Cervical intraepithelial neoplasia: Procedures for cervical conization
- Mitchel S Hoffman, MD
Mitchel S Hoffman, MD
- USF Morsani College of Medicine
- William J Mann, Jr, MD
William J Mann, Jr, MD
- Section Editor — Gynecologic Surgery
- Clinical Professor
- Department of Obstetrics and Gynecology
- Virginia Commonwealth University School of Medicine
Cervical conization (also known as cone biopsy) refers to the excision of a cone-shaped portion of the cervix surrounding the endocervical canal and including the entire transformation zone. Excisional treatment can be performed using a scalpel, laser, or electrosurgery (ie, loop electrosurgical excision procedure [LEEP], also called large loop excision of the transformation zone [LLETZ]). There is no evidence that one technique is significantly better than another .
Since squamous lesions typically arise at the transformation zone, the procedure usually enables the pathologist to study an intraepithelial or superficially invasive lesion in its entirety. However, conization does not always remove the entire transformation zone or lesion. Excision is less likely to be complete in certain situations, such as pregnancy, or when the transformation zone is large or high in the endocervical canal, or when the lesion extends onto the vaginal fornices or very deep into the cervical stroma.
Ablative procedures, which are usually done with cryosurgery or with the laser, are an alternative to conization. However, no pathologic specimen is obtained since the cervical tissue is destroyed. These procedures are purely therapeutic and not of diagnostic value. They are appropriate for selected patients with previously well characterized lesions histologically and colposcopically, in whom invasive cancer has been excluded. (See "Cervical intraepithelial neoplasia: Ablative therapies".)
The goal of cone biopsy is to remove the entire transformation zone. Too small an excision can result in inadequate removal of the lesion, while an excision that is too large can lead to immediate and delayed complications. The size and shape of the cone biopsy should be tailored to the individual situation and based upon careful preoperative colposcopy and good surgical judgment. Colposcopy in the operating room just before cone biopsy is not always practical, but may be helpful in many situations. Extending colposcopy to include evaluation of the upper vagina is worthwhile, especially in the presence of large, high-grade ectocervical lesions.
If the transformation zone and lesion are in the endocervical canal and the exocervix appears normal, the cone biopsy may be made narrower to preserve the normal ectocervical tissue, but should extend well upward along the endocervical canal (figure 1). By comparison, if the lesion and transformation zone are largely confined to the ectocervix and the endocervical canal appears to be free of disease, then the cone is taken wide enough to clear the transformation zone with minimal resection of the endocervical canal (figure 1).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Martin-Hirsch PL, Paraskevaidis E, Kitchener H. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2000; :CD001318.
- Martin-Hirsch PL, Kitchener H. Interventions for preventing blood loss during the treatment of cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2000; :CD001421.
- Rubin SC, Battistini M. Endometrial curettage at the time of cervical conization. Obstet Gynecol 1986; 67:663.
- Pearl ML, Beretta S. Routine endometrial curettage is not indicated at the time of cervical cone biopsy. Surg Gynecol Obstet 1993; 176:251.
- Krebs HB. Outpatient cervical conization. Obstet Gynecol 1984; 63:430.
- Gilbert L, Saunders NJ, Stringer R, Sharp F. Hemostasis and cold knife cone biopsy: a prospective randomized trial comparing a suture versus non-suture technique. Obstet Gynecol 1989; 74:640.
- Krebs HB, Helmkamp BF. Assuring successful cone biopsy. Contemp OB/GYN March 1991.
- Helmkamp BF, Krebs HB, Averette HE. Meeting the challenge of cervical cone biopsy. Contemp OB/GYN December 1983.
- Trimbos JB, Heintz AP, van Hall EV. Reliability of cytological follow-up after conization of the cervix; a comparison of three surgical techniques. Br J Obstet Gynaecol 1983; 90:1141.
- Kamat AA, Kramer P, Soisson AP. Superiority of electrocautery over the suture method for achieving cervical cone bed hemostasis. Obstet Gynecol 2003; 102:726.
- Partington CK, Turner MJ, Soutter WP, et al. Laser vaporization versus laser excision conization in the treatment of cervical intraepithelial neoplasia. Obstet Gynecol 1989; 73:775.
- Vergote IB, Makar AP, Kjørstad KE. Laser excision of the transformation zone as treatment of cervical intraepithelial neoplasia with satisfactory colposcopy. Gynecol Oncol 1992; 44:235.
- Indman PD. Conization of the cervix with the CO2 laser as an office procedure. J Reprod Med 1985; 30:388.
- Iversen T. Outpatient cervical conization with the CO2 laser. J Reprod Med 1985; 30:607.
- Wagner AL Jr. Laser excisional conization in an office environment. J Gynecol Surg 1990; 6:47.
