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    Is scalpel or laser better for cold knife cone biopsy?

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Posted on Fri, 3 Jun 2016 in Cervical and Ovarian Cancer
Question: I have been diagnosed with HPV high risk and also with C1N1 cervical dysplasia - XXXXXXX 2015 my PAP was normal - XXXXXXX 2016 the results showed abnormal cells with high risk HPV - my doctor recommends a cold knife cone biopsy (either laser or scalpel - but prefers scalpel) and a D&C (both done at the same time with general anesthesia) - I have a mitral valve prolapse and I am frightened of general because of my heart - I am also aware that there is another approach to further detection called L.E.E.P. (which my doctor does not want to do) - QUESTION - what is the least invasive procedure that I should do at this juncture to protect myself against cervical cancer and to avoid general anesthesia - I am 49 years old, married with three young adult children - thank you
My doctor is a gyn oncologist - I have not talked to an anesthesiologist - is it possible or feasible to perform this kind of surgery with a regional such as spinal block or epidural? Or is twilight sufficient? Is L.E.E.P with cervical block recommended for CIN1 dysplasia?

Also, in general anesthesia, what combination of drugs are used and is the dosage commensurate with the time it takes to perform the surgery?

What are the statistics? In other words, probability of my having cancer with CIN1? As mentioned earlier, my XXXXXXX 2015 PAP was normal.

What is the best choice for cold knife cone biopsy - scalpel or laser? and why?

From my HPV testing, the risky strains of 16 and 18 were not detected - are there other high-rise strains that i should be concerned about?

With the combination of HPV high risk and CIN1 dysplasia, what is the prognosis of developing cervical or uterine cancer. Could all this go away in time or will it definitely advance to the next stage of dysplasia or cancer.

What are the treatment options for CIN1? At what point, is a hysterectomy recommended? Can Robotics detect cervical or uterine cancer?

Besides vaginal, anal, or oral sex, I have read that HPV can be transmitted skin to skin - please explain how this can happen.
My doctor is a gyn oncologist - I have not talked to an anesthesiologist - is it possible or feasible to perform this kind of surgery with a regional such as spinal block or epidural? Or is twilight sufficient? Is L.E.E.P with cervical block recommended for CIN1 dysplasia?

Also, in general anesthesia, what combination of drugs are used and is the dosage commensurate with the time it takes to perform the surgery?

What are the statistics? In other words, probability of my having cancer with CIN1? As mentioned earlier, my XXXXXXX 2015 PAP was normal.

What is the best choice for cold knife cone biopsy - scalpel or laser? and why?

From my HPV testing, the risky strains of 16 and 18 were not detected - are there other high-rise strains that i should be concerned about?

With the combination of HPV high risk and CIN1 dysplasia, what is the prognosis of developing cervical or uterine cancer. Could all this go away in time or will it definitely advance to the next stage of dysplasia or cancer.

What are the treatment options for CIN1? At what point, is a hysterectomy recommended? Can Robotics detect cervical or uterine cancer?

Besides vaginal, anal, or oral sex, I have read that HPV can be transmitted skin to skin - please explain how this can happen.

doctor
Answered by Dr. Jacqueline Brown 7 hours later
Brief Answer:
You do not need to have a cold knife cone biopsy for CIN1 nor a D and C

Detailed Answer:
Hello, and i hope I can help you today. You have quite a few detailed questions, but some of them might not be so relevant after answer and explanation.

As a board certified OBS & GYN generalist who works in a university-affiliated medical center, I have managed many patients with abnormal PAP smears and I follow the guidelines put out by the ASCCP (the XXXXXXX Society for Colposcopy and Cervical Pathology), which is what ACOG (American College of OBGYN) recognizes as the standard of care for the U.S. They have algorithms that summarize the recommendations for management of both abnormal PAP smears and dysplasia found on the cervix. They are written in medical language, but I think it would be helpful for you to review them.

Here is the link to the ASCCP webpage and guidelines: http://www.asccp.org/Portals/9/docs/ASCCP%20Management%20Guidelines_August%202014.pdf

The bottom line is- if this is your first abnormal PAP smear, and you have been getting PAP smears at least every three years until now that have been normal, and your biopsy only showed CIN1, you actually do not need any treatment at all.

I know this may be hard to believe given the level of concern of your oncologist, but once i explain the biology of HPV, and you read the ASCCP guidelines, it may make more sense to you.

HPV is a risk factor for cervical cancer, not a disease in itself. There are hundreds of HPV types in humans- from the kinds that cause warts (on the hands and feet or elsewhere on the body) to the kinds that only infect the reproductive tract. It is true that HPV can be spread from skin-to-skin contact, even in the genitals, as i have seen virgins with HPV as well as women who have only had female partners. So some type of genital skin-to-skin contact is required for HPV infection to occur.

Genital warts are generally associated with non-cancer causing HPV types, however cervical HPV does not usually cause warts, but rather mutates the cells of the cervix to grow abnormally, which is what causes dysplasia.

HPV types 16 and 18 are the most aggressive types associated with cervical cancer. There are other types that can cause cancer, so a negative 16/18 test does not rule out a cancer causing strain... But generally, a negative test for 16/18 basically rules out any immediate danger of cervical cancer. Dysplasia is graded based on the percentage of abnormal cells in the cervical biopsy. CIN1 means that less than half the basal skin cells of the cervix are abnormal. CIN2 means more than half and CIN3 is full-thickness abnormal cells that are not yet invasive cancer.

CIN3 has a risk of turning into cervical cancer if left untreated within 7-10 years of diagnosis. CIN1 is NOT considered a precancerous condition, and treatment of CIN1, unless it is persistent for at least one year, is NOT recommended.

Most HPV infections, as long as they do not cause severe dysplasia (HGSIL or CIN3) go away by themselves within 1-2 years. So the recommended management of CIN1 is just to repeat a PAP and HPV test in one year.

Furthermore, unless you had post-menopausal bleeding or abnormal UTERINE calls detected on a biopsy, there is no need to have a D and C either.

The only reason that your oncologist may have recommended the cone biopsy is if your abnormal cells on your biopsy were located only in the canal of your cervix, which is assessed during a colposcopy by a scraping called an ECC. The cervical canal cannot be seen from the outside, and if there is CIN1 deep in your cervix, there can be a concern that some areas that may not have been detected in the scraping may have CIN 2-3 that cannot be assessed easily.

If that is the case, it is recommended that you have an excision procedure to remove the cells of the canal of the cervix. This is most commonly performed by a LEEP procedure, which uses an electric instrument to remove tissue from the cervix. It is done under local anesthesia in a doctors' office, so it does not convey any risks associated with general anesthesia.

There is no role for hysterectomy for CIN1, no matter what type. Robotic surgery is no better than conventional surgery for treatment of dysplasia, but it can be more effective for radical hysterectomies that are used to treat invasive cervical cancer, which you DO NOT have.

I know this is a lot of information and that you may have more questions about what I just told you. I suggest you read the ASCCP guidelines and if you look at their website asccp.org, there are patient information

Now, I know this is radically different from what your oncologist said, and i would be happy to discuss this further, however I sincerely recommend you seek a second opinion from a non-oncologist, because I think you are being treated much too aggressively. You could be treated by a LEEP procedure in a doctors' office, and if your oncologist does not offer that, you may want to look at other options.

I hope that I was able to answer most of your queries and I would be happy to discuss this further if you want to contact me again.

Best wishes,

Dr. Brown


Above answer was peer-reviewed by : Dr. Arnab Banerjee
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Answered by
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Dr. Jacqueline Brown

OBGYN

Practicing since :1996

Answered : 1425 Questions

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