CA: A Cancer Journal for Clinicians, Vol 37, 334-347, Copyright
© 1987 by American Cancer Society
Laser Treatment of Patients with Condylomata and Squamous Carcinoma Precursors of the Lower Female Genital Tract
Alex Ferenczy MD1
1 Professor of Pathology and Obstetrics & Gynecology at The Sir Mortimer B. Davis Jewish General Hospital and McGill University in Montreal, Canada.
CO2 laser vaporization and/or cutting of lesional tissues has become an attractive therapeutic modality for condylomata and squamous cell carcinoma precursor lesions of the lower female anogenital region. With respect to the laser's use for cervical lesions, it appears that size and distribution of cervical cancer precursors or condylomata, rather than arbitrary histologic grades, are the two key features that influence treatment results. Therefore, although the laser is more precise than cryotherapy or electrocautery, it offers no better results for lesions smaller than three cm in diameter. Laser vaporization is indicated for lesions larger than three cm or with extension into the external os that are still fully visible or that fail to respond to two cryocautery or electrocautery treatments. Laser excision of endocervical lesions removes considerably less disease-free tissue than the traditional cold-knife cone biopsy. Appropriate laser therapy for cervical disease provides a well-positioned squamocolumnar junction for cytologic follow-up, a situation that is not necessarily true for electrocautery or cryocautery.
The CO2 laser appears to be the instrument of choice for treating vaginal, vulvar, and anal intraepithelial neoplasia and conventional treatment-resistant condylomata. If depth of vaporization does not exceed 1.0 to 1.5 mm, and the adjacent one to two cm of epidermis is also included in the therapeutic field, both the cosmetic and the cure results are excellent. The best treatment results are obtained with a clear understanding of laser physics and the anatomy and histology of lesional tissues, expertise in colposcopy, and appropriate posttreatment patient management that includes examination and, if appropriate, treatment of sexual partners.
The CO2 laser, and particularly the Yag laser, have one major disadvantage. They are expensive, and necessitate a high fee for the patient. In a nonreferral private practice, cervical lesions larger than three cm or those with limited endocervical extension, vaginal and vulvar intraepithelial neoplasia, and extensive external genital condylomata are seen infrequently. As a result, the cost of a CO2 or Yag laser is difficult to justify in routine gynecologic practices. Rather, patients with indications for laser therapy are best referred to a hospital/laser unit with adequate patient volume and expertise. The laser in a medical center may also serve a multidisciplinary role, which means that more patients will have a chance at improved care.
