What Is a Cone Biopsy?

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A cone biopsy, also called conization, is a surgical procedure that is used to remove a cone-shaped piece of tissue from the cervix and cervical canal. Cone biopsy is useful when diagnosing or treating a cervical condition such as cervical intraepithelial neoplasia (CIN), a precancerous condition, or cervical cancer.

Purpose of Test

There are a few reasons why your doctor may order a cone biopsy. In some cases, the procedure is recommended if a woman has a Pap smear results indicating there are abnormal cells in the cervix, followed by a colposcopy and biopsy that is inconclusive. In this setting, a biopsy will look for premalignant lesions (CIN) or cancerous cells on your cervix.

A cone biopsy may also be used to removing abnormal tissue from the cervix as part of treatment, or to evaluate the extent of cervical cancer that is already diagnosed.

A cone biopsy may be considered as a treatment for women who want to preserve their fertility after cancer treatment or when the cervical cancer is in the very early stages (stage 0 or IA1). If the edges of the biopsy have cancer cells, the cone biopsy may need to be repeated or a radical trachelectomy (removal of the cervix as well as upper vagina and nearby tissue) may be considered.

There are three approaches to performing a cone biopsy:

  • Using a carbon dioxide laser to excise a portion of tissue
  • Loop electrosurgical excision procedure (LEEP), which employs a thin wire loop attached to a generator to electrically remove a piece of tissue
  • Cold knife conization (CKC) in which a surgical scalpel is used

Risks and Contraindications

Your doctor will explain the long-term risks associated with a cone biopsy but it can be helpful to have an idea of what those might be prior to that discussion, so that you can ask any specific questions you may have. Potential short-risks include:

  • Bleeding
  • Infection
  • Inadequate removal of tissue

Longer term risks may include:

  • Persistence of human papillomavirus (HPV) infection: HPV infection may persist, especially in women who have high-risk HPV strains (particularly type 16) as well as high HPV viral loads. In a review of studies, the incidence of persistent HPV infection was found to be 42% with LEEP and 7% with CKC.
  • Recurrence of abnormal cervical cells (dysplasia): The risk tends to be lowest for cold knife conization (less than 2%) when compared to LEEP (loop electrosurgical excision procedure) and cryosurgery.
  • Preterm delivery: This is uncommon but can happen as a result of a cone biopsy. A 2016 study suggested that the risk following cold knife conization was higher compared to LEEP or cryosurgery. It's important to note, however, that untreated dysplasia (such as CIN2 or CIN3) is also associated with premature delivery. If an incompetent cervix occurs, a procedure called a cerclage is sometimes used, in which the cervix is essentially "sewn shut.".
  • Inconclusive Pap smears: Cone biopsy may make it harder to interpret future Pap smears.
  • Cervical stenosis: Scarring and narrowing of the cervix may result in sperm being unable to pass through the cervix, and subsequent infertility.

These factors reinforce the importance of consistent, routine follow-ups with your health provider as well as ensuring that any obstetric or gynecologic specialist knows all the details of your medical history.

Contraindications, or reasons the procedure should not be performed include severe cervicitis (inflammation of the cervix), or, in the case of LEEP, the presence of a demand type cardiac pacemaker. Relative contraindications include pregnancy (the risks and benefits must be weighed for each women), a history of bleeding disorders, or the use of blood thinners.

Before the Test

Before surgery, your doctor will explain the procedure and give you a chance to ask any questions. They will discuss which anesthesia will be best for you, whether general or regional.

At that time, tell your doctor if you’re pregnant or think you might be. Also, let your doctor know about any allergies or if you have a bleeding disorder that can affect healing.

Your doctor will also need to know about any medications, either over-the-counter or prescription, or herbal supplements your take, in case there are any you should discontinue until after your cone biopsy.

During the 24 hours before to the procedure you will need to abstain from sex and using tampons, vaginal creams or medications, and douching.

Timing

A cone biopsy takes about 15 minutes. However, you should plan to be at the hospital for several hours, as you'll need time to fill out forms and for pre-operative and post-operative care.

Location

Cone biopsies typically are performed in a hospital or a surgery center, usually by an obstetrician-gynecologist.

What to Wear

Because you'll change into a hospital gown for the procedure, there's no reason to dress in a particular way. However, hospitals tend to be chilly so you may want to bring a pair of socks. It's advisable to leave your jewelry and valuables at home or with a family member so they don’t get lost.

Food and Drink

Because you'll be receiving anesthesia you'll need to abstain from eating or drinking for six to eight hours before the procedure.

Cost and Health Insurance

Check with your health insurance to determine how much of the cost is covered before undergoing the procedure.

What to Bring

Make sure you bring paperwork and health insurance card to the hospital. Your doctor may also advise you to bring a sanitary pad to use after the procedure.

Other Considerations

Because you'll be given anesthesia and as a result will feel weak and tired after the procedure, you will be required to arrange for someone to drive you home afterward.

During the Test

On the day of your cone biopsy, your health care team will include a preoperative nurse, an anesthesiologist or nurse anesthetist, and your obstetrician-gynecologist. They can answer any questions you may have before the procedure.

