GYNECOLOGIC
ONCOLOGY
36,
217-218 (1990)
A New Way to Expose Endocervical Lesions at Colposcopy NICHOLAS JOHNSON,
MRCOG, FRCS, AND ARCHIBALD C. CROMPTON, M.D., FRCS, FRCOG
Department of Obstetrics and Gynecology, St. James’s University Hospital, Beckett Street, Leeds LS9 7TF, England Received
April
14, 1989
cervix with a transcervical tent was offered and ac-
If there are atypical cells on a cytological smear and if the cepted. At a later date she was recolposcoped by an squamo-columnar junction can not be visualized during a colindependent colposcopist, the initial diagnosis was conposcopic examination, then in order to exclude an early invasive firmed, and a 3-mm-diameter Lamicel’ was passed incancer in the nonvisualized area within the endocervix it is mantracervically. Four hours later she was reexamined, the datory to perform a diagnostic cone biopsy. A woman with abLamicel was removed, and the cervix was reassessed. normal cervical cytology and an unsatisfactory colposcopic exCervical softening, dilatation, and effacement had ocamination who refused a cone biopsy was offered Lamicel in an attempt to expose the entire transformation zone. After 4 hr the curred (Fig. 1) and inspection of the entire lesion and sponge was removed and colposcopy repeated. The lesion and the entire transformation zone was now possible to the the squamo-columnar junction was then fully visible and she was satisfaction of both colposcopists. Histological examispared a cone biopsy. 8 IWOACAIIIC seas,IIIC. nation of a biopsy of the lesion confirmed the clinical
INTRODUCTION If a cervical intraepithelial neoplastic (CIN) lesion extends beyond the view of the colposcope then a diagnostic cone biopsy must be recommended. Many patients will be keen to avoid a surgical cone biopsy and we can report a case where a new technique enabled a CIN lesion to be fully visualized. THE CASE A 35year-old asymptomatic nulliparous nurse presented to the colposcopy unit after a routine cervical smear revealed moderately atypical cells. Although she was planning a family in the near future she had relied on barrier contraception for the last 6 years. Prior to this she had used the oral combined contraceptive pill until a series of cluster headaches had forced her to change. General examination was unremarkable and colposcopy was performed in the usual manner. An acetowhite, glycogen-negative area compatible with moderate CIN was visible but despite replacing the Cusco’s specuulum and using endocervical forceps, the inner margins extended high up the cervical canal, beyond the view of the colposcope. As the patient was keen to avoid a diagnostic cone biopsy (she refused) an alternative treatment had to be devised. An attempt to medically dilate and efface her
impression of CIN II which was treated by local ablation. A follow-up cytological examination of a cervical smear was normal. DISCUSSION The proper colposcopic evaluation of a CIN lesion is impossible in 15% of 35year-olds as it is hidden within the endocervical canal. Techniques to visualize such lesions include microhysterocolposcopy and opening the cervix with a radial laser incision but they have not found favor because they require considerable expertise and can be uncomfortable for the patient. Oral estrogen administration has been proposed but unfortunately the dose used produces nausea in one-third of the patients [ 11and would have been unsuitable for our patient. Laser cone biopsy would be an alternative but the effect on subsequent pregnancies is unknown and facilities for this new procedure are limited. In most hospitals a surgical cone biopsy is the only alternative. Lamicel is a synthetic form of laminaria. It is a compressed, dried synthetic sponge and when it is placed in the cervical canal it becomes moist and expands, dilating and effacing the cervix. The moist sponge is extremely soft and exerts a pressure on the cervical wall of only 2 psi (compared to 28 psi for laminaria) [2]. It does not ’ Lamicel is manufactured by Cabot Medical, West, Langhome, PA 19047.
2021 Cabot Boulevard
217
0090-8258/90 $1.50 Copyright 6 1990 by Academic Press, Inc. All rights of reproduction in any form reserved.
218
JOHNSON AND CROMI’TON
FIG. 1. Colpophotograph before and after Lamicel (note the relative position of the 2-week-old biopsy site).
seem to affect the topographical features of the cervix and 4 hr of tent exposure does not effect the histological findings [3]. Previously Lamicel has been used to dilate the pregnant cervix [4] but its use outside pregnancy has also been described [5,6]. In this case Lamicel dilatated and effaced the cervix and allowed inspection of the entire lesion and transformation zone and the patient could be spared a cone biopsy.
2. 3.
4.
5.
REFERENCES 1. Prendiville, W. J., Davies, W. A. R., Davies, J. O., and Shepherd, A. M. Medical dilatation of the non-pregnant cervix: The effect of
6.
ethinyl oestradiol on the visibility of the transformation zone, &it. J. Obstet. Gynaecol. 93, 508-511 (1986). Wheeler, R. G., and Schneider, K. Properties and safety of cervical dilators, Amer. J. Obstet. Gynecol. M(6), 597401 (1983). Nicolaides, K. H., Welsh, C. C., Koullapis, E. N., and Filshie, G. M. Cervical dilatation by Lamicel-Studies on the mechanism of action, hit. J. Obstet. Gynnecol. 90, 1060-1064 (1983). Johnson, I. R., Macpherson, M. B. A., Welsh, C. C., and Filshie, G. M. A comparison of Lamicel and prostaglandin E, vagina1 gel for cervical ripening before induction of labour, Amer. J. Obstet. Gynecol. M(5), 604407 (1985). Johnson, N., and Moodley, J. Retrieval of intrauterine contraceptive devices with missing tails, using Lamicel, hit. J. Obstet. Gynaecol. 95, 97-100 (1988). Johnson, N. Intracervical tents: Use and mode of action, Obstet. Gynecol. Surv. 44(6), 410-420 (1989).
