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    Cervix excisions including LLETZ and cone biopsies

    Background

    Cervical excisions are utilised for the diagnosis and treatment of premalignant lesions and in some cases with limited invasion. Cervical excisions include cone biopsies and electrosurgical procedures (LLETZ and LEEP biopsies).

    Cold-knife cone biopsy is a cervical excision specimen performed using a surgical blade without electrocautery, and is performed in an operating theatre with general anaesthesia. Cold-knife cone biopsies have the highest rates of single specimens and type 3 excisions, and there is no thermal damage. Cold–knife cone biopsies have been used in the treatment of invasive disease and suspected or known glandular disease. Disadvantages of the procedure include higher rates of primary haemorrhage and pre-term labour compared to other excisional procedures.1,2,3-6

    Electrosurgical procedures such as LEEP/LLETZ or straight wire, are used for the diagnosis and treatment of predominantly squamous intraepithelial neoplasia,7 and are used as a type 2/3 excision for adenocarcinoma in situ in some units.8 They are the most commonly used therapy for HSIL in resource-rich countries.

    These specimens may show variable degrees of specimen fragmentation and thermal artefact which appear to be related to technique.9-14

    Laser Cone Biopsy was originally introduced to obtain a histologically assessable specimen, following concern that laser ablation on its own might result in the under-diagnosis of invasive disease.

    However, laser cone biopsies result in thermal artefact and they are now an uncommon specimen. The duration of the laser cone procedure is longer than LLETZ/LEEP and is considered to require greater expertise.7

    Please refer to the NCSP guidelines15 for further information on cervical excision procedures and clinical guidelines. See also Appendix 7 of the Structured Reporting Protocol for Cervix pre-neoplasia16 for further information on excision types 1-3. Another valuable reference is the International Federation for Cervical Pathology and Colposcopy (IFCPC) publication on colposcopic terminology.17

    See separate cut-up protocols for small biopsies and hysterectomy for invasive cervical tumours.


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen, if possible.

    Cold knife cone (conical) excisions are usually orientated, typically with a suture at 12 o’clock. Ideally all cervical excision specimens should be orientated. If not orientated, the specimen is often able to be partially orientated according to the shape of the os, as the parous os is often slit-like in the coronal plane (3 to 9 o’clock).

    Describe the following features of the specimen:

    Procedure

    Record as stated by the clinician

    • Cervical excision type (i.e. type 1 to 3)
    • Cervical excision modality
      • Electrosurgical excision (i.e. LLETZ, LEEP)
      • Cold-knife cone (conical) biopsy
      • Laser cone (conical) biopsy
      • Other, specify
    • Type 1 excision (for Type 1 TZ) - at least 6mm and up to 10mm length of cervical tissue excised*
    • Type 2 excision (for Type 2 TZ) - not more than 15mm length of tissue excised*
    • Type 3 excision (for Type 3 TZ) - equivalent to ‘cone biopsy’ and >15mm length*

    *Length of canal excised.

    See Appendix 7 of the Structured Reporting Protocol for Cervical pre-neoplasia,16 for more information on Cervical excision types.

    See also separate cut-up protocol for invasive tumours of cervix.

    Specimen description

    Specimen integrity

    • Intact
    • Disrupted -note the presence of significant macroscopic artefact or significant irregularity/distortion.

    Specimen measurement

    Measure the anatomical components present.

    Dimensions (mm)

    • ​Ectocervical area
      • 12-6 o'clock
      • 3-9 o'clock
    • Length of cervical canal (from external os to apex)
    • Length of specimen

    Dimensions (mm)

    • Ectocervical area in two dimensions
    • Length of cervical canal (from external os to apex)
    • Length of specimen

    Where it is not possible to measure the canal and ectocervix diameters

    • Measure the specimen in three dimensions

    Macroscopically visible lesions

    • Absent
    • Present
      • Record the number and maximum dimension of any lesions

    Refer to the cut-up protocol for Invasive cervical cancer and Structured Reporting Protocol for Cervix pre-neoplasia if applicable.


    Dissection

    In orientated specimens, differentially paint the anterior and posterior stromal margins with ink and record the colours applied.

    As illustrated, section the specimen at 3mm serial intervals in the sagittal plane (12 to 3 o'clock) sequentially from left to right (9 to 3 o’clock).18,19 See illustrations for orientated conical excisions.

    A range of other specimens such as LLETZ and profiled electrosurgical specimens may be received.

    Specimens are usually taken in one-pass but occasionally a multi-pass excision specimen may be received. Where the ectocervix and endocervix can be identified, section along this plane to include the transformation zone. Alternatively, sequentially section in 3mm intervals transversely along the longitudinal axis of the mucosal surface. See illustrations provided for unorientated non-conical excisions.

    Profiled electrosurgical excision instruments (e.g. Fischer cone) may be used in some institutions. Due to the nature of the instrument, the specimen is received with a full length incision along one side. It may be more appropriate to section these specimens in a similar fashion to non-conical excision specimens.

    Mucosa can be fragile, particularly where lesion is present, so care must be taken when handling cervical tissue.


    Internal Inspection

    Not required.


    Processing

    Submit all sections of the specimen.

    For cone biopsies and orientated LLETZ and LEEP specimens, submit sections for processing in sequential order, ideally with each piece in an individual cassette.17 Turn each piece the same way so that opposing faces of consecutive slices are embedded to ensure examination of the specimen at equal intervals. One method recommends marking the top surface (opposite to the surface to be examined) with a dot of ink so it can be identified at embedding.18 Optimally, the end pieces are thin slices placed cut surface down to allow for subsequent deeper sectioning if required for assessment of these ectocervical and stromal margins.