Pre-Test

When you get to the hospital, the preoperative nurse will conduct an exam and make sure you’ve had all the needed tests prior to the procedure. After you change into a hospital gown, you may be given a blanket to keep warm.

An anesthesiologist will talk to you about your medical history. Anesthesia is either given through intravenously (through a needle into a vein) IV or a mask. You and your doctor will decide beforehand whether you should be given general anesthesia or medicines to help you relax and stay sleepy.

For the procedure you'll be lying on your back with your feet in stirrups to keep your legs apart and provide access to your cervix. The doctor will insert a lubricated tool called a speculum into your vagina to widen it. If a LEEP biopsy is performed, you may be injected with a medication to numb the cervix.

Throughout the Test

During the procedure e surgical team will monitor your vital signs throughout the procedure to make sure that everything is going smoothly.

Whatever method is used to excise a sample, the amount of tissue collected will likely measure around 1.5 centimeters (cm) wide and 1 cm deep. Later, that sample of tissue is analyzed with a microscope to determine whether it has cancerous cells or precancerous cells.

Post-Test

After a cone biopsy, your cervix may be packed with a pressure dressing. Your doctor will give you instructions on when and how to remove it.

Expect to spend three to four hours in the recovery room before you're allowed to leave the hospital or surgical center. Again, you will need to have someone drive you home or arrange to be picked up by a cab or car service.

After the Test

It will take four to six weeks for your cervix to heal after the procedure. Follow your doctor’s instructions for at-home care, which may include:

  • Take showers instead of baths: Don’t soak in water, including hot tubs and swimming pools.
  • Avoid strenuous physical activity: This includes vacuuming, yard work, or carrying heavy groceries and laundry.
  • Don't lift anything over 10 pounds: The strain could increase your bleeding.
  • Do not use tampons or douches or have sexual intercourse: Any of these could prolong the amount of time it takes your cervix to heal and increase the chance of infection.

Managing Side Effects

Recovery varies from person to person. You may feel tired and have abdominal cramping for a couple of days after having a cone biopsy. You may also have bloody discharge for two to three weeks after the procedure. You’ll probably need to wear sanitary pads during this time. Your doctor can advise you about what medicines you can take for pain relief.

While your doctor will likely recommend that someone stay with you for 24 hours following the procedure, you should consider having a friend or family member stay with you for several days if you live alone to help with any heavy lifting and chores.

The cone biopsy procedure is usually well tolerated. Excessive bleeding rarely occurs. Infection is sometimes possible and is usually characterized by a yellow or green discharge with a foul smell.

After any surgical procedure, there is always a small risk of blood clots in the legs. While this is uncommon with a cone biopsy, contact your doctor if you have any pain, redness, or swelling in one or both of your legs.

Get medical help immediately if you have persistent pelvic pain, abnormally heaving bleeding, foul-smelling discharge, chills, a fever greater than 101 Fahrenheit, or any symptoms that seem alarming you.

Interpreting Results

You will likely get the results of your cone biopsy within five to seven business days. A normal result means there are no precancerous or cancerous cells in the cervix.

Abnormal results mean that precancerous or cancerous cells have been detected. Precancerous cells fall into these categories:

  • CIN 1: Slightly abnormal cells, also called low-grade or mild dysplasia. These often goes away without treatment but can become cancerous in some instances.
  • CIN 2: Moderately abnormal cells, also called high-grade or moderate to marked dysplasia. For roughly 50% of woman, the changes will regress, while for others, the changes may remain the same or progress without treatment. CIN 2 is not cancer, but may become cancer if not treated.
  • CIN 3: Highly abnormal cells that may be classified as high-grade or severe dysplasia or carcinoma in situ. CIN 3 is considered a direct precursor to cancer, and If not treated, it may become cancer.

In each case, your doctor will let you know whether the cone biopsy was able to remove all the abnormal tissue.

Follow-Up

You will likely be instructed to schedule a follow-up appointment for around four weeks after your procedure.

Further treatment and future monitoring will depend on the results of your cone biopsy.

If the biopsy shows that there may still be abnormal cells, the cone biopsy may need to be repeated or your doctor may discuss other options, such as a radical trachelectomy.

If the cone biopsy removes all of the abnormal tissue, you will still need to be monitored, with the frequency of monitoring dependent on your results as well as your age, pregnancy status, whether your have a persistent HPV infection, and your history of abnormal Pap smears in the past.

Most often, HPV testing will be recommended in 6 months, and if normal, will be followed by yearly testing (either HPV testing or a combination of a Pap smear and HPV testing) until you have at least three consecutive negative tests.

Long term monitoring is important as well. Once you have completed the recommended short term follow-up, this usually means either HPV testing or a combination of a Pap smear and HPV testing every 3 years for at least 25 years.

A Word From Verywell

It’s normal to feel anxious or worried when waiting for or receiving test results. To ease your nervousness, turn to trusted family members, friends, and, of course, your doctor. Don't hesitate to ask them any and all questions you have before your procedure. And if you're in doubt about whether you need a cone biopsy, don’t hesitate to get a second opinion.

It can also be helpful to reach out to someone else who's had a cone biopsy, but be selective. As with other fields of medicine, cone biopsies are constantly improving. The chances that your procedure will be effective and without complications is higher than someone who may have had the procedure in the distant past.

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Article Sources
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