Objective To investigate the reasons for cone biopsies reported as not containing intraepithelial or invasive malignancy and thereby find ways to decrease their incidence.Design One hundred cone biopsies reported as negative were identified out of a total of 436 consecutive cone biopsies. The patients' cytology, colposcopy and histology reports and cytology and histology slides were reviewed. Further opinions in cases of doubt were obtained in cytology and histology. In cone biopsies still considered negative after reviews, deeper levels were cut, exhausting all paraffin blocks. Follow up cytology, colposcopy and histology were reviewed.Setting Gynaecological oncology unit in a university teaching hospital.Results After re-evaluation the final diagnoses of cone biopsies initially reported as negative were positive (n = 21), unsatisfactory (n = 27) and true negative (n = SI), with one case excluded because of insufficient material for review. The positive cases were diagnosed on review (n = 11) or extra levels (n = 10). The unsatisfactory cases were all due to denudation. The 5 1 true negative cases were divided into those which never had had histologic confirmation by punch biopsy or endocervical curettage (n = 47) and those with a previously confirmed histological abnormality (n = 4). Conclusions The number of negative cone biopsies can be reduced by: 1. taking Pap smears after correction of atrophy and inflammation; 2. more scrupulous colposcopy aimed at reducing the number of unsatisfactory colposcopies or misinterpreted colposcopic findings; this thorough examination should include the vagina and vulva; 3. confirmation of smear and colposcopic findings by biopsy prior to cold-knife conisation and performing a large loop excision of the transformation zone (LLETZ) for cases where there is a discrepancy between the smear abnormality and colposcopy/biopsy findings; 4. good quality cone biopsies using a technique that does not handle the mucosa and is performed after the mucosa has had time to regenerate following the colposcopic investigations; and 5. exhausting all blocks with multiple levels before reporting a cone biopsy as negative. INTRODUCTIONThe traditional management of preinvasive disease of the cervix begins with an abnormal smear detected on routine screening. The patient is referred to a colposcopist who attempts to grade, delineate and biopsy the abnormality. A colposcopic-directed biopsy confirms the smear and colposcopic diagnoses and, at a second visit, the abnormal transformation zone is destroyed. Where there is suspicion of invasion or adenocarcinoma in situ or an unsatisfactory colposcopy (defined as an inability to see the full transformation zone, the endocervical limits of a lesion or a discrepancy between the smear and colposcopic findings) a cone biopsy is performed. The cone biopsy usually provides a definitive diagnosis, with type, grade, extent of the lesion and state of the resection lines. Not infrequently, however, no lesion is found on histological examination of the cone biops...

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We studied 2 groups of women whose management is controversial: those with cervical intraepithelial neoplasia (CIN) grade 2 or 3 on smear, but only CIN grade 1 or no abnormality on target biopsy (Group 1), and those with persistent CIN grade 1 on smear and up to CIN 1 on biopsy (Group 2). We set out to assess whether large loop excision of the transformation zone (LLETZ) was an acceptable method of treating these 2 groups of women. A review of 100 consecutive patients was undertaken. There were 71 women in Group 1 and 29 women in Group 2. The LLETZ procedures were performed under local analgesia and no immediate problems were encountered. Delayed haemorrhage requiring vaginal packing and admission to hospital occurred in 1 patient. In Group 1, histopathology of the LLETZ biopsies showed CIN 2 or 3 in 29 (40.8%) of the women, CIN 1 in 24 (33.8%) and no CIN in 18 (25.3%), and in Group 2, CIN 2 or 3 was seen in 5 (17.2%) of the women, CIN 1 in 11 (37.9%) and no CIN in 13 (44.8%). At 12 months completed follow-up, 4 patients in Group 1 had recurrent CIN 1 or equivocal CIN 1 and 1 patient from Group 2 had recurrent CIN 1, giving an overall recurrence rate of 5 of the 94 patients who completed follow-up (5%). We concluded that LLETZ was a useful procedure in both groups. In Group 1 the provision of a histological diagnosis on the LLETZ biopsy was a check on the accuracy of the cervical smear report. In Group 2, LLETZ offered the advantage of rapidly returning the smear to normal in most patients, and the diagnosis and treatment of those women who actually had a high-grade lesion.