    In the rare event that the length of the cone biopsy exceeds that of the cassette, submit composite blocks of superior and inferior sections to demonstrate the whole length of the specimen.

    See illustrations provided for orientated specimens.

    For specimens where margins cannot be assessed (multiple piece LEEP or LLETZ with no orientation), multiple sections can be submitted in the same cassette. Many LLETZ specimens may not have specific marking sutures but are able to be partially orientated (see external inspection) thus allowing margin assessment. It is suggested that the ‘end pieces’ be thin slices, be separately identifiable and placed cut surface down to allow subsequent deeper sectioning if required for assessment of these ectocervical and stromal margins.

    See illustrations provided for unorientated specimens.

    Record details of each cassette.

    An block key similar to those provided may be useful.

    See also the illustrations provided.

    Block allocation key

    Cassette id
    Site
    No. of pieces
    A
    Cervix, 9 o’clock
     
    B-D
    Cervix, sequential sections from 9 o’clock towards centre
     
    E
    Cervix, 3 o’clock, cut surface down
     
    Cassette id
    Site
    No. of pieces
    A
    Cervix, end pieces cut surface down
     
    B-F
    Cervix, remaining sequential sections
     
     

    Acknowlegements

    Drs Kerryn Ireland-Jenkin and Marsali Newman for their contribution in reviewing and editing this protocol.


    References

    1. Kristensen J, Langhoff-Roos J and Kristensen FB. Increased risk of preterm birth in women with cervical conization. Obstet Gynecol 1993;81(6):1005-1008.
    2. Sadler L, Saftlas A, Wang W, Exeter M, Whittaker J and McCowan L. Treatment for cervical intraepithelial neoplasia and risk of preterm delivery. JAMA 2004;291(17):2100-2106.
    3. Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W and Paraskevaidis E. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet 2006;367(9509):489-498.

    4. Arbyn M, Kyrgiou M, Simoens C, Raifu AO, Koliopoulos G, Martin-Hirsch P, Prendiville W and Paraskevaidis E. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ 2008;337:a1284.

    5. Mathevet P, Dargent D, Roy M and Beau G. A randomized prospective study comparing three techniques of conization: cold knife, laser, and LEEP. Gynecol Oncol 1994;54(2):175-179.

    6. Giacalone PL, Laffargue F, Aligier N, Roger P, Combecal J and Daures JP. Randomized study comparing two techniques of conization: cold knife versus loop excision. Gynecol Oncol 1999;75(3):356-360.

    7. Cancer Council Australia. National Cervical Screening Program: Guidelines for the Management of Screen-Detected Abnormalities, Screening in Specific Populations and Investigation of Abnormal Vaginal Bleeding. 2016

    8. Munro A, Leung Y, Spilsbury K, Stewart CJ, Semmens J, Codde J, Williams V, O'Leary P, Steel N and Cohen P. Comparison of cold knife cone biopsy and loop electrosurgical excision procedure in the management of cervical adenocarcinoma in situ: What is the gold standard? Gynecol Oncol 2015;137(2):258-263.

    9. Dalrymple C and Russell P. Thermal artefact after diathermy loop excision and laser excision cone biopsy. Int J Gynecol Cancer 1999;9(3):238-242

    10. Jakus S, Edmonds P, Dunton C and King SA. Margin status and excision of cervical intraepithelial neoplasia: a review. Obstet Gynecol Surv 2000;55(8):520-527.

    11. Ioffe OB, Brooks SE, De Rezende RB and Silverberg SG. Artifact in cervical LLETZ specimens: correlation with follow-up. Int J Gynecol Pathol 1999;18(2):115-121.

    12. Messing MJ, Otken L, King LA and Gallup DG. Large loop excision of the transformation zone (LLETZ): a pathologic evaluation. Gynecol Oncol 1994;52(2):207-211.

    13. Garcia Ramos AM, Garcia Ramos ES, Dos Reis HL and de Rezende RB. Quality evaluation of cone biopsy specimens obtained by large loop excision of the transformation zone. J Clin Med Res 7(4):220-224.

    14. Nagar HA, Dobbs SP, McClelland HR, Price JH, McClean G and McCluggage WG. The large loop excision of the transformation zone cut or blend thermal artefact study: a randomized controlled trial. Int J Gynecol Cancer 2004;14(6):1108-1111.

    15. Clinical guidelines and resources, National Cervical Screening Program: Austalian Government, Dept. of Health [Accessed 3 Mar 2017].

    16. Ireland-Jenkin K and Newman M. Structured Reporting Protocol for Excisions and Colposcopic Biospies Performed for the Diagnosis and Treatment of Pre-invasive Cervical Neoplasia, Royal College of Pathologists Australasia, Surry Hills, NSW, 2017.
    17.  Bornstein J, Bentley J, Bosze P, Girardi F, Haefner H, Menton M, et al. 2011 colposcopic terminology of the International Federation for Cervical Pathology and Colposcopy. Obstet Gynecol. 2012;120(1):166-72.
    18. Hirschowitz L, Ganesan R, Singh N and McCluggage WG. Dataset for histological reporting of cervical neoplasia, The Royal College of Pathologists, London, 2011.
    19. Heatley MK. Dissection and reporting of the organs of the female genital tract. J Clin Pathol 2008;61(3):241-257.

    Jump To

      Cone bx 1

      Cervix -orientated conical excision

      Cone bx 2

      Cervix -orientated conical excision, stromal aspect

      Cone bx 3

      Cervix -orientated conical excision, block allocation

      Cervix excision 1

      Cervix -unorientated non-conical excision

      Cervix excision 2

      Cervix -unorientated non-conical excision, sectioned transversely along the longitudinal axis

      Cervix excision 3

      Cervix -unorientated non-conical excision, with end pieces in a separate cassette for processing

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      25-Mar-2019
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