The Effect of Loop Electrosurgical Excision Procedure on Future Pregnancy Outcome

Association between loop electrosurgical excision procedure and adverse pregnancy outcomes: a meta-analysis

OBJECTIVE

To assess the association between loop electrosurgical excision procedure (LEEP) and adverse pregnancy outcomes.

METHODS

The databases including PubMed, Embase, Cochrane Library and Web of science were searched from inception to December 27th, 2020. Odds ratio (OR) and 95% confidence interval (CI) were utilized to calculate the association between LEEP and adverse pregnancy outcomes. Heterogeneity test was performed for each outcome effect amount. If I² ≥ 50%, the random-effects model was conducted, otherwise, fixed-effects model was performed. Sensitivity analysis was performed on all outcomes. Publication bias was performed by Begg's test.

RESULTS

A total of 30 studies containing 2,475,421 patients were included in this study. The results showed that patients who received the LEEP before pregnancy had a higher risk of preterm delivery (OR: 2.100, 95%CI: 1.762-2.503, p  <  .001), premature rupture of fetal membranes (OR: 1.989, 95%CI: 1.630-2.428, p  <  .001) and low birth weight infants (OR: 1.939, 95%CI: 1.617-2.324, p  <  .001) in comparison with controls. Subgroup analysis further found that prenatal LEEP treatment was associated with the risk of preterm birth subsequently.

CONCLUSION

LEEP treatment before pregnancy may increase the risk of preterm delivery, premature rupture of fetal membranes and low birth weight infants. It is necessary to do a regular prenatal examination and early intervention in a timely manner to reduce the risk of adverse pregnancy outcomes after LEEP.

Diagnostic Accuracy of p16INK4a/Ki-67 Dual Immunostaining for Detection of High-Grade Cervical Intraepithelial Neoplasia in Women Involved in Cervical Cancer Screening in Georgia

Background

Despite the widespread introduction of primary and secondary preventative measures, death rates for cervical cancer are still significantly high among females, especially in developing countries. Pap cytology and human papillomavirus-based screening often lead to unnecessary additional testing. The aim of this study is to analyze diagnostic accuracy of p16^INK4a/Ki-67 dual immunostaining (DS) in cervical smear for identifying high-grade cervical intraepithelial neoplasia (CIN2+).

Materials and Methods

We studied the diagnostic performance of p16^INK4a/Ki-67 DS in cervical smear of those women, who enrolled in cervical cancer screening due to abnormal previous screening results and compared it with Pap test results in identifying CIN2+. The reference standard was histopathology results. p16^INK4a/Ki-67 DS and Pap test results for 162 women and histopathology results for 29 women were available, respectively.

Results

In our study, sensitivity, specificity, positive predictive value, and negative predictive value of p16^INK4a/Ki-67 DS, irrespective of the morphology of stained cells to detect CIN2+ were 100%, 89%, 85%, and 100% (p < 0.01), respectively. The diagnostic accuracy of p16^INK4a/Ki-67 DS is superior to that of existing cervical screening tests in the detection of CIN2+.

Conclusion

The findings of cervical cancer screening based on Pap cytology highlight the importance of assessing the cost-effectiveness of integrating p16^INK4a/Ki-67 biomarkers in cervical cancer cytology. Furthermore, these findings emphasize the need to enhance support for preventive programs for cervical cancer in Georgia.

Obstetric outcomes after cervical loop electrosurgical excision procedure

OBJECTIVES

This study aimed to investigate whether a history of loop electrosurgical excision procedure (i.e., conisation) affects obstetric and neonatal outcomes.

METHODS

A retrospective cohort study was carried out in Västernorrland county, Sweden. 57 nulliparous women with singleton pregnancies and previous conisation were compared with 100 age-matched pregnant controls without history of conisation.

RESULTS

There was significantly lower gestational age by delivery (p = 0.036), however, the premature delivery rate was not different. Caesarean section was also less frequent (OR: 0.29, 95% CI: 0.081-1.04, p = 0.047) in the conisation group than those in the control group. There were no differences in neonatal outcomes.

CONCLUSIONS

Previous conisation does not affect the risk of prematurity or cervical dilatation during the first stage of labour. Women with history of conisation had a lower rate of caesarean section, and lower gestational age by delivery.

Female Sexual Dysfunction in Women After Treatment of Cervical Dysplasia

INTRODUCTION

Cervical cancer is the fourth most common cancer worldwide and accounted for approximately 570,000 new cancer cases and 311,000 cancer deaths in 2018. Despite advances in screening algorithms many US women undergo excisional cervical procedures for the treatment of cervical dysplasia. The effects of loop electrosurgical excisional procedure (LEEP) and cold knife conization (CKC) on sexual function are relatively unknown.

OBJECTIVES

To conduct a comprehensive review of the literature regarding the effects cervical cancer screening and treatment on female sexual function and satisfaction METHODS: We conducted a review of the medical literature up to and including November 2021 on PubMED using search terms related to cervical dysplasia and sexual health. We identified 831 articles and selected 39 articles for inclusion in our review. Nine studies were included that specifically focused on the effect of loop electrosurgical excisional procedure (LEEP) on female sexual function.

RESULTS

Multiple studies demonstrated adverse psychologic and sexual effects in patients with cervical dysplasia and after colposcopy. Some studies reported that women experience decreased arousal and interest 6 months following colposcopy. Several studies documented adverse effects on lubrication, sexual pain, and desire following LEEP.

CONCLUSIONS

There is a lack of high quality research on the effect of LEEP and colposcopy on female sexual function. Important limitations in the review of the current literature include, a small sample size, inconsistent comparison groups, observer bias, and lack the use of standardized questionnaires. Clinicians should continue to provide patients education regarding the risks and benefits of different treatment modalities and potential for effects on sexual function should be included in comprehensive counseling. Ethan Litman. Female Sexual Dysfunction in Women After Treatment of Cervical Dysplasia. Sex Med Rev 2022;10:360-366.

Midtrimester cervical elastography in pregnant women with a history of loop electrosurgical excision procedure (LEEP)

We aimed to compare cervical elastographic parameters based on a previous loop electrosurgical excision procedure (LEEP) and to determine whether they can predict preterm delivery in pregnant women with a history of LEEP. This multicenter prospective case-control study included 71 singleton pregnant women at 14-24 weeks of gestation with a history of LEEP and 1:2 gestational age-matched controls. We performed cervical elastography using E-cervix and compared maternal characteristics, delivery outcomes, cervical length (CL), and elastographic parameters between the two groups. The median mid-trimester CL was significantly shorter in the LEEP group. Most elastographic parameters, including internal os (IOS), external os (EOS), elasticity contrast index (ECI), and hardness ratio (HR), were significantly different in the two groups. In the LEEP group, the sPTD group compared to the term delivery (TD) group showed a higher rate of previous sPTD (50% vs. 1.7%, p < 0.001), higher IOS and ECI (IOS: 0.28 [0.12-0.37] vs. 0.19 [0.10-0.37], p = 0.029; ECI: 3.89 [1.79-4.86] vs. 2.73 [1.48-5.43], p = 0.019), and lower HR (59.97 [43.88-92.43] vs. 79.06 [36.87-95.40], p = 0.028), but there was no significant difference in CL (2.92 [2.16-3.76] vs. 3.13 [1.50-3.16], p = 0.247). In conclusion, we demonstrated that a history of LEEP was associated with a change in cervical strain measured in mid-trimester as well as with CL shortening. We also showed that cervical elastography can be useful in predicting sPTD in pregnant women with previous LEEP.

Disclosure of Loop Electrosurgical Excision Procedure Complications: Qualitative Analysis of Hospital Affiliated Online Resources in Canada

OBJECTIVE

Determine the current level of knowledge translation presented in hospital-affiliated online resources (HAOR) related to Loop Electrosurgical Excision Procedure (LEEP) and critically evaluate how these resources convey information to patients using validated measures of health literacy.

METHODS

Qualitative analysis was conducted to assess HAOR content. Reading level was calculated using the Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), and Simple Measure of Gobbledygook (SMOG). Actionability and understandability were measured using the Patient Education Material Assessment Tool for Print (PEMAT-P).

RESULTS

Twenty-four HAORs relating to LEEP were identified on Canadian healthcare institution websites (n = 167). Bleeding (n=15), discharge (n=14), pain/discomfort (n=14), infections (n=9), and cervical stenosis (n=7) were disclosed as short-term complications. Less frequently disclosed were long-term risks relating to pregnancy (n=5) and fertility (n=1). Complications related to sexual health and well-being were absent. Discrepancies were observed in the disclosure of when updates were performed (n=21) and sourcing details (n=2). The mean readability scores were above the recommended grade-level 5/6 for patient education materials (FKGL: x̄ = 6.64, σ = 1.07; GFI: x̄ = 8.58, σ = 1.50; SMOG: x̄ = 9.92, σ = 0.92). All HAORs scored above the PEMAT-P threshold (≥70%) for good actionability. Few HAORs (n=7) exceeded the threshold (≥70%) for good understandability (x̄ = 68.7%, σ = 11.0).