- Baggish MS, Dorsey JH. Carbon dioxide laser for combination excisional-vaporization conization. Am J Obstet Gynecol 1985; 151:23.
- Baggish MS, Dorsey JH, Adelson M. A ten-year experience treating cervical intraepithelial neoplasia with the CO2 laser. Am J Obstet Gynecol 1989; 161:60.
- Mor-Yosef S, Lopes A, Pearson S, Monaghan JM. Loop diathermy cone biopsy. Obstet Gynecol 1990; 75:884.
- Keijser KG, Kenemans P, van der Zanden PH, et al. Diathermy loop excision in the management of cervical intraepithelial neoplasia: diagnosis and treatment in one procedure. Am J Obstet Gynecol 1992; 166:1281.
- Murdoch JB, Grimshaw RN, Morgan PR, Monaghan JM. The impact of loop diathermy on management of early invasive cervical cancer. Int J Gynecol Cancer 1992; 2:129.
- Wright TC Jr, Gagnon S, Richart RM, Ferenczy A. Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Obstet Gynecol 1992; 79:173.
- Hallam NF, West J, Harper C, et al. Large loop excision of the transformation zone (LLETZ) as an alternative to both local ablative and cone biopsy treatment: a series of 1000 patients. J Gynecol Surg 1993; 9:77.
- Gajjar K, Martin-Hirsch PP, Bryant A. Pain relief for women with cervical intraepithelial neoplasia undergoing colposcopy treatment. Cochrane Database Syst Rev 2012; 10:CD006120.
- Vanichtantikul A, Charoenkwan K. Lidocaine spray compared with submucosal injection for reducing pain during loop electrosurgical excision procedure: a randomized controlled trial. Obstet Gynecol 2013; 122:553.
- Baggish MS, Noel Y, Brooks M. Electrosurgical thin loop conization by selective double excision. J Gynecol Surg 1991; 7:83.
- Phadnis SV, Atilade A, Young MP, et al. The volume perspective: a comparison of two excisional treatments for cervical intraepithelial neoplasia (laser versus LLETZ). BJOG 2010; 117:615.
- Lipscomb GH, Roberts KA, Givens VM, Robbins D. A trial that compares Monsel's paste with ball electrode for hemostasis after loop electrosurgical excision procedure. Am J Obstet Gynecol 2006; 194:1591.
- Brown CF, Mashini IS, Turner WA, Gallup DG. Retroperitoneal hematoma: an unusual complication of cold knife conization of the cervix. Obstet Gynecol 1986; 68:66S.
- Krebs HB, Pastore L, Helmkamp BF. Loop electrosurgical excision procedures for cervical dysplasia: experience in a community hospital. Am J Obstet Gynecol 1993; 169:289.
- Koonings PP, d'Ablaing G, Schlaerth JB, Curtin JP. A clinical-pathology review of cervical intraepithelial neoplasia following cryotherapy failure. Gynecol Oncol 1992; 44:213.
- Larsson G, Gullberg B, Grundsell H. A comparison of complications of laser and cold knife conization. Obstet Gynecol 1983; 62:213.
- Delmore J, Horbelt DV, Kallail KJ. Cervical conization: cold knife and laser excision in residency training. Obstet Gynecol 1992; 79:1016.
- Oyesanya OA, Amerasinghe CN, Manning EA. Outpatient excisional management of cervical intraepithelial neoplasia. A prospective, randomized comparison between loop diathermy excision and laser excisional conization. Am J Obstet Gynecol 1993; 168:485.
- Claman AD, Lee N. Factors that relate to complications of cone biopsy. Am J Obstet Gynecol 1974; 120:124.
- Nolan TE, Gallup DG. Managing hemorrhage associated with cold-knife conization. The Female Patient 1990; 15:57.
- Baggish MS. A comparison between laser excisional conization and laser vaporization for the treatment of cervical intraepithelial neoplasia. Am J Obstet Gynecol 1986; 155:39.
- McIndoe GA, Robson MS, Tidy JA, et al. Laser excision rather than vaporization: the treatment of choice for cervical intraepithelial neoplasia. Obstet Gynecol 1989; 74:165.
- Dorsey JH, Diggs ES. Microsurgical conization of the cervix by carbon dioxide laser. Obstet Gynecol 1979; 54:565.
- Oyesanya OA, Amerasinghe C, Manning EA. A comparison between loop diathermy conization and cold-knife conization for management of cervical dysplasia associated with unsatisfactory colposcopy. Gynecol Oncol 1993; 50:84.
- Spitzer M, Chernys AE, Seltzer VL. The use of large-loop excision of the transformation zone in an inner-city population. Obstet Gynecol 1993; 82:731.
