Comparison of two surgical methods for the treatment of CIN: classical LLETZ (large-loop excision of the transformation zone) versus isolated resection of the colposcopic apparent lesion - study protocol for a randomized controlled trial

Abstract

Background: In compliance with national and international guidelines, non-pregnant women with cervical intraepithelial neoplasia grade 3 should be treated by cervical conization. According to the definition of the large loop excision of the transformation zone (LLETZ) operation, the lesion needs to be resected, including the transformation zone. It is well known from the literature that the cone size directly correlates with the risk of preterm delivery in the course of a future pregnancy. Thus, it would be highly desirable to keep the cone dimension as small as possible while maintaining the same level of oncological safety.

Methods/design: The aim of this study is to analyze whether resection of the lesion only, without additional excision of the transformation zone, is equally as effective as the classical LLETZ operation regarding oncological outcome. We are performing this prospective, patient-blinded multicenter trial by randomly assigning women who need to undergo a LLETZ operation for cervical intraepithelial neoplasia grade 3 to either of the following two groups at a ratio of 1:1: (1) additional resection of the transformation zone or (2) resection of the lesion only. To evaluate equal oncological outcome, we are performing human papillomavirus (HPV) tests 6 and 12 months postoperatively. The study is designed to consider the lesion-only operation as oncologically not inferior if the rate of HPV high-risk test results is not higher than 5 % compared with the HPV high-risk rate of women undergoing the classical LLETZ operation.

Discussion: In case that non-inferiority of the "lesion-only" method can be demonstrated, this operation should eventually become standard treatment for all women at childbearing age due to the reduction in risk of preterm delivery.

Trial registration: German Clinical Trials Register (DRKS) Identifier: DRKS00006169 . Date of registration: 30 July 2014.

Fig. 1

Resection margins of classical large loop excision of the transformation zone operation including the transformation zone, which is defined as 3 to 4 mm around the squamocolumnar junction. CIN, Cervical intraepithelial neoplasia; LLETZ, Large loop excision of the transformation zone; SCJ, Squamocolumnar junction

Fig. 2

Resection margins in lesion-only operation, where a distance of 2 mm around the lesion should be kept. CIN, Cervical intraepithelial neoplasia

Fig. 3

Comparison of the extent of both surgical methods, example 1. LLETZ, Large loop excision of the transformation zone; SCJ, Squamocolumnar junction

Fig. 4

Comparison of the extent of both surgical methods, example 2. LLETZ, Large loop excision of the transformation zone; SCJ, Squamocolumnar junction