Adenocarcinoma in situ of the Cervix – is Loop Electrosurgical Excision Procedure an Acceptable Alternative to Cold Knife Cone Biopsy?

European Oncology & Haematology, 2017;13(1):24–7 DOI:


Objective: To compare cone specimen size between loop electrosurgical excision procedure (LEEP) and cold knife cone (CKC), and evaluate the association between specimen size and margin status. Methods/materials: A retrospective review was performed of women with adenocarcinoma in situ (AIS) who underwent CKC or LEEP between 1998 and 2013. Specimen size, including length (distance from the external cervical os to the endocervical margin) and volume were compared between LEEP and CKC, and correlated with margin status. Results: Eighty-five patients underwent a total of 136 procedures, including 91 CKCs (67%) and 45 LEEPs (33%), with 27 removed as a single specimen (one-piece LEEP) and 18 as two specimens with an ectocervical specimen and a deeper endocervical tophat specimen (two-piece LEEP). The two-piece LEEP specimen median length was significantly longer (2.1 cm) versus CKC (1.4 cm, p<0.01) and one-piece LEEP (0.6 cm, p<0.01). Median specimen volume was greater for two-piece LEEP (7.4 cm3) versus CKC (3.4 cm3, p<0.01) and one-piece LEEP (1.6 cm3, p<0.01). A higher rate of positive margins was noted when comparing all LEEP (67.6%) with CKC specimens (34.2%), p<0.01. However, when the LEEP specimens were analysed separately, one-piece LEEPs had a higher rate of positive margins (81.0%) versus CKC (34.2%) (p<0.01), but there were no significant differences between two-piece LEEP (50.0%) and CKC (34.2%), p=0.26. Conclusion: Our results suggest that a two-piece LEEP produces a larger specimen size with similar rates of positive margins compared with CKC. Given the decreased cost and morbidity compared with CKC, a two-piece LEEP should be considered in the management of women with AIS.
Keywords: Cervical adenocarcinoma in situ, AIS, cold knife cone (CKC), loop electrosurgical excision procedure (LEEP)
Disclosure: Mila Pontremoli Salcedo, Anthony Costales, Mark F Munsell, Preetha Ramalingam, Ricardo Dos Reis, Andrea Milbourne, Patrícia El Beitune and Kathleen M Schmeler have nothing to disclose in relation to this article. This research was supported in part by the National Institutes of Health through MD Anderson’s Cancer Center Support Grant CA016672. No funding was received for the publication of this article.
Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit.
Received: November 04, 2016 Accepted February 10, 2017
Correspondence: Kathleen M Schmeler, Department of Gynecologic Oncology and Reproductive Medicine, Unit 1362, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030. E:

Cervical adenocarcinoma in situ (AIS) is recognised as a premalignant glandular condition and is a precursor to invasive cervical adenocarcinoma.1 It usually affects women of childbearing age in which a more conservative approach is preferred.1–3 The incidence of both AIS and adenocarcinoma of the cervix has been increasing, especially among young women.4,5 Cervical conisation, or cone biopsy, can be performed using a scalpel (cold knife cone [CKC]), laser, or electrosurgery (loop electrosurgical excision procedure [LEEP]). For patients with squamous dysplasia (cervical intraepithelial neoplasia [CIN]) there appears to be no difference in outcomes between techniques.6,7 However, it remains unclear if CKC is preferred over LEEP in patients with AIS. Studies have consistently shown that patients with AIS with a positive margin after an excisional procedure of the cervix are at significantly higher risk for residual disease.2,8,9 In addition, several studies have shown that a higher proportion of patients with AIS have negative margins if they undergo CKC versus LEEP.8,10,11 However, it remains unclear if this is due to a larger specimen being obtained when CKC is performed compared with LEEP.

For women who desire future fertility, conservative management with cervical conisation is considered a feasible option.1 However, the treatment can be challenging in women with AIS where the lesions are often located high in the endocervical canal, and may be multifocal. Repeat conisations are often required until negative margins are obtained.2 In addition, an unnecessarily large specimen is sometimes removed in an attempt to be certain of obtaining negative margins. These large and repeat cervical conisations are known to be associated with adverse obstetrical outcomes, including preterm delivery and low birth weight infants.12–14 It remains unclear if CKC should be performed over LEEP in patients with AIS in order to obtain negative margins. Furthermore, to date, there are limited data comparing specimen size between LEEP and CKC, and the correlation between specimen size and positive margins is largely unknown. The purpose of this study was to compare cone specimen size obtained using LEEP compared with CKC in patients with AIS. In addition, we sought to determine if there was any association between cone size and positive margins.

Materials and methods
We performed a retrospective cohort study at The University of Texas MD Anderson Cancer Center, of all women diagnosed with cervical AIS between 1998 and 2013. Institutional Review Board approval was obtained with a waiver of informed consent. Patients were identified using computerised databases from the Departments of Gynecologic Oncology and Pathology and were included if they had a diagnosis of AIS on cervical biopsy, cone specimen and/or hysterectomy and had undergone a CKC or LEEP. Patients with invasive disease and those without documentation of cone specimen size and/or margin status were excluded. All pathology slides were read by a gynecologic pathologist with expertise in cervical cancer and pre-invasive disease. Medical records were reviewed for demographic data, treatment history, pathologic findings, including the dimensions of the cone specimens and margin status, as well as outcomes. A positive margin was defined as AIS within 1 mm of the surgical margin. The follow-up period was defined as the time between initial AIS diagnosis and the date of last contact.

Descriptive statistics were used to summarise patient demographic and clinical characteristics. Specimen size, including length (distance from the external cervical os to the endocervical margin) and volume were compared between LEEP and CKC and correlated with margin status. The Wilcoxon test was used to compare medians between procedure types. Fisher’s exact test was used to compare distributions of categorical variables between procedure type, excluding “unknown” categories. Study data were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at MD Anderson.15

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Keywords: Cervical adenocarcinoma in situ, AIS, cold knife cone (CKC), loop electrosurgical excision procedure (LEEP)