- Luesley D, Shafi M, Finn C, Buxton J. Haemorrhagic morbidity after diathermy loop excision: effect of multiple pre-treatment variables including time of treatment in relation to menstruation. Br J Obstet Gynaecol 1992; 99:82.
- Gunasekera PC, Phipps JH, Lewis BV. Large loop excision of the transformation zone (LLETZ) compared to carbon dioxide laser in the treatment of CIN: a superior mode of treatment. Br J Obstet Gynaecol 1990; 97:995.
- Holdt DG, Jacobs AJ, Scott JC Jr, Adam GM. Diagnostic significance and sequelae of cone biopsy. Am J Obstet Gynecol 1982; 143:312.
- Monteiro AC, Russomano FB, Camargo MJ, et al. Cervical stenosis following electrosurgical conization. Sao Paulo Med J 2008; 126:209.
- Brun JL, Youbi A, Hocké C. [Complications, sequellae and outcome of cervical conizations: evaluation of three surgical technics]. J Gynecol Obstet Biol Reprod (Paris) 2002; 31:558.
- Suh-Burgmann EJ, Whall-Strojwas D, Chang Y, et al. Risk factors for cervical stenosis after loop electrocautery excision procedure. Obstet Gynecol 2000; 96:657.
- Penna C, Fambrini M, Fallani MG, et al. Laser CO2 conization in postmenopausal age: risk of cervical stenosis and unsatisfactory follow-up. Gynecol Oncol 2005; 96:771.
- Mossa MA, Carter PG, Abdu S, et al. A comparative study of two methods of large loop excision of the transformation zone. BJOG 2005; 112:490.
- Mathevet P, Chemali E, Roy M, Dargent D. Long-term outcome of a randomized study comparing three techniques of conization: cold knife, laser, and LEEP. Eur J Obstet Gynecol Reprod Biol 2003; 106:214.
- Baldauf JJ, Dreyfus M, Ritter J, et al. Risk of cervical stenosis after large loop excision or laser conization. Obstet Gynecol 1996; 88:933.
- Ferris DG, Hainer BL, Pfenninger JL, et al. Electrosurgical loop excision of the cervical transformation zone: the experience of family physicians. J Fam Pract 1995; 41:337.
- DiMusto JC. Reliability of frozen sections in gynecologic surgery. Obstet Gynecol 1970; 35:235.
- Rouzier R, Feyereisen E, Constancis E, et al. Frozen section examination of the endocervical margin of cervical conization specimens. Gynecol Oncol 2003; 90:305.
- Torres JE, Moorman J, Shiu A, Gyer D. Colposcopically directed conization for frozen-section examination in the management of cervical intraepithelial neoplasia. J Reprod Med 1983; 28:123.
- Hannigan EV, Simpson JS, Dillard EA Jr, Dinh TV. Frozen section evaluation of cervical conization specimens. J Reprod Med 1986; 31:11.
- Hoffman MS, Collins E, Roberts WS, et al. Cervical conization with frozen section before planned hysterectomy. Obstet Gynecol 1993; 82:394.
- MALINAK LR, JEFFREY RA Jr, DUNN WJ. THE CONIZATION-HYSTERECTOMY TIME INTERVAL: A CLINICAL AND PATHOLOGIC STUDY. Obstet Gynecol 1964; 23:317.
- Van Nagell JR Jr, Roddick JW Jr, Cooper RM, Triplett HB. Vaginal hysterectomy following conization in the treatment of carcinoma in situ of the cervix. Am J Obstet Gynecol 1972; 113:948.
- Elkins TE, Gallup DG, Slomka CV, Phelan JP. Postoperative morbidity in cases of cervical conization followed by vaginal hysterectomy. South Med J 1982; 75:264.
- Giuntoli RL 2nd, Winburn KA, Silverman MB, et al. Frozen section evaluation of cervical cold knife cone specimens is accurate in the diagnosis of microinvasive squamous cell carcinoma. Gynecol Oncol 2003; 91:280.
- Gu M, Lin F. Efficacy of cone biopsy of the uterine cervix during frozen section for the evaluation of cervical intraepithelial neoplasia grade 3. Am J Clin Pathol 2004; 122:383.
- Webb MJ, Symmonds RE. Radical hysterectomy: influence of recent conization on morbidity and complications. Obstet Gynecol 1979; 53:290.
- OPERATIVE TECHNIQUE
- Cold knife conization
- Laser conization
- Loop electrosurgical excision procedure
- POSTOPERATIVE INSTRUCTIONS
- COMPARISON OF METHODS
- Intraoperative bleeding
- Uterine perforation
- Postoperative bleeding
- Late complications
- Cone margins
- Microinvasive disease or adenocarcinoma in situ
- Planned hysterectomy
- PREGNANT WOMEN
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS