Recurrence after Treatment by Loop Electrosurgical Excision Procedure (LEEP) of High-Grade Cervical Intraepithelial Neoplasia

Benefits, harms and cost-effectiveness of cervical screening, triage and treatment strategies for women in the general population

In 2020, the World Health Organization (WHO) launched a strategy to eliminate cervical cancer as a public health problem. To support the strategy, the WHO published updated cervical screening guidelines in 2021. To inform this update, we used an established modeling platform, Policy1-Cervix, to evaluate the impact of seven primary screening scenarios across 78 low- and lower-middle-income countries (LMICs) for the general population of women. Assuming 70% coverage, we found that primary human papillomavirus (HPV) screening approaches were the most effective and cost-effective, reducing cervical cancer age-standardized mortality rates by 63-67% when offered every 5 years. Strategies involving triaging women before treatment (with 16/18 genotyping, cytology, visual inspection with acetic acid (VIA) or colposcopy) had close-to-similar effectiveness to HPV screening without triage and fewer pre-cancer treatments. Screening with VIA or cytology every 3 years was less effective and less cost-effective than HPV screening every 5 years. Furthermore, VIA generated more than double the number of pre-cancer treatments compared to HPV. In conclusion, primary HPV screening is the most effective, cost-effective and efficient cervical screening option in LMICs. These findings have directly informed WHO's updated cervical screening guidelines for the general population of women, which recommend primary HPV screening in a screen-and-treat or screen-triage-and-treat approach, starting from age 30 years with screening every 5 years or 10 years.

Clinical Outcomes Associated with Endocervical Glandular Involvement in Patients with Cervical Intraepithelial Neoplasia III

This study aimed to determine whether endocervical glandular involvement (GI) affects the clinical prognosis of patients with cervical intraepithelial neoplasia (CIN) III who underwent the loop electrosurgical excision procedure (LEEP). This retrospective study included 250 patients who underwent LEEP for the treatment of CIN III between August 2005 and May 2020. The medical records of 234 patients were analyzed; 137 (58.5%) patients were GI negative, and 97 (41.5%) were GI positive. Margin involvement of the LEEP specimen was found in 59 (45.4%) patients in the GI-negative group and 54 (58.7%) patients in the GI-positive group (p = 0.051). The additional surgical procedures (repeat conization or hysterectomy) were significantly more performed in GI-positive patients than in GI-negative patients (40.9% vs. 23.1%, p = 0.004). When comparing the LEEP specimens of GI-1 (GI-positive confirmed via cervical biopsy before conization) and GI-2 (GI-positive confirmed via conization), we found that the mean depth was significantly greater in the GI-1 group (10.9 mm) than in the GI-2 group (7.6 mm) (p = 0.024). Surgical margin involvement was more frequently observed in the GI-2 group than in the GI-1 group (p = 0.030). There was no significant difference in the recurrence rates of CIN between the GI-negative and GI-positive groups (p = 0.641). In conclusion, despite no significant differences in residual disease and CIN recurrence between the GI-negative and GI-positive groups, additional surgical treatments were more frequently performed in GI-positive patients. Repeat surgery based on GI positivity should be carefully considered to avoid overtreatment and surgical complications.

Prognostic value of HPV 16/18 genotyping and geminin mRNA quantification in low-grade cervical squamous intraepithelial lesion

Low-grade cervical squamous intraepithelial lesion is a precancerous neoplasia that has appreciable probability to evolve into malignancy. To explore the prognostic value of HPV 16/18 genotyping and geminin mRNA quantification in predicting the progressiveness of LSIL. We recruited 212 participants who were negative for intraepithelial lesion or malignancy (NILM 76), low-grade squamous intraepithelial lesion (LSIL 85), high-grade squamous intraepithelial lesion (HSIL 36) and cervical intraepithelial neoplasia grade cervical cancer grade 3, (CIN3 15) patients. Tissues were obtained during excisional treatment. HPV 16/18 genotyping and geminin mRNA qRT-PCR were performed. HPV 16/18 positivity rate and geminin mRNA level were integrated with the clinical parameters into a multivariate logistic model. Area under curve was yielded based on receiver operation curve derived from this multivariate logistic model. Follow-up visits were performed to LSIL patients with progression. HSIL patients have higher HPV 16/18 positivity rate and geminin mRNA levels than LSIL. Among HSIL, CIN3 have higher HPV 16/18 positivity rate and geminin mRNA levels. Multivariate logistic analysis showed that HPV 16/18 positivity and geminin mRNA expression status are independent factors for differentiating HSIL and LSIL. The baseline HPV 16/18 positivity rate and geminin mRNA levels of 18 LSIL patients who developed HSIL are significantly higher than non-progressive LSIL patients. The values examined at follow-up timepoints were also higher than baseline. These results suggest that geminin is implicated in the progression of LSIL and combining HPV 16/18 genotyping and geminin mRNA qRT-PCR could potentially differentiating the progressive LSIL and improve the efficacy of clinical intervention.

