Atlas of Colposcopy: Principles and Practice

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Treatment by cold-knife conization – Principles  

Cold-knife conization (CKC) is an excisional method of treating high-grade CIN, adenocarcinoma in situ, and microinvasive cancer, in which a cone-shaped portion of the cervix is removed using a scalpel. The width and length of the cone will depend on the extent and the severity of the disease. The removed cone must include the entire transformation zone, the diseased epithelium, and adequate lesion free margin. The major advantages of CKC are that the specimen can be removed in a single piece and the margins are free of any thermal damage. Pathologists can better evaluate the specimen for disease severity and margin status. The procedure is more complicated than LLETZ and needs highly skilled providers, requires regional/general anaesthesia and hospitalization, and has higher complication rates.

Indications for cold-knife conization
  • Glandular lesions suspected on cytology and/or detected on histology
  • Evidence of microinvasive carcinoma
  • High-grade squamous lesions in which the upper limit of the lesion is not visible
  • Disparity between diagnostic modalities
  • Treating high-grade lesions not suitable for ablation in settings where LLETZ facilities are not available
  • A positive HPV DNA test and glandular lesion suspected on cytology and/or detected on histology
Obtaining a cone biopsy for the first four indications is also known as a diagnostic excisional procedure..

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