ONCOLOGY
36,
217-218 (1990)
A New Way to Expose Endocervical Lesions at Colposcopy NICHOLAS JOHNSON,
MRCOG, FRCS, AND ARCHIBALD C. CROMPTON, M.D., FRCS, FRCOG
Department of Obstetrics and Gynecology, St. James’s University Hospital, Beckett Street, Leeds LS9 7TF, England Received
April
14, 1989
cervix with a transcervical tent was offered and ac-
If there are atypical cells on a cytological smear and if the cepted. At a later date she was recolposcoped by an squamo-columnar junction can not be visualized during a colindependent colposcopist, the initial diagnosis was conposcopic examination, then in order to exclude an early invasive firmed, and a 3-mm-diameter Lamicel’ was passed incancer in the nonvisualized area within the endocervix it is mantracervically. Four hours later she was reexamined, the datory to perform a diagnostic cone biopsy. A woman with abLamicel was removed, and the cervix was reassessed. normal cervical cytology and an unsatisfactory colposcopic exCervical softening, dilatation, and effacement had ocamination who refused a cone biopsy was offered Lamicel in an attempt to expose the entire transformation zone. After 4 hr the curred (Fig. 1) and inspection of the entire lesion and sponge was removed and colposcopy repeated. The lesion and the entire transformation zone was now possible to the the squamo-columnar junction was then fully visible and she was satisfaction of both colposcopists. Histological examispared a cone biopsy. 8 IWOACAIIIC seas,IIIC. nation of a biopsy of the lesion confirmed the clinical
INTRODUCTION If a cervical intraepithelial neoplastic (CIN) lesion extends beyond the view of the colposcope then a diagnostic cone biopsy must be recommended. Many patients will be keen to avoid a surgical cone biopsy and we can report a case where a new technique enabled a CIN lesion to be fully visualized. THE CASE A 35year-old asymptomatic nulliparous nurse presented to the colposcopy unit after a routine cervical smear revealed moderately atypical cells. Although she was planning a family in the near future she had relied on barrier contraception for the last 6 years. Prior to this she had used the oral combined contraceptive pill until a series of cluster headaches had forced her to change. General examination was unremarkable and colposcopy was performed in the usual manner. An acetowhite, glycogen-negative area compatible with moderate CIN was visible but despite replacing the Cusco’s specuulum and using endocervical forceps, the inner margins extended high up the cervical canal, beyond the view of the colposcope. As the patient was keen to avoid a diagnostic cone biopsy (she refused) an alternative treatment had to be devised. An attempt to medically dilate and efface her
impression of CIN II which was treated by local ablation. A follow-up cytological examination of a cervical smear was normal. DISCUSSION The proper colposcopic evaluation of a CIN lesion is impossible in 15% of 35year-olds as it is hidden within the endocervical canal. Techniques to visualize such lesions include microhysterocolposcopy and opening the cervix with a radial laser incision but they have not found favor because they require considerable expertise and can be uncomfortable for the patient. Oral estrogen administration has been proposed but unfortunately the dose used produces nausea in one-third of the patients [ 11and would have been unsuitable for our patient. Laser cone biopsy would be an alternative but the effect on subsequent pregnancies is unknown and facilities for this new procedure are limited. In most hospitals a surgical cone biopsy is the only alternative. Lamicel is a synthetic form of laminaria. It is a compressed, dried synthetic sponge and when it is placed in the cervical canal it becomes moist and expands, dilating and effacing the cervix. The moist sponge is extremely soft and exerts a pressure on the cervical wall of only 2 psi (compared to 28 psi for laminaria) [2]. It does not ’ Lamicel is manufactured by Cabot Medical, West, Langhome, PA 19047.
2021 Cabot Boulevard
217
0090-8258/90 $1.50 Copyright 6 1990 by Academic Press, Inc. All rights of reproduction in any form reserved.
218
JOHNSON AND CROMI’TON
FIG. 1. Colpophotograph before and after Lamicel (note the relative position of the 2-week-old biopsy site).
seem to affect the topographical features of the cervix and 4 hr of tent exposure does not effect the histological findings [3]. Previously Lamicel has been used to dilate the pregnant cervix [4] but its use outside pregnancy has also been described [5,6]. In this case Lamicel dilatated and effaced the cervix and allowed inspection of the entire lesion and transformation zone and the patient could be spared a cone biopsy.
2. 3.
4.
5.
REFERENCES 1. Prendiville, W. J., Davies, W. A. R., Davies, J. O., and Shepherd, A. M. Medical dilatation of the non-pregnant cervix: The effect of
6.
ethinyl oestradiol on the visibility of the transformation zone, &it. J. Obstet. Gynaecol. 93, 508-511 (1986). Wheeler, R. G., and Schneider, K. Properties and safety of cervical dilators, Amer. J. Obstet. Gynecol. M(6), 597401 (1983). Nicolaides, K. H., Welsh, C. C., Koullapis, E. N., and Filshie, G. M. Cervical dilatation by Lamicel-Studies on the mechanism of action, hit. J. Obstet. Gynnecol. 90, 1060-1064 (1983). Johnson, I. R., Macpherson, M. B. A., Welsh, C. C., and Filshie, G. M. A comparison of Lamicel and prostaglandin E, vagina1 gel for cervical ripening before induction of labour, Amer. J. Obstet. Gynecol. M(5), 604407 (1985). Johnson, N., and Moodley, J. Retrieval of intrauterine contraceptive devices with missing tails, using Lamicel, hit. J. Obstet. Gynaecol. 95, 97-100 (1988). Johnson, N. Intracervical tents: Use and mode of action, Obstet. Gynecol. Surv. 44(6), 410-420 (1989).