Defining the short-term disease recurrence after loop electrosurgical excision procedure (LEEP)

BACKGROUND

The goal of cervical cancer screening is to identify dysplastic lesions for subsequent excision in order to prevent invasive disease. There is clinical equipoise, on how to best follow women for disease surveillance after treatment with some Canadian provinces exclusively performing colposcopy and some utilizing Human Papilloma Virus (HPV) testing in addition to cervical cytology. Loop Electrosurgical Excision Procedure (LEEP) is used to treat pre-invasive HPV-mediated disease and patients are typically followed for 12 months after disease excision. This study aims to quantify the prevalence of high-grade disease at the time of the second follow-up colposcopy visit, in a practice setting that utilizes laser ablation in addition to LEEP.

METHODS

In a retrospective cohort study, consecutive patient charts were accessed through the electronic medical record system, ARIA, at the Tom Baker Cancer Centre, in Calgary, Alberta, from January 2010 to December 2015. Data was extracted and a REDCap database was used to compile pertinent information from charts meeting inclusion criteria. Descriptive and analytic statistics were performed.

RESULTS

Of the 303 patients identified, 221 patients met inclusion criteria. 86% of these patients met discharge criteria from colposcopy after the second follow up visit. 31 (14%) were seen in a subsequent visit for abnormal findings. Of these, 7 (3.2%) underwent further treatment for high-grade disease/Cervical Intraepithelial Neoplasia (CIN 2/3). Of the 31, 23 (10.6%) had a third - negative - visit, resulting in discharge from colposcopy. One patient had a repeat LEEP for persistent Low-Grade Squamous Intraepithelial Lesion (LSIL).

CONCLUSION

In summary, our data demonstrates a prevalence of 3.2% of high-grade disease at the time of a second colposcopic follow up visit after treatment, in a setting which frequently utilizes laser ablation in combination with LEEP, for large lesions. This recurrence rate is consistent with most published literature on recurrence rates of CIN2/3.

Persistent Human Papilloma Virus Infection as an Indicator of Risk of Recurrence of High-Grade Cervical Intraepithelial Neoplasia Treated by the Loop Electrosurgical Excision Procedure

Objective

To evaluate the recurrence rate of high-grade cervical intraepithelial neoplasia (CIN) treated by the loop electrosurgical excision procedure (LEEP) according to the persistence of human papilloma virus (HPV) infection.

Design

Prospective observational study.

Setting

The Florence District screening program for cervical cancer.

Sample

Eighty-four cases of CIN2/3 consecutively treated by LEEP and actively followed up.

Method

Cases underwent HPV testing (polymerase chain reaction) prior to LEEP and after 6 months, and then cyto-colposcopic followup every 6 months.

Main outcomes measures

Recurrence was defined as histological evidence of high-grade CIN. The association of recurrence to age and CIN grade at treatment and to cytologic and HPV test findings at recurrence was determined.

Results

The average recurrence rate was 11.9% (10/84 cases; 95% CI, 5.9-20.8%). Recurrence probability was not significantly associated to age (χ2 = 0.25, df = 2, P = 0.88) or CIN grade (CIN 3 = 8/57, CIN2 = 2/27, χ2 = 0.26, df = 1, P = 0.6), whereas a significant association was evident for the cytology report (<LSIL = 6/76, HSIL ≥4/8, χ2 = 8.55, df = 1, P = 0.003) and HPV testing (absent = 1/48, present = 9/36, χ2 = 8.23, df = 1, P = 0.004).

Conclusions

Most CIN2> recurrences after LEEP occur in subjects with persistent HPV infection. Subjects with negative findings at cytology, colposcopy and HPV testing are at negligible risk of recurrence and might return safely to standard screening protocol.

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.

