How can the incidence of negative specimens resulting from large loop excision of the cervical transformation zone (LLETZ) be reduced? An analysis ofnegative LLETZ specimens and development of a predictive model
Rej. Howells et al., How can the incidence of negative specimens resulting from large loop excision of the cervical transformation zone (LLETZ) be reduced? An analysis ofnegative LLETZ specimens and development of a predictive model, BR J OBST G, 107(9), 2000, pp. 1075-1082
Objective To analyse biopsies of large loop excision of the transformation
zone of the cervix; to identify factors associated with negative histology;
and to develop predictive models in order to reduce the number of negative
loop excisions.
Design Retrospective analysis of patient notes and audit database.
Setting Colposcopy clinic of a large district general hospital in North Sta
ffordshire. Population Four hundred and fifty-two women who underwent a lar
ge loop excision of the transformation zone (LLETZ) procedure for suspected
cervical intraepithelial neoplasia.
Methods Women who underwent a LLETZ procedure were placed in two different
groups, one positive for cervical intra epithelial neoplasia and the other
negative for cervical intra epithelial neoplasia. Information was obtained
on a number of clinical and colposcopic variables. Analysis was undertaken
to determine if there were any differences between the two groups. These fa
ctors were then identified and three predictive models generated. Receiver-
operator characteristic curves were used to assess and test these models.
Main outcomes measures To identify factors associated with negative histolo
gy on a LLETZ specimen. To predict how to reduce the number of negative LLE
TZ specimens.
Results Four hundred and fifty-two women underwent a LLETZ procedure, 88 we
re negative (19%) and 364 were positive (81%). In women who were treated at
their first visit, 56/316 (18%) had negative histology. There were signifi
cant associations between negative histology in the LLETZ and negative or l
ow grade cytological atypia, negative colposcopic findings and years of age
> 50 in both bivariate analysis and stepwise logistic regression. In the p
redictive models, the sensitivity ranged between 72% and 80%, the specifici
ty 59%-72%, and the area under the receiver-operator characteristic was 0.7
5-0.77. If we had used the predictor models and managed women with negative
or low grade cervical atypia and negative colposcopy findings conservative
ly, we would have reduced the negative biopsy rate from 19% to 14%, but fiv
e cases of high grade disease and 25 cases of low grade disease would have
been missed. If we had also included women aged > 50 years in this model, t
he negative biopsy rate would have dropped from 19% to 15%, with only one c
ase of high grade disease and 11 cases of low grade disease missed. All the
se women would require continued cytological and colposcopic surveillance.
Importantly, no cases of invasion would have been missed.
Conclusion Using a predictive model can reduce the number of negative LLETZ
specimens, but at the expense of continued cytological and colposcopic sur
veillance and cannot be recommended in normal practice. This raises the que
stion whether current standards for negative histology in LLETZ specimens a
re set unrealistically high.