CONCLUSIONS

Inconsistent disclosure of LEEP risks and complications suggests critical elements of knowledge translation are inadequately applied to the curation process of HAORs. Measures of readability, understandability, and actionability indicate poor resource accessibility.

Relationship between cervical excisional treatment for cervical intraepithelial neoplasia and obstetrical outcome

INTRODUCTION

The aim of our systematic review was the assessment of effects of excisional treatments for the management of cervical intraepithelial neoplasia (CIN) on preterm delivery (PD), lower birth weight (LBW), preterm premature rupture of membrane (PPROM) and obstetrical outcomes.

EVIDENCE ACQUISITION

A structured search was carried out in PubMed-Medline, Embase, and Cochrane Controlled Trials Register databases through November 30, 2019. The search included a combination of the following terms: "loop electrosurgical excision procedure (LEEP)," "large loop excision of transformation zone (LLETZ)," "cold-knife conization (CKC)," "laser cervical conization (CLC)," "preterm delivery" and "neonatal outcome."

EVIDENCE SYNTHESIS

Thirty-two of 561 publications considered were included: 28 retrospective series, 2 prospective studies and 2 multicenter trials. Globally in several studies there was a significant increase in PD, measured by the relative risk, in the women underwent a surgical procedure for the CIN. In their majority, the studies were retrospective and therefore a high risk of bias.

CONCLUSIONS

This systematic review shows that the surgical treatment of the CIN was associated with an increased risk of PD, LBW and pPROM before 37 pregnancy weeks compared to untreated women, especially in a CKC and LLETZ procedure. Moreover, the increase of the of PD was associated with cone size, cervical length, repeated treatment and a short conization-to-pregnancy interval.

Maternal History of Cervical Surgery and Preterm Delivery: A Retrospective Cohort Study

Introduction: Our aim was to investigate whether cervical conization and/or loop electrosurgical excision procedure (LEEP) increases the risk of preterm delivery. Materials and Methods: We conducted a retrospective cohort study of singleton deliveries at our institution from 2010 to 2015. Women aged 16-49 years were included in our study. Univariate and logistic regression were used for statistical analyses. An interaction test was used to assess whether maternal human papillomavirus (HPV) positivity within the 3 years before delivery (referred to as maternal HPV status in this study) is an effect modifier. Results: Of 3933 women who delivered at our institution, 19.8% (n = 792) delivered prematurely. Of these women, 9.1% (n = 362) had a history of cervical surgery, including cervical conization and/or LEEP. Notably, a history of cervical surgery was not associated with current HPV status based on the most recent Pap smear results (p > 0.05). In univariate analysis, a history of cervical surgery was associated with preterm delivery (odds ratio [OR] = 1.54, 95% confidence interval [CI]: 1.26-1.88). This effect was the same among mothers positive (OR = 1.95, 95% CI: 1.16-3.28) and negative (OR = 1.91, 95% CI: 1.10-3.30) for HPV. Pregnancy-induced hypertension, preterm premature rupture of membranes, bacterial vaginosis infection, HPV infection, placenta previa, placental abruption, ethnicity, maternal body mass index, nulliparity, and smoking or drug use were also associated with preterm delivery (p < 0.05). In multivariable analysis, history of cervical surgery remained associated with preterm delivery (OR = 1.75, 95% CI: 1.31-2.33). There was no interaction (p = 0.91) between maternal HPV status and history of cervical conization or LEEP. Discussion and Conclusions: Maternal history of cervical conization and/or LEEP increases the risk of preterm delivery irrespective of concurrent maternal HPV positivity within the 3 years preceding delivery. Maternal HPV status does not modify the effect of history of cervical conization and/or LEEP on preterm delivery.

A randomized trial comparing limited-excision conisation to Large Loop Excision of the Transformation Zone (LLETZ) in cervical dysplasia patients

Objective

To show noninferiority of a limited-excision (resection of the dysplastic lesion only) vs. classical Large Loop Excision of the Transformation Zone (LLETZ).

Methods

In this prospective, randomized, multicenter trial, women with human papillomavirus (HPV) positive cervical intraepithelial neoplasia grade 3 were randomized into two groups (1:1). Primary outcome was the rate of negative HPV tests after 6 months, secondary outcomes included cone size, complete resection rates as well as cytological and histological results after 6 and 12 months. A sample size of 1,000 was calculated to show noninferiority of the limited-excision compared to the LLETZ group using a noninferiority margin of 5%. Enrollment was stopped after 100 patients due to slow accrual.

Results

Patients in the limited-excision group did not show a lower number of negative HPV tests (78% [LLETZ]−80% [limited-excision]=−2%; 90% confidence interval=−15%, 12%). The limited-excision resulted in a substantially lower cone size (LLETZ: 1.97 mL vs. limited-excision: 1.02 mL; p<0.001) but higher numbers of involved margins (LLETZ: 8% vs. limited-excision: 20%). Although postoperative cytological results slightly differed, histological results were similar in both groups. One limited-excision patient received immediate re-conisation, whereas one patient in each group was scheduled for re-conisation after 6 months.

Conclusion

The limited-excision could represent a promising option to reduce the surgical extent of conisations while maintaining oncological safety. The trial was not sufficiently powered to reach statistical significance due to early termination. Nevertheless, the study provides important insights in the feasibility of a limited-excision and could serve as a pilot study for future trials.

Trial Registration

German Clinical Trials Register Identifier: DRKS00006169

The Clearance of High-Risk Human Papillomavirus is Sooner After Thin Loop Electrosurgical Excision Procedure (t-LEEP)

Purpose/aim of the study: To investigate high-risk human papillomavirus (HPV) infection clearance following thin loop electrosurgical excision procedure (t-LEEP) among patients with cervical benign lesion. Materials and Methods: This retrospective study analyzed clinical data from patients with cervical benign lesion and HPV infection, who had undergone t-LEEP (T-Group), compared with patients with HPV infection undergone no treatment (NT-Group). Both groups attended regular follow-up between January 2008 and January 2012. Kaplan-Meier analysis was used to compare the HPV clearance time. Results: The average clearance time was 7.7 months (M) (95% confidence interval [CI]: 6.5-8.9 M) in T-Group, and 10.4 M (95%CI: 9.4-11.3 M) in NT-Group, with significant difference between groups (p = 0.003). Among patients with low viral load, the HPV clearance times were 7.6 M (95%CI: 6.3-9.0 M) in T-Group and 9.7 M (95%CI: 8.6-10.8 M) in NT-Group (p = 0.042). Among patients with high viral load, the HPV clearance times were 8.0 M (95%CI: 5.3-10.6 M) in T-Group and 11.4 M (95%CI: 9.7-13.1 M) in NT-Group (p = 0.041). The average time of HPV clearance in T-Group was shorter than NT-Group in all age groups, with significant differences in ≤29Y-group (p = 0.008) and 30-39Y-group (p = 0.005). The accumulated clearance rate of HPV infection at sixth month and 12th month were 24.5% and 67.9% in T-Group, 7.8% and 43.1% in NT-Group, with significant differences (p = 0.001 at 6th month, p = 0.032 at 12th month). Conclusions: T-LEEP accelerates the clearance of high-risk HPV infection and make the HPV infection rates dropped rapidly in the first year.

Evaluation of the Cervix After Cervical Conization by Transvaginal Elastography

OBJECTIVES

The purpose of this study was to investigate the stiffness of the cervix after the loop electrosurgical excision procedure (LEEP) by transvaginal elastography and its potential ability to predict future pregnancy.

METHODS

A retrospective study included patients of reproductive age who underwent LEEP for cervical high-grade squamous intraepithelial lesions on the basis of colposcopic findings and who desired fertility. The characteristics on conventional transvaginal ultrasonography and elastography before and 6 months after LEEP were reviewed and analyzed. Each case had a 12-month follow-up, and the information on pregnancy and a cervical cytologic examination was recorded.

RESULTS

Fifty-three patients who completed the 12-month follow-up were included in the analysis. Thirty-two cases (group 1) were pregnant during the follow-up, and the other 21 (group 2) had pregnancy failure. The cervical lengths of group 1 and 2 as measured by traditional transvaginal ultrasonography were similar before and 6 months after LEEP. The resistive index of group 1 was significantly higher 6 months after LEEP than before LEEP (mean ± SD, 0.88 ± 0.36 versus 0.42 ± 0.22; P = .007). The mean elasticity score for the cervix was statistically significantly lower after LEEP (2.21 ± 0.53) than before (3.46 ± 0.78; P = .001) in group 1. However, in group 2, the mean elasticity scores were similar after LEEP (3.19 ± 0.58) and before (3.25 ± 0.66; P = .75).

