eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Gynecologic Cryosurgery: Follow-up

Author: E L Kristiina Parviainen, MD, Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh
Coauthor(s): Nancy D Gaba, MD, Residency Program Director, Assistant Professor, Department of Obstetrics and Gynecology, George Washington University School of Medicine
Contributor Information and Disclosures

Updated: May 12, 2008

Outcome and Prognosis

Cryosurgery can be an effective treatment for premalignant squamous lesions of the uterine cervix. Recurrence rates are low and depend, in part, on the size and grade of the lesion, as well as its location (ectocervix versus endocervix). Boonstra and colleagues examined hysterectomy specimens of women who received cryosurgery for CIN prior to hysterectomy. They reported that a success rate as high as 100% could be achieved using a large conical probe and an adequate freeze time based on the 64 patients they studied.23

Technical aspects that impact results include the method utilized, freeze and thaw time, size and extent of the ice ball that is formed, probe size and shape, and the refrigerant temperature.

Although many authors have investigated overall success rates, few have conducted large-scale prospective studies. Benedet and others reported on 1675 women with varying degrees of CIN and demonstrated an overall success rate of 94%.38 Further work by this same group in 1990 demonstrated an 88% success rate in 962 women in a higher-risk group in which more than half of the patients had severe dysplasia or CIS. Gordon and Duncan presented data from 1628 patients with severe dysplasia and found an initial 93% success rate. This study followed patients' cases for as long as 6 years after the procedure, and, in this group, the long-term success rate was 91%.39

Assessment of the subset of patients with severe dysplasia (CIN 3) treated with cryosurgery has yielded disparate results from different authors, with failure rate ranges of 7.1-38.8%. Bryson reported an 11-year study of patients with biopsy-proven severe dysplasia or CIS and found a 7.1% failure rate.40 Townsend and Ostergard followed the cases of 62 patients with severe dysplasia or CIS and found an 11.8% failure rate for those with severe dysplasia and 10% for those with CIS.4 In a follow-up study, Ostergard reported a 7.1% failure rate in 28 patients with severe dysplasia and an alarming 38.8% failure rate in 18 patients with the diagnosis of CIS.41 Failure rates for cryosurgical treatment have been reported to be consistently higher in patients with severe dysplasia and CIS than in patients with mild or moderate dysplasia.

Numerous investigators have compared the efficacy of cryosurgery and laser vaporization in the treatment of CIN. The 2 methods appear to be equally efficacious. Proponents of laser therapy stress the capacity to achieve precise destruction, and thereby more complete destruction, of the lesion by this method. Recurrence and persistence rates reported in the literature do not support this assertion. Laser equipment also is significantly more expensive than the cryoprobe apparatus, and patients report more pain during the laser vaporization. No proven benefit of laser therapy over cryosurgery exists.

A study comparing cryosurgery, laser vaporization, and LEEP concluded that no difference exists in success rates or complication rates. However, persistence was reported to be greater in patients with larger lesions, patients with history of prior treatment, older women (>30 y), and those with HPV 16 or 18.42,43

These and other earlier studies, along with the 2001 Consensus Guidelines, support the use of cryosurgery as an acceptable method for the treatment of CIN 1 and CIN 2/CIN 3 provided that the criteria listed above have been met, and that appropriate follow-up is conducted.

A recently published cost-effectiveness model on management of CIN 2/CIN 3 found cryotherapy LEEP and hysterectomy to be superior to observation, laser therapy, and cold knife cone.44 LEEP was more effective than cryotherapy but also more expensive at a cost of $31,347 per CIN cure and $1.8 million per cancer prevented. Hysterectomy was most effective and most expensive. Cryotherapy should continue to have a role in the treatment of cervical intraepithelial dysplasia, with increasing focus on resource utilization in our health care system.

Future and Controversies

Despite the 85-95% success rate reported in most series, practitioners continue to be concerned about the potential for persistent disease and missed diagnosis of invasive carcinoma. Several investigators have reported a disparity between colposcopic biopsies and cone biopsy specimens.45 For this reason, LEEP, which provides tissue for pathologic diagnosis, has replaced cryosurgery in many cases in the ambulatory setting.

Several topical agents, including imiquimod, are currently being evaluated for efficacy in treatment of CIN. Future studies will no doubt determine their role in clinical practice.

Increasingly, physicians also are offering expectant management for patients with CIN 1 lesions and reserving therapy for CIN 2/CIN 3. Remember that eliminating HPV from the genital tract is not possible, and, therefore, women with a history of CIN remain at risk for recurrence.

Given the recent availability of the HPV vaccine, the prevalence and management of CIN may be dramatically altered in the decades to come.

 


More on Gynecologic Cryosurgery

Overview: Gynecologic Cryosurgery
Workup: Gynecologic Cryosurgery
Treatment: Gynecologic Cryosurgery
Follow-up: Gynecologic Cryosurgery
References
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Further Reading

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Keywords

gynecologic cryosurgery, cryotherapy, cryocautery, gynecologic surgery, gynecological surgery, gynecologic cryotherapy, cervical intraepithelial neoplasia, CIN, Papanicolaou test, Pap test, Papanicolaou smear, Pap smear

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Contributor Information and Disclosures

Author

E L Kristiina Parviainen, MD, Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Pittsburgh
E L Kristiina Parviainen, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Nancy D Gaba, MD, Residency Program Director, Assistant Professor, Department of Obstetrics and Gynecology, George Washington University School of Medicine
Nancy D Gaba, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, and Medical Society of the District of Columbia
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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