Acquiring good long-term follow-up is difficult because the patient population tends to be young and itinerant, but it is important, since the natural history of cervical intraepithelial dysplasia can extend over several years. I. 13 Our long-term follow-up shows that late recurrences, while uncommon, may still occur several years after successful treatment, confirming this need for long-term follow-up. However, in most patients electrocautery appears able to effect a permanent reversal of the premalignant changes. Reports on the other modalities of conservative management indicate that a small percentage of patients have complications that we have not seen from treatment with electrocautery. Significant bleeding complications have been reported in from O%U to 2.3%16 to 5.6%3 of patients treated with laser vaporization, and complications of hemorrhage, infection, and cervical stenosis have been reported in up to 3% treated with electrocoagulation diathermy." Complications of significant bleeding or pelvic infection are occasionally reported following cryotherapy.6. II General or regional anesthesia is not required for electrocautery, although it usually is for adequate treatment with electrocoagulation diathermy' and for some patients undergoing laser vaporization procedures.' Recently a review comparing cryotherapy and the carbon dioxide laser for the treatment of cervical intraepithelial neoplasia found that, while the two methods had similar effectiveness, cryotherapy was considerably less expensive in both capital and maintenance costs and it was technically easier to perform. 11 The equipment required for electrocautery is less expensive
Electrocautery of cervical intraepithelial neoplasia
259
than either of these modalities. The cost of a machine for electrocautery is currently approximately $500 (U.S.), and maintenance costs are almost nonexistent. Special training in the use of the equipment is not required, as it is for laser surgery, 16 and the time required in treating with electrocautery is less than is generally reported for either laser surgeriO or cryotherapy. I I Electrocautery (hot cautery) is as effective in treating cervical intraepithelial neoplasia as the other methods available for conservative management. In addition to the advantages of lack of need for anesthesia, fewer significant complications, and ease of use, it is also the most cost-effective method of treatment available. REFERENCES I. Younge PA, Hertig AT, Armstrong D. A study of I:{5 cases of carcinoma in situ of the cervix at the Free Hospital for Women. AM J OBSTET GY:\ECOL 1949;58:867. 2. Schuurmans SN, Ohlke ID, CarmichaelJA. Treatment of cervical intraepithelial neoplasia with electrocautery: report of 426 cases. AM .l OBsnT GY:\ECOl. 1984; 148:.')44. 3. Hollyock VE, Chanen W. Electrocoagulation diathermy for the treatment of cervical dysplasia and carcinoma in situ. Obstet Gynecol 1976;47:196. 4. Creasman WT, Hinshaw WM, Clarke-Pearson DL. Cryosurgery in the management of cervical intraepithelial n~o plasia. Obstet Gynecol 1984;63: 14.'). .'). Wright CV, Davies E, Riopelle MA. Laser surgery for cervical intraepithelial neoplasia: principles and results. A~IJ OflSHT GY!\ECOL 1983;145:181. 6. Hemmingsson E, Stendahl U, Stenson S. Cryosurgical treatment of cervical intraepithelial neoplasia with f()llo\\up of five to eight years. A\I .l OBSTH GY:\ECOl. 1981; 139:144. 7. Hunner GL. The treatment of leuco'rrhea with the actual cautery. .lAMA 1906;46: 191. 8. Pemberton FA, Smith GVS. The early diagnosis and prevention of carcinoma of the cervix: a clinical pathologic study of borderline cases treated at the Free Hospital for Women. A:I1 J OBSTET GY:-.IECOl. 1929; 17: 165. 9. Ostergard DR. Cryosurgical treatment of cervical intraepithelial neoplasia. Obstet Gynecol 1980;56:231. 10. Wright VC, Davies EM. The conservative management of cervical intraepithelial neoplasia: the use of cryosurgery and the carbon dioxide laser. Br J Obstet Gynaecol 1981 ;88:683. II. Popkin DR, Scali V, Ahmed M:>J. Cryosurgerv for the treatment of cervical intraepithelial neoplasia. A\1 JOB. STET GYNECOL 1978;130:551. 12. Benedet JL, Nickerson KG, Anderson GH. Cryotherapy in the treatment of cervical intraepithelial neoplasia. Obstet Gynecol 1981;58:725. 13. Popkin DR. Treatment of cervical intraepithelialneoplasia with the carbon dioxide laser. A\I J OI\Sn:T GnECOl. 1983; 145: 177. 14. Wetchler SJ. Treatment of cervical intraepithelialneoplasia with the CO, laser: laser versus cryotherapy-a review of effectiveness and cost. Obstet Gynecol Surv 1984: 39:469. 15. Kolstad P, Klem V. Long-term follow-up of 1121 cases of carcinoma in situ. Obstet Gynecol 1976;48: 125. 16. Baggish MS. Complications associated with carbon dioxide laser surgery in gynecology. A\1 J OBSTE"I GY:\ECOI. 1981;139:568.