CONCLUSIONS

Our results suggest that elastography was a useful technique for evaluating the stiffness of the cervix after LEEP. Elastography could provide a potential means to predict future pregnancy after LEEP.

Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease

BACKGROUND

The mean age of women undergoing local treatment for pre-invasive cervical disease (cervical intra-epithelial neoplasia; CIN) or early cervical cancer (stage IA1) is around their 30s and similar to the age of women having their first child. Local cervical treatment has been correlated to adverse reproductive morbidity in a subsequent pregnancy, however, published studies and meta-analyses have reached contradictory conclusions.

OBJECTIVES

To assess the effect of local cervical treatment for CIN and early cervical cancer on obstetric outcomes (after 24 weeks of gestation) and to correlate these to the cone depth and comparison group used.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, 2017, Issue 5), MEDLINE (up to June week 4, 2017) and Embase (up to week 26, 2017). In an attempt to identify articles missed by the search or unpublished data, we contacted experts in the field and we handsearched the references of the retrieved articles and conference proceedings.

SELECTION CRITERIA

We included all studies reporting on obstetric outcomes (more than 24 weeks of gestation) in women with or without a previous local cervical treatment for any grade of CIN or early cervical cancer (stage IA1). Treatment included both excisional and ablative methods. We excluded studies that had no untreated reference population, reported outcomes in women who had undergone treatment during pregnancy or had a high-risk treated or comparison group, or both DATA COLLECTION AND ANALYSIS: We classified studies according to the type of treatment and the obstetric endpoint. Studies were classified according to method and obstetric endpoint. Pooled risk ratios (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model and inverse variance. Inter-study heterogeneity was assessed with I2 statistics. We assessed maternal outcomes that included preterm birth (PTB) (spontaneous and threatened), preterm premature rupture of the membranes (pPROM), chorioamnionitis, mode of delivery, length of labour, induction of delivery, oxytocin use, haemorrhage, analgesia, cervical cerclage and cervical stenosis. The neonatal outcomes included low birth weight (LBW), neonatal intensive care unit (NICU) admission, stillbirth, perinatal mortality and Apgar scores.

MAIN RESULTS

We included 69 studies (6,357,823 pregnancies: 65,098 pregnancies of treated and 6,292,725 pregnancies of untreated women). Many of the studies included only small numbers of women, were of heterogenous design and in their majority retrospective and therefore at high risk of bias. Many outcomes were assessed to be of low or very low quality (GRADE assessment) and therefore results should be interpreted with caution. Women who had treatment were at increased overall risk of preterm birth (PTB) (less than 37 weeks) (10.7% versus 5.4%, RR 1.75, 95% CI 1.57 to 1.96, 59 studies, 5,242,917 participants, very low quality), severe (less than 32 to 34 weeks) (3.5% versus 1.4%, RR 2.25, 95% CI 1.79 to 2.82), 24 studies, 3,793,874 participants, very low quality), and extreme prematurity (less than 28 to 30 weeks) (1.0% versus 0.3%, (RR 2.23, 95% CI 1.55 to 3.22, 8 studies, 3,910,629 participants, very low quality), as compared to women who had no treatment.The risk of overall prematurity was higher for excisional (excision versus no treatment: 11.2% versus 5.5%, RR 1.87, 95% CI 1.64 to 2.12, 53 studies, 4,599,416 participants) than ablative (ablation versus no treatment: 7.7% versus 4.6%, RR 1.35, 95% CI 1.20 to 1.52, 14 studies, 602,370 participants) treatments and the effect was higher for more radical excisional techniques (less than 37 weeks: cold knife conisation (CKC) (RR 2.70, 95% CI 2.14 to 3.40, 12 studies, 39,102 participants), laser conisation (LC) (RR 2.11, 95% CI 1.26 to 3.54, 9 studies, 1509 participants), large loop excision of the transformation zone (LLETZ) (RR 1.58, 95% CI 1.37 to 1.81, 25 studies, 1,445,104 participants). Repeat treatment multiplied the risk of overall prematurity (repeat versus no treatment: 13.2% versus 4.1%, RR 3.78, 95% CI 2.65 to 5.39, 11 studies, 1,317,284 participants, very low quality). The risk of overall prematurity increased with increasing cone depth (less than 10 mm to 12 mm versus no treatment: 7.1% versus 3.4%, RR 1.54, 95% CI 1.09 to 2.18, 8 studies, 550,929 participants, very low quality; more than 10 mm to 12 mm versus no treatment: 9.8% versus 3.4%, RR 1.93, 95% CI 1.62 to 2.31, 8 studies, 552,711 participants, low quality; more than 15 mm to 17 mm versus no treatment: 10.1 versus 3.4%, RR 2.77, 95% CI 1.95 to 3.93, 4 studies, 544,986 participants, very low quality; 20 mm or more versus no treatment: 10.2% versus 3.4%, RR 4.91, 95% CI 2.06 to 11.68, 3 studies, 543,750 participants, very low quality). The comparison group affected the magnitude of effect that was higher for external, followed by internal comparators and ultimately women with disease, but no treatment. Untreated women with disease and the pre-treatment pregnancies of the women who were treated subsequently had higher risk of overall prematurity than the general population (5.9% versus 5.6%, RR 1.24, 95% CI 1.14 to 1.34, 15 studies, 4,357,998 participants, very low quality).pPROM (6.1% versus 3.4%, RR 2.36, 95% CI 1.76 to 3.17, 21 studies, 477,011 participants, very low quality), low birth weight (7.9% versus 3.7%, RR 1.81, 95% CI 1.58 to 2.07, 30 studies, 1,348,206 participants, very low quality), NICU admission rate (12.6% versus 8.9%, RR 1.45, 95% CI 1.16 to 1.81, 8 studies, 2557 participants, low quality) and perinatal mortality (0.9% versus 0.7%, RR 1.51, 95% CI 1.13 to 2.03, 23 studies, 1,659,433 participants, low quality) were also increased after treatment.

AUTHORS' CONCLUSIONS

Women with CIN have a higher baseline risk for prematurity. Excisional and ablative treatment appears to further increases that risk. The frequency and severity of adverse sequelae increases with increasing cone depth and is higher for excision than it is for ablation. However, the results should be interpreted with caution as they were based on low or very low quality (GRADE assessment) observational studies, most of which were retrospective.

See-and-Treat for High-Grade Cytology: Do Young Women Have Different Rates of High-Grade Histology?

OBJECTIVE

To compare rates of cervical intraepithelial neoplasia grade 3 or greater (CIN3+) between women aged 21 to 24 and women aged 25 or older undergoing a see-and-treat strategy for high-grade squamous intraepithelial lesion (HSIL) cytology.

METHODS

In this retrospective cohort study, women treated with a see-and-treat loop electrosurgical excisional procedure (LEEP) for HSIL cytology at our university-based colposcopy clinic between 2008 and 2013 were identified. Data collected included age, race, parity, smoking status, method of contraception, history of abnormal cytology, HIV status, and LEEP histology. Cohorts were compared using Pearson chi-squared test of association and Fisher exact test.

RESULTS

Three hundred sixty-nine women were included in this analysis. The mean age was 30 (SD, 7.2; range, 21-56). Ninety-seven women (26.3%) were 21 to 24 years old. The rate of CIN3 in all women undergoing a see-and-treat LEEP for HSIL cytology was 65.9% (95% CI, 60.8-70.5). The rate of CIN 2 was 15.2% (95% CI, 11.9-19.2). Three women (1.1%) had invasive carcinoma. There was no difference in risk of CIN3+ in the young women compared with women aged 25 years or older (RR, 1.37; 95% CI, 0.92-2.02). Within this see-and-treat population, there was no correlation between presence of CIN3+ and race, smoking, contraception, or HIV status.

CONCLUSIONS

Most women undergoing see-and-treat for HSIL cytology will have CIN3 on final histology. In this large cohort, women aged 21 to 24 did not have lower rates of CIN3 compared with women aged 25 and older, suggesting that see-and-treat is still a valid treatment option for the prevention of invasive disease in young women.

See-and-Treat Loop Electrosurgical Excision Procedure for High-Grade Cervical Cytology: Are We Overtreating?

OBJECTIVES

To report the overtreatment rate for see-and-treat versus 3-step conventional strategy (cervical cytology, colposcopic biopsies, then LEEP) for patients with high-grade squamous intraepithelial lesion (HSIL) cytology. Our second aim was to identify risk factors for overtreatment.