Development of a quality framework for models of cervical screening and its application to evaluations of the cost-effectiveness of HPV vaccination in developed countries

BACKGROUND

HPV vaccination has now been introduced in most developed countries, but this has occurred in the context of established cervical cancer screening mechanisms which provide population-level protection against the most common HPV-related cancer. Therefore, estimating the cost-effectiveness of HPV vaccination to further reduce HPV-related disease depends in large part on the estimation of the effectiveness of the cervical screening 'background'. The aim of this study was to systematically review and assess methods for simulating cervical screening in decision analytic models used for evaluation of HPV vaccination.

METHODS

Existing quality frameworks for economic models were extended to develop a specific quality framework for models of cervical screening. This involved domains for model structure, parameterisation (data sources) and validation (consistency). A systematic review of economic evaluations of HPV vaccination was then conducted, and assessment of cervical screening model components was then performed via application of the new quality framework.

RESULTS

Generally, models took into account population-level cervical screening participation, but were inconsistent in their approach to modelling abnormal smear management, diagnostic evaluation and treatment of precancerous disease. There was also considerable variability in the accuracy of modelling clinical pathways and the scope of validation performed for screening-related outcomes, with focus directed towards cervical cancer targets. Only a few models comprehensively validated against observed pre-cancerous abnormalities.

CONCLUSION

Models of HPV vaccination in developed countries can be improved by further attention to the 'background' modelling of secondary protection via cervical screening. The quality framework developed for this review can be used to inform future HPV vaccination evaluations, including evaluations of the cost-effectiveness of male vaccination and next generation HPV vaccines, and to assess models used to evaluate new cervical screening technologies and recommendations.

Minimally invasive therapy of cervical intraepithelial neoplasia for fertility preservation

The aim of this study was to determine the extension of cervical intraepithelial neoplasia grade III (CIN III) into endocervical canal and depth of endocervical crypts involvement by CIN with the regard to patients' age and parity. Correlation between the area of CIN involvement and the extension into endocervical canal was estimated. A total of 218 cervical cone specimens with histologically proven CIN III were included in this study. Extension of CIN into the endocervical canal, depth of involved crypts and ectocervical area affected by CIN were histologically analyzed. The average endocervical crypt involvement was at 1.2 mm of depth. The excision of >4 mm (1.2 mm x 3S.D.) in depth removes >99% of CIN. With the cone length of 15 mm (nulliparous patients) and 18 mm (multiparous patients), no endocervical cone margins were affected with CIN. Since the cone length is the most important determining factor for fertility preservation, the measurement of cervical cone could be essential for future pregnancies.

Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia

Invasive cancer of the cervix after treatment for cervical intraepithelial neoplasia (CIN) is becoming more important, as screening reduces the incidence of invasive disease. The rate of invasive cervical or vaginal cancer following treatment for CIN in UK remains elevated for at least 8 years. The aim of our study was to determine from international data how long this rate remains elevated and whether the rate of invasive disease reflects the rate of posttreatment CIN. The aim was to determine why the rate of invasive disease does not fall. A search of Medline and a secondary search of cited references identified 1,848 articles referring to the success rate of the treatment of CIN. Only 26 cohorts from 25 articles met all the inclusion criteria. The policy in these was to perform at least annual smears. After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 woman years until at least 20 years after treatment. This rate is approximately 2.8 times greater than expected. In contrast, the risk of posttreatment CIN declined steadily with time to about 190 per 100,000 women in the 10th year. Although the posttreatment rate of CIN falls with time, the rate of invasive disease remains static. It seems likely that this is due to diminishing compliance with follow-up. Women should be encouraged to persevere with annual smears for at least 10 years after their treatment as this may offer them the best chance of detecting recurrence at a treatable stage.

Tools for Post LEEP Surveillance

Recurrences of cervical intraepithelial neoplasia (CIN) as well as invasive cervical carcinoma have been reported to arise following ablative or excisional treatment for cervical intraepithelial neoplasia. This review utilizes MEDLINE and National Library of Medicine's PubMed review of the various screening tools used in follow-up protocols for women treated by loop excision for CIN. Cervical cytology, colposcopy, endocervical curettage and HPV typing have been advocated for use as tools for follow up. Involvement of the surgical margins and the presence of HPV-DNA are associated with higher risks of recurrence and should be taken into consideration. The psychological impact of undergoing colposcopy may affect compliance with follow-up visits and should be dealt with appropriately.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the various tools that can be used for the surveillance of patients after treatment for CIN, to compare the advantages and disadvantages of each surveillance method, and summarize methods to improve compliance with follow-up.