Frozen Section Evaluation of CIN3 in Cervical Cone Biopsy
Frozen Section Evaluation of CIN3 in Cervical Cone Biopsy
We retrospectively selected 22 cases in which patients with a biopsy-proven diagnosis of cervical intraepithelial neoplasia grade 3 underwent cervical conization for frozen section (FS) evaluation followed by hysterectomy at the University of California Irvine Medical Center, Orange, during the August 1995 to September 9, 2001. All slides from FS and permanent section (PS) and hysterectomy specimens were reviewed. FS diagnoses were compared with those of previous biopsies, PS, and hysterectomy specimens. The PS correlated with FS in all cases but 1. Appropriate surgery was performed for all patients based on FS diagnosis. The McNemar test was used to compare the results of FS and PS, with a 2-sided P value of 1.0 and a κ coefficient of 0.7755 with a 95% confidence level, indicating that the 2 groups were not significantly different. FS evaluation of cervical conization is as efficacious and accurate as evaluation of regular specimens in providing information for the appropriateness of same-day surgery. We recommend that entire tissue be submitted for FS to avoid sampling errors and to increase diagnostic accuracy.
In patients with grade 3 cervical intraepithelial neoplasia (CIN), it is important to use cone biopsy to evaluate the presence or absence of invasive carcinoma before performing a hysterectomy as the definitive treatment of this disease. This can be achieved in 24 to 48 hours after a diagnostic cone biopsy for interpretation on formalin-fixed tissue sections or after a delay of 6 weeks to allow the biopsy site to heal before a hysterectomy procedure. The advantage of this method is that the evaluation of invasion in formalin-fixed, paraffin-embedded sections is accurate and void of artifact. The disadvantage is that one must wait at least 24 hours for the diagnosis, during which the cervix becomes edematous, making subsequent surgery technically difficult. There also is an increased risk of infection when the hysterectomy is performed 24 to 48 hours after the conization. In addition, patients are subjected not only to increased costs related to additional anesthesia and 2 surgical procedures but also the increased level of anxiety while waiting for the results.
The application of frozen section evaluation of the cone biopsy specimen before hysterectomy is performed on the same day while the patient is still anesthetized will overcome these disadvantages, and this has been reported previously ( Table 1 ). However, this technique has not gained widespread acceptance by pathologists and gynecologists. The rationale is that the evaluation of a sufficient section of the entire cervix prolongs the operative time, and, more important, it is believed that freezing artifact and sampling error prevent accurate evaluation of the extent of the disease.
In the present managed care environment in the United States, it is important to readdress the issue of same-day hysterectomy procedures guided by frozen section evaluation of cone biopsy specimens to decrease significantly the cost and patient anxiety and to gain the advantages associated with this technique. The aims of the present study were to review the literature and to report our institutional experience during the past few years related to the usefulness of frozen sections of cervical cone biopsy specimens in the management of same-day hysterectomy procedures for patients with CIN 3 compared with the usefulness of nonfrozen cone biopsy specimens.
We retrospectively selected 22 cases in which patients with a biopsy-proven diagnosis of cervical intraepithelial neoplasia grade 3 underwent cervical conization for frozen section (FS) evaluation followed by hysterectomy at the University of California Irvine Medical Center, Orange, during the August 1995 to September 9, 2001. All slides from FS and permanent section (PS) and hysterectomy specimens were reviewed. FS diagnoses were compared with those of previous biopsies, PS, and hysterectomy specimens. The PS correlated with FS in all cases but 1. Appropriate surgery was performed for all patients based on FS diagnosis. The McNemar test was used to compare the results of FS and PS, with a 2-sided P value of 1.0 and a κ coefficient of 0.7755 with a 95% confidence level, indicating that the 2 groups were not significantly different. FS evaluation of cervical conization is as efficacious and accurate as evaluation of regular specimens in providing information for the appropriateness of same-day surgery. We recommend that entire tissue be submitted for FS to avoid sampling errors and to increase diagnostic accuracy.
In patients with grade 3 cervical intraepithelial neoplasia (CIN), it is important to use cone biopsy to evaluate the presence or absence of invasive carcinoma before performing a hysterectomy as the definitive treatment of this disease. This can be achieved in 24 to 48 hours after a diagnostic cone biopsy for interpretation on formalin-fixed tissue sections or after a delay of 6 weeks to allow the biopsy site to heal before a hysterectomy procedure. The advantage of this method is that the evaluation of invasion in formalin-fixed, paraffin-embedded sections is accurate and void of artifact. The disadvantage is that one must wait at least 24 hours for the diagnosis, during which the cervix becomes edematous, making subsequent surgery technically difficult. There also is an increased risk of infection when the hysterectomy is performed 24 to 48 hours after the conization. In addition, patients are subjected not only to increased costs related to additional anesthesia and 2 surgical procedures but also the increased level of anxiety while waiting for the results.
The application of frozen section evaluation of the cone biopsy specimen before hysterectomy is performed on the same day while the patient is still anesthetized will overcome these disadvantages, and this has been reported previously ( Table 1 ). However, this technique has not gained widespread acceptance by pathologists and gynecologists. The rationale is that the evaluation of a sufficient section of the entire cervix prolongs the operative time, and, more important, it is believed that freezing artifact and sampling error prevent accurate evaluation of the extent of the disease.
In the present managed care environment in the United States, it is important to readdress the issue of same-day hysterectomy procedures guided by frozen section evaluation of cone biopsy specimens to decrease significantly the cost and patient anxiety and to gain the advantages associated with this technique. The aims of the present study were to review the literature and to report our institutional experience during the past few years related to the usefulness of frozen sections of cervical cone biopsy specimens in the management of same-day hysterectomy procedures for patients with CIN 3 compared with the usefulness of nonfrozen cone biopsy specimens.
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