METHODS

We included 178 women with HSIL cytology from our university-based colposcopy clinic who underwent LEEP between 2007 and 2014. Overtreatment was defined as cervical intraepithelial neoplasia (CIN) 1 or less on LEEP specimen. Differences between treatment groups were compared using chi-square test, 2-sample t test, or Mann-Whitney rank-sum test as appropriate.

RESULTS

CIN2+ was found in 69 (80%) of women in the see-and-treat group and 69 (75%) of the conventional management group (P = 0.093), with overtreatment in 17 (20%) and 23 (25%, P = 0.403), respectively. Women who underwent see-and-treat (n = 86) were older (mean age, 36 vs 31 years; P = 0.007), and a greater proportion completed childbearing (30% vs 13%, P = 0.024). There were no differences in top hat excision; however, a higher proportion of the see-and-treat group had CIN2+ in endocervical samples (54% vs 27%, P = 0.047). Overtreatment, regardless of management strategy, was associated with age at time of LEEP, where older women were more likely to be overtreated (median age, 37 vs 32 years, respectively; OR, 1.04; 95% CI, 1.01-1.08; P = 0.011).

CONCLUSIONS

A see-and-treat strategy minimizes risk of loss to follow-up with a similar overtreatment rate compared with conventional management. With CIN2+ in some three-fourths of women with HSIL, a see-and-treat should be favored especially when adherence to follow-up is questionable.

Pregnancy Outcomes after Treatment for Cervical Cancer Precursor Lesions: An Observational Study

Objective

To examine whether surgical procedures involving the uterine cervix were associated with pregnancy outcomes, including preterm birth, low birth weight, cesarean delivery and pregnancy loss.

Design

Population-based observational study nested in retrospective matched cohort

Setting

Kaiser Permanente Northwest integrated health plan in Oregon/Washington, U.S.A.

Population

Female health plan members age 14–53 years with documented pregnancies from 1998–2009. Women with prior excisional and ablative cervical surgical procedures (N = 322) were compared to women unexposed to cervical procedures (N = 4,307) and, separately, to those having undergone only diagnostic/biopsy procedures (N = 847).

Methods

Using log-linear regression models, we examined risk of adverse pregnancy outcomes in relation to prior excisional or ablative cervical surgical procedures. We stratified excisional procedures by excision thickness. We evaluated for confounding by age, body mass index, race, smoking history, previous preterm birth, and parity.

Results

We found a positive association between excisional treatment > = 1.0 cm and the outcomes preterm birth and low birth weight (preterm birth unadjusted risk ratio [RR] = 2.15, 95% confidence interval [CI] 1.16–3.98 for excisions ≥1.0 cm compared to unexposed women), particularly in women who delivered within one year of surgery (RR = 3.26, 95% CI 1.41–7.53). There was no clear association between excisional treatment and cesarean delivery, and treated women did not have a substantially higher risk of dysfunctional labor. Ablative treatment was not associated with low birth weight, preterm birth, or cesarean delivery but was associated with pregnancy loss (RR = 1.43, 95% CI 1.05–1.93 vs. unexposed women). Analyses using the diagnostic procedures comparison group produced similar results.

Conclusion

Women with > = 1.0 cm excisional treatment had elevated risk of preterm birth and low birth weight when compared to unexposed women and women with cervical diagnostic procedures. This suggests that increased risk derives from the treatment itself, not from other characteristics. The observed association between pregnancy loss and ablative surgical treatment requires further investigation.

p16ink4 and cytokeratin 7 immunostaining in predicting HSIL outcome for low-grade squamous intraepithelial lesions: a case series, literature review and commentary

p16ink4 and cytokeratin 7 (CK7) have been proposed to identify low-grade squamous intraepithelial lesions (LSIL) at greater or lesser risk for an outcome of high-grade squamous intraepithelial lesion (HSIL). We correlated CK7 and p16ink4 staining in LSILs with outcome on follow-up and placed this information in the context of prior reports. Cervical LSIL biopsies with at least 1-year follow-up information were immunostained for CK7 and p16ink4. Follow-up outcomes included no SIL, LSIL (persistence) or HSIL (CIN2+). In all, 109 LSILs were studied and 18.3% stained positive for CK7. Ninety-one percent of CK7-negative LSILs regressed, 4.5% persisted, and 4.5% had an HSIL outcome, versus 60, 20, and 20% of CK7-positive LSILs, respectively (P=0.036). p16ink4 status did not significantly associate with outcome. Review of the literature revealed a highly variable rate of both positive p16ink4 immunoreactivity in LSIL and CIN2+ outcome for p16-positive LSIL but a consistently high negative predictive value (>90%) in the case of no/low p16 expression. Inter-observer reproducibility for the diagnosis of CIN2 in the literature ranged from poor to good, with unanimous agreement on the diagnosis of CIN2 occurring in less than 25% of cases. As with high-risk human papillomavirus testing, the most clinically useful result of p16ink4 staining is a negative test, implying no lesion or CIN1 and conferring a low risk of HSIL outcome. HSIL outcomes ('progression') are highly variable and are subject to wide differences in inter-observer interpretation for CIN2. This argues against the wisdom of relying on p16ink4 to both predict CIN2+ or upgrade CIN1 to CIN2. It also begs the question of whether CIN2 should be replaced by an alternate and less pejorative term (SIL of intermediate grade) for lesions that are not reproducibly classified as LSIL or HSIL, with an appropriate management scheme.

Four categories of LEEP for CIN of various areas: a retrospective cohort study

PURPOSE

To compare the effectiveness and safety of loop electrosurgical excision procedures (LEEP) with four different excisions in treating cervical intraepithelial neoplasia (CIN) of different areas.

METHODS

Four hundred and sixty-six cases of CIN were treated with different types of LEEP. Following visual inspection with acetic acid and Lugol's iodine, LEEP were performed to excise the transformation zone to a 20-25 mm depth with a 2-3 mm margin. Four categories of procedures are described below: (i) LEEP-A for lesion ≥2/3 of cervical area: conization of ≥2/3 of cervical tissue. (ii) LEEP-B for ≥1/3 but <2/3: conization of 1/3 to <2/3. (iii) LEEP-C for <1/3: conization of <1/3. (iv) LEEP-D: endocervical canal resection.

RESULTS

The cases included 108 of CIN I, 232 of CIN II, and 106 of CIN III (not including carcinoma in situ) patients. No positive margin was found in any specimens. The cure rates for LEEP-A, B, C, and D were 99.1%, 98.5%, 100.0%, and 93.2%, respectively (p > .05). The pregnancy rate at two years after LEEP was significantly higher in groups C and D compared to group A (p < .05).

CONCLUSIONS

Four categories of LEEP are highly effective in the treatment of CIN when appropriately applied. However, large loop excision may lead to adverse obstetric outcomes in pregnancy.

Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis

OBJECTIVE

 To assess the effect of treatment for cervical intraepithelial neoplasia (CIN) on obstetric outcomes and to correlate this with cone depth and comparison group used.

DESIGN

 Systematic review and meta-analysis.

DATA SOURCES

 CENTRAL, Medline, Embase from 1948 to April 2016 were searched for studies assessing obstetric outcomes in women with or without previous local cervical treatment.

DATA EXTRACTION AND SYNTHESIS

 Independent reviewers extracted the data and performed quality assessment using the Newcastle-Ottawa criteria. Studies were classified according to method and obstetric endpoint. Pooled risk ratios were calculated with a random effect model and inverse variance. Heterogeneity between studies was assessed with I(2) statistics.

MAIN OUTCOME MEASURES

 Obstetric outcomes comprised preterm birth (including spontaneous and threatened), premature rupture of the membranes, chorioamnionitis, mode of delivery, length of labour, induction of delivery, oxytocin use, haemorrhage, analgesia, cervical cerclage, and cervical stenosis. Neonatal outcomes comprised low birth weight, admission to neonatal intensive care, stillbirth, APGAR scores, and perinatal mortality.

