eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Carbon Dioxide Laser Surgery for Cervical Dysplasia: Follow-up

Author: Janice L Bacon, MD, Professor and Chair, Department of Obstetrics and Gynecology, University of South Carolina School of Medicine
Contributor Information and Disclosures

Updated: Dec 5, 2007

Outcome and Prognosis

Disease eradication and recurrence rates following carbon dioxide laser therapy are often compared with those following cold-knife conization procedures or LEEPs. Outcomes are compared with the assumption that similar preprocedural evaluations (eg, Papanicolaou test, colposcopy, biopsies) have been performed.

Carbon dioxide laser procedures eradicate CIN in up to 90% of cases.19 However, because of the physiology of the HPV, an operative procedure results in a reduced viral load and the excision of overtly diseased tissue, but it does not completely eradicate the virus from the host. Complete eradication is a function of the patient's immune system.

A randomized trial of cryotherapy, carbon dioxide laser vaporization, and a LEEP for CIN reveals relatively equal rates of disease persistence and recurrence after each of the modalities, with follow-up periods from 6-37 months. Recurrences are more likely to occur in older women (aged 30 y or older), women with HPV type 16, and women with prior dysplasia. Persistent disease was more common in women with larger lesions, a factor that, in other studies, has been shown to be better managed by carbon dioxide laser procedures than other modalities.12

Several investigators have found that the results of carbon dioxide laser procedures are similar to those of cold-knife conization procedures or LEEPs for the recurrence of neoplasia. Many recurrences are associated with positive ectocervical or endocervical margins.15

Women infected with HIV have a higher prevalence of CIN than those who are not infected. This is presumably related to coexistent HPV infection and immune function in these patients. Current care recommendations include more frequent surveillance of cervical cytology and more aggressive management using colposcopy, biopsy, and treatment of CIN.

Dysplasia has been noted to recur more often in HIV-positive patients, despite a variety of dysplasia treatment modalities, including carbon dioxide laser procedures. Evaluation of patients with recurrent disease may reveal decreased CD4 counts and increased viral loads.20 One study cited a relative risk for recurrence of 17.517 after standard therapy with negative margins.21 This high risk has resulted in recommendations for excisional therapy rather than ablation22,23 , although excision also carries a higher risk for recurrent disease in the presence of compromised immune status. Even after hysterectomy, HPV infection and neoplasia development are still possible.21

On a more positive note, in immunologically intact women, appropriate dysplasias treated with carbon dioxide laser procedures may result in complete eradication of the HPV genome. In a study by Kjellberg et al, cervical dysplasias ranging from mild to severe were evaluated and documented based on colposcopy and/or biopsy results, and the patients were treated with carbon dioxide laser conization. The presence of HPV in the removed specimen was documented by HPV testing and was positive in 73.2% of patients before excision. At follow-up, only 3 women were positive for HPV, but no women had the same HPV type at 2 follow-up visits over 22-46 months. Only 2 postoperative samples had squamous cell atypia.24

Future and Controversies

The 2001 Bethesda Workshop reaffirmed ASCUS as the designation for squamous atypias that cannot be readily designated as benign or preinvasive. The only subcategory of ASCUS is now ASCUS favoring high-grade SIL. All other prior subsets are now combined under ASCUS, and reflex HPV testing is recommended when the lesion is deemed present after cytologic interpretation. HPV-negative ASCUS is a high-grade SIL or worse in fewer than 1% of cases.25 The results of colposcopy and those of HPV typing have equivalent sensitivity, and both help detect cervical dysplasia that requires treatment, including carbon dioxide laser procedures.

The appropriate long-term follow-up protocol for women with high-risk HPV types and those with unclassified HPV types remains unknown. The most reasonable course of long-term follow-up is not yet determined.

 


More on Carbon Dioxide Laser Surgery for Cervical Dysplasia

Overview: Carbon Dioxide Laser Surgery for Cervical Dysplasia
Workup: Carbon Dioxide Laser Surgery for Cervical Dysplasia
Treatment: Carbon Dioxide Laser Surgery for Cervical Dysplasia
Follow-up: Carbon Dioxide Laser Surgery for Cervical Dysplasia
References
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References

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Further Reading

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Keywords

CO2 laser surgery, laser surgery, cervical intraepithelial neoplasia, CIN, human papilloma virus, HPV, squamous cervical abnormality, squamous carcinoma, squamous cell cancer, squamous intraepithelial lesion, SIL, cervical neoplasia, cervical cancer, cervical malignancy, atypical squamous cells of undetermined significance, ASCUS, cervical atypia, squamous atypias

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Contributor Information and Disclosures

Author

Janice L Bacon, MD, Professor and Chair, Department of Obstetrics and Gynecology, University of South Carolina School of Medicine
Janice L Bacon, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Association of Reproductive Health Professionals, North American Society for Pediatric and Adolescent Gynecology, and South Carolina Medical Association
Disclosure: Organon Pharmaceuticals Honoraria Speaking and teaching; Merck & Company Honoraria Speaking and teaching

Medical Editor

Karen Loeb Lifford, MD, Director of General Gynecology, Associate Program Director, Department of Obstetrics and Gynecology, Instructor, Brigham and Women's Hospital, Harvard Medical School
Karen Loeb Lifford, MD is a member of the following medical societies: Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
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

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals OB/GYN Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

 
 
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