The use and success of cold coagulation for the treatment of high grade squamous cervical intra-epithelial neoplasia: a retrospective review

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Abstract

Objective

Cold coagulation is recognised as a viable, cost-effective and successful treatment for cervical intraepithelial neoplasia (CIN), being used less frequently than excisional treatments for high grade lesions. We set out to demonstrate successful long term follow-up of patient with high grade CIN treated with cold coagulation.

Study design

We conducted a retrospective review over a one-year period of women with biopsy-proven CIN 2 and 3 who were treated with cold coagulation to the cervix, attending the colposcopy service of a large tertiary referral hospital. We examined follow-up cervical smear data for three years post treatment of low and high grade CIN, evaluated the success of treatment and re-treatment rates.

Results

93 patients were included in our study, with 39 (41.9%) having CIN 1 and 54 (58.1%) diagnosed with CIN 2 or 3. Follow-up smears revealed low levels of recurrent high grade changes in both groups, with 31 (79.5%) of our CIN 1 group having a negative smear one year following treatment with cold coagulation, compared to 44 (81.1%) of patients with CIN 2 and 3. Successful primary treatment (i.e. no requirement for further treatment after 3 year follow-up) occurred in 33 (84.6%) of the CIN 1 group, and 42 (77.7%) of the CIN 2/3 group, demonstrating no statistical significance between re-treatment rates between both groups.

Conclusions

This study demonstrates the effectiveness of cold coagulation for the treatment of high grade cervical intraepithelial neoplasia. High success rates, and low re-treatment rates confirm that this is an acceptable primary treatment for CIN 2 and 3.

Introduction

In the last forty years, gynaecology has been revolutionised by the implementation of cervical screening programmes. Cervical Check, as part of the Irish National Cancer Screening Programme (NSCP), was introduced in September 2008 following success of a pilot scheme in the Mid-Western Region [1]. The implementation of national screening services in many countries over the past few decades has led to a significant decline in the morbidity and mortality associated with cervical carcinoma.

Through conventional Pap smears, and subsequently liquid based cytology, the implementation of a screening programme has allowed the diagnosis and treatment of cervical intra-epithelial neoplasia (CIN), thereby preventing progression of pre-invasive disease to invasive cervical carcinoma [2], [3]. Colposcopy allows magnification, directed biopsies and treatment of such pre-cancerous lesions. Treatment can take the form of resection techniques (such as cone biopsy and Large Loop Excision of the Transformation Zone (LLETZ)), or ablative techniques (such as laser cryotherapy or cold coagulation). It has been demonstrated that excisional techniques, such as LLETZ, can increase obstetric risks, such as preterm labour and mid-trimester miscarriage [4], [5], compared to minimal risk associated with cold coagulation.

The Semm cold coagulator utilises electrical energy to heat a thermosound probe, which causes ablation of cervical lesions [6]. Duncan demonstrated in 1991 that cold coagulation is an acceptable form of treatment for CIN 3 [7], which he continued to use in all grades of CIN over the coming years [8]. As well as having clinical advantages, it has been shown that patients also have a preference for cold coagulation, with decreased pain and speed of both treatment and recovery [9]. However, cold coagulation still has not been widely adopted by colposcopists, as the preference remains for excisional methods, mostly due to the advantage of histological examination of the transformation zone. In Ireland, the most recent report from the NSCP demonstrates that of those patients having treatment in colposcopy, 7236 (89.2%) had a LLETZ, with only 758 (9.3%) having cold coagulation out of 8109 over a one-year period [8]. Cold coagulation has continually been shown to have a comparable success rate to excisional treatment [10], [11].

We aimed to demonstrate that our success rates were comparable to those in other centres, and further endorse cold coagulation as a feasible option to pursue for the treatment of high grade CIN, especially in young women.

Section snippets

Materials and methods

We conducted a retrospective study of all women referred to the Colposcopy Service of the University Maternity Hospital Limerick referred with high grade cervical smear abnormalities (e.g. high grade squamous intraepithelial lesion), who underwent a cold coagulation procedure for histologically confirmed CIN over a one-year period from January 2009 until January 2010. Patients were excluded if they had a previously treated cervical abnormality. All women were treated by application of the Semm

Results

In total, 3850 patients attended our service during the study period. 651 patients underwent a treatment in 2009, with 321 (49.3%) having a LLETZ treatment and 309 (47.4%) having an ablative treatment. Of those treated with a CC, 93 patients had a high grade smear referral and were included in our study cohort. Of these 93 patients treated with CC, 41.9% (n = 39) women had biopsy proven CIN I, and 58.1% (n = 54) women had biopsy proven CIN 2/3. The average age was 29.2 years (SD = 5.5 years), with a

Main findings

The compliance with follow-up was incomplete. Reassuringly, only one patient in our low risk cohort and two patients in the high risk group did not attend for their yearly follow-up appointment, with all patients attending for at least one follow-up smear. However, the level of non-compliance increased dramatically after three years, with 7 (17.9%) and 11 (20.8%) of patients in the low and high risk groups respectively not attending for follow-up. However, the Irish national cervical screening

Disclosures of interest

The authors have no conflicting interests.

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