RESULTS

 71 studies were included (6 338 982 participants: 65 082 treated/6 292 563 untreated). Treatment significantly increased the risk of overall (<37 weeks; 10.7% v 5.4%; relative risk 1.78, 95% confidence interval 1.60 to 1.98), severe (<32-34 weeks; 3.5% v 1.4%; 2.40, 1.92 to 2.99), and extreme (<28-30 weeks; 1.0% v 0.3%; 2.54, 1.77 to 3.63) preterm birth. Techniques removing or ablating more tissue were associated with worse outcomes. Relative risks for delivery at <37 weeks were 2.70 (2.14 to 3.40) for cold knife conisation, 2.11 (1.26 to 3.54) for laser conisation, 2.02 (1.60 to 2.55) for excision not otherwise specified, 1.56 (1.36 to 1.79) for large loop excision of the transformation zone, and 1.46 (1.27 to 1.66) for ablation not otherwise specified. Compared with no treatment, the risk of preterm birth was higher in women who had undergone more than one treatment (13.2% v 4.1%; 3.78, 2.65 to 5.39) and with increasing cone depth (≤10-12 mm; 7.1% v 3.4%; 1.54, 1.09 to 2.18; ≥10-12 mm: 9.8% v 3.4%, 1.93, 1.62 to 2.31; ≥15-17 mm: 10.1% v 3.4%; 2.77, 1.95 to 3.93; ≥20 mm: 10.2% v 3.4%; 4.91, 2.06 to 11.68). The choice of comparison group affected the magnitude of effect. This was higher for external comparators, followed by internal comparators, and ultimately women with disease who did not undergo treatment. In women with untreated CIN and in pregnancies before treatment, the risk of preterm birth was higher than the risk in the general population (5.9% v 5.6%; 1.24, 1.14 to 1.35). Spontaneous preterm birth, premature rupture of the membranes, chorioamnionitis, low birth weight, admission to neonatal intensive care, and perinatal mortality were also significantly increased after treatment. :

CONCLUSIONS

 Women with CIN have a higher baseline risk for prematurity. Excisional and ablative treatment further increases that risk. The frequency and severity of adverse sequelae increases with increasing cone depth and is higher for excision than for ablation.

Cold-knife conisation and large loop excision of transformation zone significantly increase the risk for spontaneous preterm birth: a population-based cohort study

OBJECTIVES

Our aim was to explore the association between cold-knife conisation and large loop excision of transformation zone (LLETZ) with spontaneous preterm birth in a large 10-year national sample. We wanted to explore further the association of these procedures with preterm birth according to gestation.

STUDY DESIGN

We conducted a population based retrospective cohort study, using data from national Medical Birth Registry. The study population consisted of all women giving birth to singletons in the period 2003-2012 in Slovenia, excluding all induced labors and elective cesarean sections before 37 weeks of gestation (N=192730). We compared the prevalence of spontaneous preterm births (before 28 weeks, before 32 weeks, before 34 weeks and before 37 weeks of gestation) in women with cold-knife conisation or LLETZ compared to women without history of conisation, calculating odds ratios (OR), adjusted for potential confounders. Chi-square test was used for descriptive analysis. Logistic regression analyses were performed to estimate crude odds ratio (OR) and adjusted odds ratio (aOR) and their 95% confidence intervals (95% CI) with two-sided probability (p) values.

RESULTS

A total of 8420 (4.4%) women had a preterm birth before 37 weeks of gestation, 2250 (1.2%) before 34 weeks of gestation, 1333 (0.7%) before 32 weeks of gestation and 603 (0.3%) before 28 weeks of gestation. A total of 4580 (2.4%) women had some type of conisation in their medical history: 2083 (1.1%) had cold-knife conisation and 2498 (1.3%) had LLETZ. In women with history of cold-knife conisation, the adjusted OR for preterm birth before 37 weeks of gestation was 3.13 (95% CI; 2.74-3.57) and for preterm birth before 28 weeks of gestation 5.96 (95% CI; 4.3-8.3). In women with history of LLETZ, the adjusted OR was 1.95 (95% CI; 1.68-2.25) and 2.88 (95% CI; 1.87-4.43), respectively.

CONCLUSIONS

Women with cervical excision procedure of any kind have significantly increased odds for preterm birth, especially for preterm birth before 28 weeks and before 32 weeks of gestation.

A Small Molecule Inhibitor Selectively Induces Apoptosis in Cells Transformed by High Risk Human Papilloma Viruses

A phenotypic high-throughput cell culture screen was performed to identify compounds that prevented proliferation of the human Papilloma virus type 16 (HPV-16) transformed cell line Ca Ski. A series of quinoxaline compounds exemplified by Compound 1 was identified. Testing against a panel of cell lines demonstrated that Compound 1 selectively inhibited replication of all HPV-16, HPV-18, and HPV-31 transformed cell lines tested with 50% Inhibitory Concentration (IC₅₀) values of 2 to 8 μM relative to IC₅₀ values of 28 to 73 μM in HPV-negative cell lines. Treatment with Compound 1 resulted in a cascade of multiple apoptotic events, including selective activation of effector caspases 3 and 7, fragmentation of cellular DNA, and PARP (poly(ADP-ribose) polymerase) cleavage in HPV-positive cells relative to HPV-negative cells. Unregulated proliferation of HPV transformed cells is dependent on the viral oncogenes, E6 and E7. Treatment with Compound 1 resulted in a decrease in HPV E7 protein in Ca Ski cells. However, the timing of this reduction relative to other effects of compound treatment suggests that this was a consequence, rather than a cause, of the apoptotic cascade. Likewise, compound treatment resulted in no obvious effects on the E6- and E7- mediated down regulation of p53 and Rb, or their downstream effectors, p21 or PCNA. Further investigation of apoptotic signals induced by Compound 1 revealed cleavage of Caspase-8 in HPV-positive cells as early as 2 hours post-treatment, suggesting the compound initiates apoptosis through the extrinsic, death receptor-mediated, pathway of cell death. These studies provide proof of concept that cells transformed by oncogenic Papillomaviruses can be selectively induced to undergo apoptosis by compound treatment.

Biophysical and Biochemical Screening for the Risk of Preterm Labor: An Update

The heterogeneous causes of spontaneous preterm birth make prediction and prevention difficult. Recently developed biochemical and biophysical tests add significantly to clinicians' ability to evaluate and treat women at risk for spontaneous preterm birth. The primary importance of transvaginal cervical sonography and cervicovaginal fetal fibronectin lies in the high negative predictive values of the tests for preterm delivery risk. Cervical length may be useful in identifying women who are candidates for cervical cerclage or progesterone therapy for preterm birth prevention. Together, cervical length and fibronectin can be used in the triaging of women symptomatic for preterm labor.

Therapeutic effects of traditional Chinese medicine in patients with symptomatic cervical ectopy

PURPOSE

The aim of this study is to evaluate the treatment and efficacy of Badushengjigao, a traditional Chinese medicine (TCM) formula, for symptomatic cervical ectopy.

METHOD

A patient self-selected two group comparison study was performed. One hundred patients with symptomatic cervical ectopy admitted to the Central Hospital of E-Zhou (Hubei, China) between July 2013 and July 2014 were enrolled in the study. The patients treated with Badushengjigao were the study group and the patients treated with policresulen suppository were the control group. The medicine was administered through vagina. Patients received a three-month follow-up (once a month). The treatment results were evaluated and analyzed by variance analysis and X(2) test.

RESULTS

The curative rates of the two groups with symptomatic cervical ectopy grade 1 shows no statistical significance. As for grade 2 and grade 3, the curative rates of the study group (phase 2: 72.0%; phase 3: 62.5%) are higher than that of the control group (phase 2: 44.4%; grade 3: 54.5%) with statistical difference (P < 0.05). The study group has less adverse effects (2.5 ± 1.3 days of vagina bleeding, 6 cases of abdominal pain and 2 cases of increased discharge) than the control group (12.5 ± 1.1 days of vagina bleeding, 15 cases of abdominal pain and 42 cases of increased discharge) with distinctive statistical difference (P < 0.01).

CONCLUSION

The TCM formula, Badushengjigao, seems to be more effective than policresulen suppositories in treating symptomatic cervical ectopy phase 2 and phase 3. We suggest that it could be used as an alternative method for symptomatic cervical ectopy treatment, but further study is needed.

The LAST guidelines in clinical practice: implementing recommendations for p16 use

OBJECTIVES

To determine the impact of implementing p16 Lower Anogenital Squamous Terminology Standardization Project for HPV-Associated Lesions (LAST) guidelines, we compared p16 use and follow-up data before and after implementation of the guidelines.

METHODS

We reviewed all cervical biopsy specimens diagnosed by two pathologists before and after implementation of the LAST guidelines and calculated the rate of and reason for p16 use across all biopsy specimens, high-grade squamous intraepithelial lesion (HSIL) detection, and follow-up.

RESULTS

In total, 1,829 and 1,623 cervical biopsy specimens were reviewed in periods A and B, respectively. Overall p16 use increased from 2.8% to 6.2% (P < .001). Recommendations 2 and 4 increased from 0.16% and 0% of all cervical biopsy specimens in period A to 1.4% and 1.9% in period B, respectively (P < .0001). p16+ HSIL increased from 1.4% to 2.3% (P < .05). The positive predictive value of p16+ HSIL increased from 48% to 76% (P < .05).

CONCLUSIONS

Implementation of the p16 LAST guidelines resulted in a significant increase in p16 use and a significant increase in the positive predictive value of p16+ HSIL.

The association between cervical dysplasia, a short cervix, and preterm birth

OBJECTIVE

We sought to determine whether cervical dysplasia in the absence of an excisional procedure is associated with an increased risk of preterm birth (PTB) and whether that risk is independent of the presence of a short cervix.

STUDY DESIGN

This is a cohort study including women with a singleton pregnancy who underwent routine cervical length assessment between 18-23 6/7 weeks of gestation, stratified by cervical dysplasia (ie, no prior dysplasia, prior dysplasia but no excisional procedure, or prior excisional procedure). The frequency of a short cervix (≤2.5 cm) and PTB were compared between groups and multivariable analyses were performed to identify whether: (1) dysplasia alone or a prior excisional procedure was associated with PTB; and (2) whether these factors remained independently associated with PTB after adjusting for the presence of a short cervix.

RESULTS

Of the 18,528 women who met inclusion criteria, 3023 (16.3%) had prior dysplasia alone and 1356 (7.3%) had a prior excisional procedure. The frequency of a short cervix for women without dysplasia, with prior dysplasia alone, or with a prior excisional procedure was 0.8%, 1.0%, and 2.2%, respectively (P < .001). The frequency of PTB, respectively, was 6.4%, 6.5%, and 8.4% (P < .001). After adjusting for potential confounding factors, prior excisional procedure but not prior dysplasia alone was associated with PTB.

CONCLUSION

Having a prior cervical excisional procedure but not dysplasia alone is associated with an increased risk of PTB. This association is independent of the presence of a short cervix.

Association between cervical screening and prevention of invasive cervical cancer in Ontario: a population-based case-control study

OBJECTIVE

The aim of this study was to estimate the effect of cervical screening in the prevention of invasive cervical cancer among age groups, using a population-based case-control study in the province of Ontario, Canada.

METHODS

Exposure was defined as cervical cytology history greater than 3 months before the diagnosis date of cervical cancer (index date). Cases were women who were diagnosed with cervical cancer between January 1, 1998, and December 31, 2008. Controls were women without a diagnosis of cervical cancer on, or before, December 31, 2008. Two controls were matched to each case on year of birth and income quintile, as of the index date. Conditional logistic regression was used to estimate the odds ratio for having been screened among those with cervical cancer.

RESULTS

Cervical cancer screening performed between 3 and 36 months before the index date was protective against invasive cervical cancer in women aged 40 through 69 years. In women younger than 40 years, cervical cancer screening performed 3 to 36 months before the index date was not protective.

CONCLUSIONS

Cervical screening is associated with a reduced risk for invasive cervical cancer among women older than 40 years. Cervical cancer resources should be focused on maximizing the risk reduction.

Recurrence of high-grade cervical abnormalities following conservative management of cervical intraepithelial neoplasia grade 2

OBJECTIVE

Conservative management of cervical intraepithelial neoplasia (CIN) grade 2 in women younger than 25 years may reduce overtreatment. However, long-term efficacy remains uncertain. This retrospective cohort study aimed to determine the rate of recurrence of high-grade abnormalities among young women with a history of CIN 2 that spontaneously regressed within 2 years and compare this with the rate of high-grade abnormality in similar women with an initial diagnosis of CIN 1.

STUDY DESIGN

We identified all women aged younger than 25 years who were diagnosed with CIN 1 or CIN 2 between January 2005 and August 2009 within 2 colposcopy units. Follow-up data from the National Cervical Screening Programme were obtained to identify those women who developed recurrent high-grade lesions before October 2012. Comparisons were made using Cox proportional hazards regression.

RESULTS

A total of 683 women were included: 106 with CIN 2 that spontaneously regressed, 299 with treated CIN 2, and 278 with conservatively managed CIN 1. Median follow-up was 4 years. There was no significant difference in the risk of development of high-grade abnormalities after 2 years between the spontaneously regressing CIN 2 and CIN 1 groups (P = .83). Women with treated CIN 2 had a significantly lower risk of recurrence than women with untreated CIN 2 (P = .01).

CONCLUSION

CIN 2 that has spontaneously regressed appears to behave as a low-grade lesion. This study contributes to the growing body of evidence that careful observation of CIN 2 is an efficacious and appropriate initial management option for women aged younger than 25 years at diagnosis.

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

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.

Loop electrosurgical excision procedure and risk of vaginal infections during pregnancy: an observational study

OBJECTIVE

To investigate the risk for preterm birth associated with vaginal infections in pregnancies after a loop electrosurgical excision procedure (LEEP), compared with women with no prior LEEP.

DESIGN

Multicentre retrospective cohort study.

SETTING

USA.

POPULATION

Women with LEEP between 1996 and 2006 were compared with two unexposed groups who had cervical biopsy or Pap test, without any other cervical procedure, in the same calendar year.

METHODS

The first pregnancy progressing beyond 20 weeks of gestation in women with prior LEEP was compared with pregnancy in women without LEEP. Stratified analysis according to the presence or the absence of vaginal infection during pregnancy was used to investigate whether the risk for preterm birth differed according to the presence or the absence of infection. The interaction between LEEP and vaginal infection was investigated using multivariable logistic regression with interaction terms, as well as the Mantel-Haenszel test for homogeneity.

MAIN OUTCOME MEASURES

Spontaneous preterm birth (<37 and <34 weeks of gestation).

RESULTS

Of 1727 patients who met the inclusion criteria, 34.4% (n = 598) underwent LEEP prior to an index pregnancy. There was no increased risk for vaginal infections among women with LEEP compared with women without LEEP. Chlamydia infection and LEEP demonstrated significant interaction, suggesting that the presence of chlamydia infection in women with a history of LEEP augments the risk for preterm birth, compared with women with no history of LEEP.

CONCLUSIONS

Vaginal infections during pregnancy in women with a history of LEEP may be associated with an increased risk for preterm birth, compared with women with no history of LEEP.

Risk of preterm delivery with increasing depth of excision for cervical intraepithelial neoplasia in England: nested case-control study

OBJECTIVE

To determine the association between depth of excision of cervical intraepithelial neoplasia and risk of preterm birth.

DESIGN

Case-control study nested in record linkage cohort study.

SETTING

12 hospitals in England.

PARTICIPANTS

From a cohort of 11 471 women with at least one histological sample taken at colposcopy and a live singleton birth (before or after colposcopy), 1313 women with a preterm birth (20-36 weeks) were identified and frequency matched on maternal age at delivery, parity, and study site to 1313 women with term births (38-42 weeks).

MAIN OUTCOME MEASURES

Risk of preterm birth and very/extreme preterm birth by depth of excisional treatment of the cervical transformation zone.

RESULTS

After exclusions, 768 preterm births (cases) and 830 term births after colposcopy remained. The risk of preterm birth was no greater in women with a previous small (<10 mm) excision (absolute risk 7.5%, 95% confidence interval 6.0% to 8.9%) than in women with a diagnostic punch biopsy (7.2%, 5.9% to 8.5%). Women with a medium (10-14 mm) (absolute risk 9.6%; relative risk 1.28, 0.98 to 1.68), large (15-19 mm) (15.3%; 2.04, 1.41 to 2.96), or very large (≥ 20 mm) excision (18.0%; 2.40, 1.53 to 3.75) had a higher risk of preterm delivery than those with small excision. The same pattern was seen in 161 women with very/extremely preterm births (20-31 weeks) and with increasing volume excised. Most births were conceived more than three years after colposcopy, and the risk of preterm delivery did not seem to depend on time from excision to conception.

CONCLUSIONS

The risk of preterm birth is at most minimally affected by a small excision. Larger excisions, particularly over 15 mm or 2.66 cm(3), are associated with a doubling of the risk of both preterm and very preterm births. The risk does not decrease with increasing time from excision to conception. Efforts should be made to excise the entire lesion while preserving as much healthy cervical tissue as possible. Close obstetric monitoring is warranted for women who have large excisions of the cervical transformation zone.

Colposcopic management of abnormal cervical cytology and histology

OBJECTIVE

To provide a guideline for managing abnormal cytology results after screening for cervical cancer, to clarify the appropriate algorithms for follow-up after treatment, and to promote the best possible care for women while ensuring efficient use of available resources.

OUTCOMES

Women with abnormal cytology are at risk of developing cervical cancer; appropriate triage and treatment will reduce this risk. This guideline will facilitate implementation of common standards across Canada, moving away from the current trend of individual guidelines in each province and territory.

EVIDENCE

Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in October 2008 using appropriate controlled vocabulary (e.g., colposcopy, cervical dysplasia) and key words (e.g., colposcopy management, CIN, AGC, cervical dysplasia, LEEP, LLETZ, HPV testing, cervical dysplasia triage). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Expert opinion from published peer-reviewed literature and evidence from clinical trials is summarized. Consensus opinion is outlined when evidence is insufficient.

VALUES

The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1).

VALIDATION

This guideline has been reviewed for accuracy from content experts in cytology, pathology, and cervical screening programs. Guideline content was also compared with similar documents from other organizations including the American Society for Colposcopy and Cervical Pathology, the British Society for Colposcopy and Cervical Pathology, and the European Cancer Network.

Cervical conisation and the risk of preterm delivery: a retrospective matched pair analysis of a German cohort

PURPOSE

Since the routine screening program for cervical dysplasia by Pap smear was established in the early 1970s, the rate of cervical cancer has continually dropped. Even if a high percentage of cervical dysplasia shows spontaneous restitution, the only effective therapy for persisting cervical dysplasia is local ablation or excision which might be associated with an increased risk of preterm delivery in subsequent pregnancies. However, data from German patients are missing, so the aim of this study was to evaluate the risk of preterm delivery and associated risks in a cohort of patients who had undergone cervical conisation previous to their pregnancies.

METHODS

A total of 144 patients with conisation and subsequent pregnancy were identified. They were compared regarding week of delivery and preterm birth, fetal birth weight, fetal outcome and birth procedure (spontaneous delivery, vacuum extraction, primary and secondary cesarean section) with their matched partners.

RESULTS

135 patients with singleton pregnancies and their matched partners were evaluated in the final analysis. The mean age was 33.5 years. Comparing the case and control group we reached significant different results for week of delivery, but not preterm birth defined as birth prior to 37 weeks of gestation.

CONCLUSIONS

Within this German cohort cervical conisation did not increase the risk for preterm birth, cesarean section or poor fetal outcome. We therefore conclude that cervical conisation is an appropriate method to treat women with cervical dysplasia also at childbearing age when prevention of cervical cancer is needed.

The association between cervical excisional procedures, midtrimester cervical length, and preterm birth

OBJECTIVE

To determine whether a prior cervical excisional procedure (a loop electrosurgical excision procedure or cold knife cone) is associated with a short midtrimester cervical length (<3 cm) and whether having a short cervix explains the relationship between this procedure and preterm birth.

STUDY DESIGN

In this cohort study of women with a singleton pregnancy who underwent routine cervical length assessment between 18 and 24 weeks of gestation, women with a history of a prior cervical excisional procedure were compared with those without such a history. Bivariable and multivariable analyses were performed to identify whether a prior cervical excisional procedure remained an independent risk factor for preterm birth after controlling for cervical length.

RESULTS

Of the 6669 women who met inclusion criteria, 460 (6.9%) had a prior cervical excisional procedure. Mean cervical length was shorter (4.2 ± 0.9 cm vs 4.5 ± 0.9 cm, P < .001) and the proportion of women with a short cervix was higher (6.5% vs 1.5%, P < .001) in women with a prior cervical excisional procedure. In multivariable regression, both a short cervix (adjusted odds ratio, 6.19; 95% confidence interval, 3.85-9.95) and a prior cervical excisional procedure (adjusted odds ratio, 1.53; 95% confidence interval, 1.04-2.25) were significantly associated with preterm birth.

CONCLUSION

Women with a prior cervical excisional procedure have shorter midtrimester cervical lengths. Both a prior cervical excisional procedure and a short cervix were independently associated with preterm birth. These data suggest that the risk of preterm birth associated with a prior loop electrosurgical excision procedure or cold knife cone is not merely due to postsurgical shortening of the cervix.

Predictive value of volume of cervical tissue removed during LLETZ on subsequent preterm delivery: a cohort study

OBJECTIVE

To evaluate the impact of volume of tissue removed during large loop excision of transformation zone on subsequent preterm birth rates.

STUDY DESIGN

A retrospective cohort study was carried out in a single, large tertiary referral unit in UK. A total of 556 women who delivered between January 2008 and December 2011 following a previous large loop excision of transformation zone procedure or punch biopsy were identified from the maternity and colposcopy databases. Demographic data, gestational age at delivery, birthweight, neonatal outcome and dimensions of excised cervical specimen were collected. Pregnancy outcomes for women who had a previous loop excision were compared to a matched control group who had undergone punch biopsies only.

RESULTS

There was a significant increase in preterm birth rate in the large loop excision group compared to the control group (9.0% vs. 3.6%, respectively, RR 2.5, 95% CI 1.224-5.107). Women who had undergone at least one previous loop excision had more than a threefold increased risk of spontaneous preterm birth compared with their matched controls. However, no relationship between volume or depth of cervical tissue excised and subsequent gestation at delivery could be demonstrated.

CONCLUSIONS

Whilst LLETZ is associated with an increased rate of preterm birth, the volume of tissue removed does not appear to influence the subsequent gestational age at delivery. This should reassure clinicians who should continue to perform LLETZ with adequate tissue margins to ensure complete resection of disease.

Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis

OBJECTIVE

To assess whether loop electrosurgical excision procedure (LEEP) increases the risk for preterm birth before 37 weeks of gestation and clarify whether the increased risk for preterm birth is attributable to the procedure itself or to risk factors associated with cervical dysplasia.

DATA SOURCES

Two authors performed a search of the relevant data through February 2013 using PubMed, Embase, Scopus, CENTRAL, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

We included observational studies that compared rates of preterm birth in women with prior LEEP with women with no history of cervical excision. Nineteen of 559 identified studies met selection criteria.

TABULATION, INTEGRATION, AND RESULTS

We compared women with a history of LEEP with two unexposed groups without a history of cervical excision: 1) women with an unknown or no history of cervical dysplasia; and 2) women with a history of cervical dysplasia but no cervical excision. The primary outcome was preterm birth before 37 weeks of gestation. Secondary outcomes were preterm birth before 34 weeks of gestation, spontaneous preterm birth, preterm premature rupture of membranes, and perinatal mortality. DerSimonian-Laird random effects models were used. We assessed heterogeneity between studies using the Q and I tests. Stratified analyses and metaregression were performed to assess confounding. Nineteen studies were included with a total of 6,589 patients with a history of LEEP and 1,415,015 without. Overall, LEEP was associated with an increased risk of preterm birth before 37 weeks of gestation (pooled relative risk 1.61, 95% confidence interval [CI] 1.35-1.92). However, no increased risk was found when women with a history of LEEP were compared with women with a history cervical dysplasia but no cervical excision (pooled relative risk 1.08, 95% CI 0.88-1.33).

CONCLUSION

Women with a history of LEEP have similar risk of preterm birth when compared with women with prior dysplasia but no cervical excision. Common risk factors for both preterm birth and dysplasia likely explain findings of association between LEEP and preterm birth, but LEEP itself may not be an independent risk factor for preterm birth.

Cervical excisional treatment of young women: a population-based study

OBJECTIVE

Assessment of cytology and biopsy results preceding cervical excisional treatment and their association with excisional histology, to evaluate compliance with treatment recommendations and the potential effect of revisions in cervical histology terminology and usage.

METHOD

Data from a unique statewide population-based screening registry was used to describe the use and histologic outcomes of cervical excisional procedures in the year following an abnormal cervical screening cytology.

RESULTS

From 2007 to 2011, LEEP rates decreased 87%, 45%, and 16% for women aged 15-20, 21-24, and 25-29 years, respectively. Reductions were attributable to an overall decline in cervical screening and colposcopy, and a decrease in LEEP following a diagnosis of less than cervical intraepithelial neoplasia grade 2 (0.7) for women aged 30-39 years. Irrespective of age, CIN2 was the most common histologic antecedent of excisional treatment (42%), with most (80%) preceded by

CONCLUSION

Cervical excisions are an unavoidable consequence of cervical screening. Adherence to treatment guidelines stipulating conservative follow-up of young women with biopsies ≤CIN2 could significantly decrease the number of excisional procedures and associated harms. This opportunity will be lost if cervical intraepithelial neoplasia grade 3 (CIN3) and some or all of CIN2 are merged into a single histologic category, as has been recently recommended in the United States.

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Key Words

• Adherence to cervical treatment guidelines
• Cervical intraepithelial neoplasia grades 2 and 3 (CIN2 and CIN3)
• Cervical screening
• Colposcopy
• Effectiveness and harms of cervical screening
• Loop electrosurgical excision procedure (LEEP)

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MESH Headings

• Adolescent
• Adult
• Biopsy/methods
• Biopsy/statistics & numerical data
• Conization/methods
• Conization/statistics & numerical data
• Electrosurgery/methods
• Electrosurgery/statistics & numerical data
• Female
• Humans
• New Mexico/epidemiology
• Registries
• Uterine Cervical Neoplasms/classification
• Uterine Cervical Neoplasms/epidemiology
• Uterine Cervical Neoplasms/pathology
• Uterine Cervical Neoplasms/surgery
• Young Adult
• Uterine Cervical Dysplasia/classification
• Uterine Cervical Dysplasia/epidemiology
• Uterine Cervical Dysplasia/pathology
• Uterine Cervical Dysplasia/surgery

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Grants

• U19 AI084081 NIAID NIH HHS
• U54 CA164336 NCI NIH HHS
• U19AI084081 NIAID NIH HHS
• U54CA164336 NCI NIH HHS

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Affiliation(s)

Walter Kinney Department of Women's Health and Division of Gynecologic Oncology, The Permanente Medical Group, Oakland, CA, USA
William C Hunt Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
Helen Dinkelspiel Division of Gynecologic Oncology, Columbia University College of Physicians and Surgeons, New York, NY, USA
Michael Robertson Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
Jack Cuzick Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
Cosette M Wheeler Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA; Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.

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The association between cervical cancer screening and mortality from cervical cancer: a population based case-control study

OBJECTIVE

To estimate the effect of cervical cancer screening on mortality from cervical cancer in women between the ages of 20 and 69 residing in Ontario by 5 year age groups.

METHODS

An Ontario population based case-control study of women between ages 20 and 69 was performed. Cases were women who were diagnosed with cervical cancer between January 1, 1998 and December 31, 2008 who died from cervical cancer within this period. Controls were women without a diagnosis of cervical cancer between January 1, 1998 and December 31, 2008 who were alive on the case's date of death. Exposure was defined as cervical cytology history. Conditional logistic regression was used to estimate the strength of association between mortality from cervical cancer and screening in 5 year incremental age intervals.

RESULTS

We identified 1052 cases and 10,494 controls. Less than 2.5% of women who died from cervical cancer were under the age of 30. Cervical cancer screening performed 3-36 months prior to the date of diagnosis was found to be protective of mortality from cervical cancer in women over the age of 30 (odds ratio=0.28-0.60; p<0.05 in all strata). In women under the age of 30 cervical cancer screening was not found to be protective of mortality from cervical cancer (odds ratio=1.58-2.43; non significant).

CONCLUSION

No association between cervical cancer screening and mortality from cervical cancer under the age of 30 was found. This could be due to there being a small or having no effect or due to the fact that mortality from cervical cancer under the age of 30 is extremely rare.

Cervical squamocolumnar junction-specific markers define distinct, clinically relevant subsets of low-grade squamous intraepithelial lesions

Low-grade cervical squamous abnormalities (low-grade squamous intraepithelial lesions [LSIL, CIN1]) can be confused with or followed by high-grade (HSIL, CIN2/3) lesions, expending considerable resources. Recently, a cell of origin for cervical neoplasia was proposed in the squamocolumnar junction (SCJ); HSILs are almost always SCJ, but LSILs include SCJ and SCJ subsets. Abnormal cervical biopsies from 214 patients were classified by 2 experienced pathologists (panel) as LSIL or HSIL using published criteria. SILs were scored SCJ and SCJ using SCJ-specific antibodies (keratin7, AGR2, MMP7, and GDA). Assessments of interobserver agreement, p16 staining pattern, proliferative index, and outcome were compared. The original diagnostician agreed with the panel diagnosis of HSIL and SCJ LSIL in all cases (100%). However, for SCJ LSIL, panelists disagreed with each other by 15% and with the original diagnostician by 46.2%. Comparing SCJ and SCJ LSILs, 60.2% and 94.9% were p16 positive, 23% and 74.4% showed strong (full-thickness) p16 staining, and 0/54 (0%) and 8/33 (24.2%) with follow-up had an HSIL outcome, respectively. Some SCJ LSILs are more likely to both generate diagnostic disagreement and be associated with HSIL. Conversely, SCJ LSILs generate little observer disagreement and, when followed, have a very low risk of HSIL outcome. Thus, SCJ biomarkers in conjunction with histology may segregate LSILs with very low risk of HSIL outcome and conceivably could be used as a management tool to reduce excess allocation of resources to the follow-up of these lesions.

Risk of preterm delivery associated with prior treatment of cervical precancerous lesion according to the depth of the cone

The aim of this study was to evaluate the impact of the surgical excisional procedures for cervical intraepithelial neoplasia (CIN) treatment both on subsequent fertility (cervical factor) and pregnancy complication (risk of spontaneous preterm delivery). We retrospectively analyzed 236 fertile women who underwent conization for CIN. We included in the study 47 patients who carried on pregnancy and delivered a viable fetus. Patients were asked about postconization pregnancies, obstetrical outcomes, and a possible diagnosis of secondary infertility caused by cervical stenosis. We evaluated the depth of surgical excision, the timing between cervical conization and subsequent pregnancies, surgical technique, and maternal age at delivery. We recorded 47 deliveries, 10 cases of preterm delivery; 8 of them were spontaneous. The depth of surgical excision showed a statistically significant inverse correlation with gestational age at birth. The risk of spontaneous preterm delivery increased when conization depth exceeded a cut-off value of 1.5 cm. Our data do not demonstrated a relation between conization and infertility due to cervical stenosis.

Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis

OBJECTIVE

This study aimed at assessing the association of the relative risk (RR) of adverse pregnancy outcomes with previous treatment of loop electrosurgical excision procedure (LEEP) for the management of cervical intraepithelial neoplasia (CIN).

METHODS

Data sources were from MEDLINE, EMBASE, and SCI citation tracking.

SELECTION CRITERIA

The eligible studies had data on pregnancy outcomes of women with or without previous treatment for CIN. Considered outcomes were severe preterm delivery (<34/32 weeks), extreme preterm delivery (<28 weeks), low birth weight (<2,500 g), stillbirth, preterm spontaneous rupture of membranes, perinatal mortality, and neonatal mortality and induction.

RESULTS

36,954 cases and 1,794,174 controls in 4 prospective cohort and 22 retrospective studies were included in this meta-analysis. LEEP was associated with a higher risk of severe preterm delivery (<32 weeks, relative risk 1.98, 95% CI [1.31, 2.98] 159/11,337 vs. 7,830/860,883), extreme preterm delivery (<28 weeks, RR, 2.33, 95% CI [1.84, 2.94] 97/9,611 vs. 1,559/618,332), preterm premature rupture of the membranes (RR, 1.88, 95% CI [1.54, 2.29] 126/2,837 vs. 7,899/313,094), and low birth weight (<2,500 g, RR, 2.48, 95% CI [1.75, 3.51] 110/1,451 vs. 55/1,742). A cervical length of less than 3 cm was significantly increased in LEEP as compared with that of control group (RR, 4.88, 95% CI [1.56, 15.25]), but increasing LEEP volume or depth was not associated with an increased rate of preterm birth <37 weeks. And LEEP was not associated with a significantly increased risk of perinatal mortality, cesarean section, stillbirth mortality, neonatal mortality, induction, and neonatal intensive care unit admission.

CONCLUSIONS

LEEP is associated with an increased risk of subsequent preterm delivery (<32/34, <28 weeks) and other serious pregnancy outcomes. But increasing LEEP volume or depth is not associated with an increased rate of preterm birth.

Risk of cesarean delivery after loop electrosurgical excision procedure

OBJECTIVE

To estimate whether previous loop electrosurgical excision procedure (LEEP) affects the risk of cesarean delivery.

METHODS

A secondary analysis of a multicenter retrospective cohort study was performed. Women who underwent a prior LEEP were compared with two unexposed cohorts: 1) women with prior screening cervical cytology only; and 2) women with prior cervical punch biopsy. The pregnancy evaluated in this analysis was the first pregnancy of a duration more than 20 weeks of gestation after the identifying cervical procedure. Stratified and multivariable logistic regression analyses were used to control for confounding.

RESULTS

Five hundred ninety-eight women with prior LEEP, 588 women with screening cytology only, and 552 women with cervical biopsy were included in this study. After adjusting for relevant confounders, similar rates of cesarean delivery were seen in women with prior LEEP (31.6%) and women with prior cervical cytology only (29.3%, adjusted odds ratio [OR] 1.06, 95% confidence interval [CI] 0.79-1.41). Likewise, no differences were found in rates of cesarean delivery when women with prior LEEP were compared with those with a prior punch biopsy (29.0%, adjusted OR 0.99, 95% CI 0.74-1.33). Among women who had a cesarean delivery, arrest of labor was the indication for cesarean delivery in a similar proportion of women in the groups (LEEP compared with cytology only, P=.12; LEEP compared with biopsy, P=.50). Loop electrosurgical excision procedure specimen size did not vary by delivery mode. Length of time between LEEP and subsequent pregnancy also did not influence delivery mode.

CONCLUSION

Loop electrosurgical excision procedure does not affect mode of delivery in the subsequent pregnancy.

LEVEL OF EVIDENCE

II.