Laser CO2 conization in postmenopausal age: risk of cervical stenosis and unsatisfactory follow-up

The use of colposcopy for triage in HPV-positive women aged 65 years and older

PURPOSE

Persistent high-risk HPV infection is associated with an elevated risk for prevalent CIN II + despite normal cytology (NILM). Our study aims to evaluate the clinical relevance of a persistent high-risk HPV infection without cytologic changes in women aged ≥ 65 and to determine the role of colposcopy for triage in these cases.

METHODS

211 patients aged ≥ 65 with persistent HPV infection and normal cytology (NILM) who presented for colposcopy at five certified centers between January 2021 and April 2022 were included in the study. Colposcopic findings, HPV subtypes, when available, histology and p16/Ki67 staining were assessed as well as individual risk factors such as smoking and previous HPV-related surgery.

RESULTS

87.7% (185/211) of the included women had a type 3 transformation zone. In 83.4% (176/211), a biopsy was taken [thereof 163 endocervical curettages (ECC)]. In 35/211 women (16.6%), sampling was not possible during colposcopy due to an inaccessible cervix, pain during examination or obliteration of the cervical canal. Out of these, 6 women received a diagnostic excision. CIN II + was detected in 10.6% of all histologies (excisional or biopsy) (20/182). 50% of the women with a CIN II + where HPV 16 positive. Taking only the women diagnosed with CIN III or AIS into account, (n = 12) 75% were HPV 16 positive. Interestingly, 80% of the women with CIN II + had an abnormal cytology when repeatedly taken during colposcopy, vice versa an endocervical lesion was diagnosed in 53% of women with abnormal repeat cytology (27/51).

CONCLUSION

The prevalence of CIN II + in women is ≥ 65 with persistent hr HPV infection but NILM cytology is similar to that in younger women. However, more than 85% of the women have a type 3 transformation zone. Colposcopy is, therefore, not helpful to diagnose the women who need treatment in this age group.

A Case of Cervical Squamous Cell Carcinoma Developing 33 Years After Conization

We report a fatal case of early postoperative peritoneal dissemination in a patient who was diagnosed with cervical squamous cell carcinoma after laparoscopic hysterectomy for hematometra. A 73-year-old multiparous woman with pyometra and lower abdominal pain was referred to our hospital. Her medical history was remarkable for four open surgeries and conization at the age of 40 years. The cytology obtained from the mucosa of the palpated cervix was negative. The cytology and bacterial culture of the mucus collected from the uterine cavity were negative. Increasing fluid accumulation in the uterine cavity started to cause severe abdominal pain. A laparoscopy was performed. The small intestine showed extensive adhesions to the abdominal wall, which were dissected. A total hysterectomy was performed, and the uterus was placed in a collection bag, cut inside the bag, and retrieved transvaginally. Histopathological examination revealed nests of squamous cell carcinoma that replaced the entire uterine myometrium, and the tumor cells showed diffuse positivity for p16 on immunostaining. The patient was diagnosed with squamous cell carcinoma of the uterine cervix with invasion of the uterine myometrium. Three months later, the patient suffered from small bowel obstruction. A laparotomy was performed, and it revealed numerous disseminated lesions in the pelvic peritoneum and mesentery of the small intestine. Bypass surgery was performed. A biopsy of a disseminated lesion near the vaginal cuff revealed squamous cell carcinoma. The patient died within three weeks of bypass surgery.

FD-2, an Anticervical Stenosis Device for Patients Undergoing Radical Trachelectomy or Cervical Conization

This study aimed to introduce FD-2, a newly developed anticervical stenosis device for patients with cervical cancer undergoing radical trachelectomy. Using ethylene-vinyl acetate copolymers, we developed FD-2 to prevent uterine cervical stenosis after radical trachelectomy. The tensile test and extractables and leachables testing were performed to evaluate FD-2's safety as a medical device. FD-2 was indwelled in three patients with cervical cancer during radical trachelectomy and its utility was preliminarily evaluated. FD-2 consists of a head (fish-born-like structure), neck (connecting bridges), and body (tubular structure); the head is identical to FD-1, an intrauterine contraceptive device. FD-2 passed the tensile test and extractables and leachables testing. The average time required for the application or removal of FD-2 in cervical cancer patients was less than 10 s. The median duration of FD-2 indwelling was 8 weeks. No complications, including abdominal pain, pelvic infections, or hemorrhages, associated with FD-2 indwelling were reported. At the 3-12-month follow-up after the radical trachelectomy, no patients developed cervical stenosis or experienced dysmenorrhea. In conclusion, we developed FD-2, a novel device that can be used for preventing cervical stenosis after radical trachelectomy for uterine cervical cancer.

Endometrial squamous cell carcinoma originating from the cervix: A case report

BACKGROUND

Cervical squamous cell carcinoma (SCC) is the most common type of cervical carcinoma and is generally derived from a precancerous stage called cervical high-grade squamous intraepithelial lesion (HSIL). Usually, the cancer metastasizes through lymphatic or hematogenous dissemination, but rarely spreads upward into the uterus. Here, we report a case of cervical HSIL extending into the endometrium and finally progressing to SCC in the uterine cavity.

CASE SUMMARY

A 57-year-old postmenopausal woman visited our department and requested a routine cervical check-up. Four years ago, she had undergone a cervical loop electrosurgical excision procedure because of HSIL found during the gynecological examination, and she had not been checked again since. This time, a relapse of the cervical HSIL was diagnosed along with uterine pyometra and endometrial polyps. After 2 wk of antibiotic treatment, a laparoscopic hysterectomy was performed, and the final pathological examination revealed that the cervical HSIL had spread directly upward into the uterine cavity, gradually developing into cervical SCC in the endometrium.

CONCLUSION

Cervical HSIL/SCC can directly spread upward into the uterus with the most common symptoms of pyometra and cervical stenosis. More attention should be given to the early detection and prevention of this disease.

Histopathological findings in hysterectomy for cervical stenosis in postmenopausal women: A retrospective case series

OBJECTIVE

To analyze the histopathological findings in postmenopausal women who underwent hysterectomy for postsurgical cervical stenosis, evaluating the incidental findings of preinvasive or invasive uterine and cervical disease.

METHODS

Retrospective case series of postmenopausal women who underwent hysterectomy for postsurgical cervical stenosis at Gynecological Oncology Unit of Istituto di Ricovero e Cura a Carattere Scientifico Centro di Riferimento Oncologico Aviano-National Cancer Institute from January 2014 to January 2021.

RESULTS

During the study period, 36 women underwent hysterectomy for postsurgical cervical stenosis at our institution. Cervical stenosis occurred 10.2 ± 5.6 years from the onset of menopause. In particular, 26 (72.2%) patients underwent a single loop electrosurgical excision procedure or carbon dioxide (CO2)-laser conization before the onset of stenosis. The remaining 10 (27.8%) women had multiple surgical excision before the onset of stenosis. At the final histopathological analysis, 17 (47.2%) patients had a preinvasive or invasive gynecological disease. In particular, 9 cases of cervical disease (including 1 case of endocervical squamous cell carcinoma pT1a) and 6 cases of endometrial hyperplasia emerged. Also, 2 cases of tubo-ovarian diseases were found.

CONCLUSIONS

Postsurgical cervical stenosis is a challenging clinical condition, especially in women treated for cervical intraepithelial neoplasia or microinvasive cervical cancer. As shown, cervical stenosis can prevent an adequate gynecological follow-up and a prompt diagnosis of malignancies. Therefore, postmenopausal women with cervical stenosis should be carefully counseled, and hysterectomy could be a reasonable option, especially in those cases in which a conservative approach is not feasible, failed, or is not accepted by the patient.

Laser conization for cervical intraepithelial neoplasia: effectiveness and obstetric outcomes

PURPOSE

To evaluate the effectiveness and obstetric outcomes after laser conization for cervical intraepithelial neoplasia METHODS: This retrospective study included 757 patients who underwent laser conization between 2014 and 2020. Patients with a diagnosis of invasive lesions or adenocarcinoma in situ were excluded. Histological data from the conization specimen, pre and postoperative histological and virological data (Human PapillomaVirus (HPV) test) and obstetric outcomes were collected from the medical record. The primary endpoint was the negative surgical margin rates after laser conization. The secondary endpoint were the size of the operative specimen, the postoperative virological test results (3 to 6 months after surgery), factors associated with negative or positive margin and postoperative obstetric outcomes (prematurity). Patient characteristics and outcomes were compared using Student's t test, χ² test, or Fisher exact test. Values of p ≤0.05 were considered significant.

RESULTS

This study included 757 patients. Negative surgical margins were obtained in 76.1% of the cases and were associated with more negative HPV tests at 6 months (64.9% vs. 52.5%, p=0.006) and fewer repeat surgeries (0.2% vs. 2.2%, p=0.013) than for patients with positive margins. Among the patients under 43 years at the time of conization, 71 achieved a pregnancy with a term >22 weeks, and of these 66 (93%) delivered at term (≥37 weeks).

CONCLUSION

Laser conization appears to be an effective technique for the management of cervical intraepithelial neoplasia both in terms of the quality of the resection margins and the obstetric prognosis.

Mechanical dilatation of the stenosed cervix under local anesthesia: A prospective case series

AIM

Cervical stenosis is traditionally managed by mechanical dilatation under general anesthesia (GA). We aimed to assess the safety, effectiveness, and patient acceptability of dilatation in the outpatient setting under local anesthesia (LA).

METHODS

Data were collected prospectively from all patients attending the outpatient department with cervical stenosis from March 20, 2015 to September 23, 2020. Mechanical dilatation of the cervix was performed using Hegar dilators under LA. Subsequent colposcopic assessment, cytology, histology, and management were recorded.

RESULTS

One hundred forty-nine cases were referred for cervical dilatation, 63 (43%) of which had complete stenosis. One hundred eighteen (79%) patients had previously undergone cervical procedures. Successful dilatation under LA was achieved in 119 (83%) patients; 5 (3%) declined (requesting GA), 6 (4%) did not tolerate speculum examination, and 19 (13%) had unsuccessful procedures. The median Hegar size used was 8 mm. Dilatation under LA was acceptable in 93% attempted procedures. Thirteen episodes of restenosis were recorded with no major adverse events. Younger age (p = 0.045) and severe (compared to complete) stenosis (p < 0.0001) were associated with procedure success, with improved results over time (p = 0.003). Successful dilatation permitted cervical assessment; eight patients required cervical excisions, two underwent hysterectomies, with one confirmed case of adenocarcinoma.

CONCLUSION

Rigid cervical dilatation in the outpatient setting provides effective, instantaneous treatment for women who have failed cytological or colposcopic assessment. For the vast majority of women, the procedure was well tolerated and preferred to using GA. However, given that 1 in 10 women experienced restenosis, patients should be counseled about the possibility of requiring further management.

Cervical Stenosis: Previously Unrecognized Cause of False-Negative Human Papillomavirus Tests in Women Developing Cervical Cancer

OBJECTIVES

Cervical stenosis can jeopardize adequate posttreatment cytologic follow-up of patients treated for high-grade cervical intraepithelial lesions. An impact on human papillomavirus (HPV) testing has not been described.

MATERIALS AND METHODS

We describe 2 patients with cervical stenosis, followed by cytology and HPV co-testing after excisions of high-grade cervical intraepithelial lesions. Each had 1 or more co-test "double-negative" results. Hysterectomies revealed unexpected cervical carcinomas.

RESULTS

In case 1, an 80-year-old woman with complete cervical stenosis and earlier high-grade squamous dysplasia presented with abdominal pain, nausea, and an enlarged uterus. Attempted endometrial biopsy was unsuccessful. Cytology and HPV tests 9 months earlier were negative. Hysterectomy revealed a cervical squamous carcinoma. In case 2, a 40-year-old woman followed conservatively after excision of endocervical adenocarcinoma in situ had 5 follow-up cytology and HPV co-tests. All were HPV negative. Elective hysterectomy revealed cervical adenocarcinoma. Both carcinomas tested HPV positive.

CONCLUSIONS

Cervical stenosis in women developing cervical cancer can cause misleading sampling and false-negative HPV test results.

The effectiveness of cold-knife conization (CKC) for post-menopausal women with cervical high-grade squamous intraepithelial lesion: a retrospective study

Background

The effectiveness of surgery of high-grade squamous intraepithelial lesion in post-menopausal women needs to be investigated. This study evaluated the clinical significance of cold-knife conization in the diagnosis and surgery of cervical high-grade squamous intraepithelial lesions in post-menopausal women.

Methods

We conducted a retrospective analysis of post- and pre-menopausal patients with high-grade squamous intraepithelial lesion. All patients received cold-knife conization as the primary therapy.

Results

The satisfactory rate of colposcopy was significantly lower in the post-menopausal group than in the pre-menopausal group (38.33 vs. 71.25%; χ² = 36.202, P < 0.001). The overall positive margin rate of cold-knife conization (25.83 vs 12.50%; χ² = 10.106, P = 0.001) and rate of positive endocervical cone margins (16.67 vs. 4.58%; χ² = 14.843, P < 0.001) were significantly higher in the post-menopausal group. Moreover, 49 post- and 60 pre-menopausal women underwent subsequent surgical treatment (40.83 vs. 25.00%). Residual rate of positive and negative margins in patients before and after menopause was significantly different (χ² = 5.711, P = 0.017; χ² = 12.726, P < 0.001, respectively). The recurrence rate in post-menopausal women remained 3.85%.

Conclusions

Cold-knife conization can be performed as a primary procedure for diagnosis and surgery of post-menopausal patients with high-grade squamous intraepithelial lesions. Sufficient deep excisions are necessary to avoid positive endocervical margins, which can reduce the residual and recurrence of postoperative lesions.

Association of menopause, aging and treatment procedures with positive margins after therapeutic cervical conization for CIN 3: a retrospective study of 8,856 patients by the Japan Society of Obstetrics and Gynecology

Objective

The Japan Society of Obstetrics and Gynecology conducted a retrospective multi-institutional survey of patients who underwent cervical conization in Japan. This study aimed to determine the predictive factors for positive surgical margins in cervical intraepithelial neoplasia grade 3 (CIN 3) patients after therapeutic cervical conization and those for positive margins in patients who did not experience recurrence and did not undergo additional treatment.

Methods

In 2009 and 2013, 14,832 patients underwent cervical conization at 205 institutions in Japan. Of these, 8856 patients who underwent therapeutic conization fulfilled the inclusion criteria. Their histologic findings and clinical outcomes were evaluated based on standard statistical procedures and clinical and demographic characteristics.

Results

Negative and positive margins were observed in 7,585 and 1,271 (14.4%) patients, respectively. The predictors of positive margins were menopausal status (p<0.001), loop electrosurgical excision procedure (p<0.001), and Shimodaira-Taniguchi (S-T) conization (p<0.001). Of 1,271 patients with positive margins, 1,060 underwent no additional treatment; among those 1,060 patients, 129 (12.2%) experienced recurrence. The predictors of positive margins in patients who did not undergo additional treatment and did not experience recurrence were age, parity, gravidity, S-T conization, and laser scalpel conization.

Conclusion

Menopausal status and treatment procedures were associated with positive margins after therapeutic conization of CIN 3. It is important to understand the characteristics of treatment procedures and select an appropriate procedure for each case. For elderly or menopausal patients with positive margins, immediate additional treatment is recommended.

Analysis of pathological and clinical characteristics of cervical conization according to age group in Japan

Objective

With increased screening, more patients with precancerous or early cervical cancer are now being identified. Age at pregnancy, and thus number of patients requiring fertility preservation, have also increased, resulting in more diagnostic and therapeutic cervical conization (conization) procedures. We here investigated the pathological and clinical characteristics of patients undergoing conization, with a focus on age. The objectives of our study were to identify the risk factors potentially involved in cervical intraepithelial neoplasia (CIN) recurrence or persistence, additional treatment after conization, the effects of conization on pregnancy, and the actual status of conization in Japan.

Study design

A "Subcommittee for Investigation of Cervical Conization" within the Gynecologic Oncology Committee in the Japan Society of Obstetrics and Gynecology investigated pathological and clinical characteristics of conization at 205 institutions in Japan. We analyzed pathological and clinical characteristics according to age ≤50 and >50 years.

Results

Patients aged 20-40 years accounted for 12904 (87%) of the 14,832 study patients (median: 37 years, range: 16-88 years). However, 1838 (12.4%) were aged >50 years. The commonest post-operative diagnosis was CIN grade 3 in all age groups. Rates of invasive cancer, post-operative detection of more advanced lesions, positive surgical margins, additional treatment, and recurrence were significantly higher in patients aged ≥50 years than those aged <50 years (all p < 0.01), whereas rates of post-operative complications did not differ significantly between age groups. The relationship between cerclage and the incidence of amniorrhexis or premature birth did not differ significantly in any age group.

Conclusion

Post-conization management of patients aged ≥50 years requires considering the high rates of detection of more advanced lesions post-operatively, positive surgical margins, and recurrence. Cerclage should not be performed post-conization without careful consideration.

Extending cervicoplastic surgery: an alternative technique to overcome the limitation of office hysteroscopy

Our objective is to show a feasible approach to the hysteroscopic procedures when the cervical canal has a diameter smaller than the lesion. Our study is designed as a case series and illustration of the surgical hysteroscopic technique. A group of patients (n = 37) underwent office hysteroscopy in Regional Reference Center for Hysteroscopy Service at Palagi Hospital, Florence, Italy, to see and treat an endometrial polyp with unfavorable cervical conditions between January 2019 and December 2019. An office hysteroscopy in outpatient setting with vaginoscopic approach was performed in women with unfavorable cervical conditions. Fiber-based 3.5-mm hysteroscope, with 5F electrosurgery unit and 5F bipolar electrode, was used to perform the cervicoplasty in order to enlarge the cervical canal from internal to external os, following by the removal of the endometrial polyp with the excision of the base only without slicing. After 90 days, a follow-up hysteroscopy was performed. The procedure was performed successfully in 89.2% of patients.

The surgical technique of cervicoplastic allows to perform an operative procedure without analgesia/sedation or anesthesia or blind cervical dilation, reducing the risk of complications and costs. Furthermore, cervicoplasty allowed the removal en bloc of the endocavitary lesion in all cases. At the follow-up hysteroscopy, the cervical passage was straight and smooth, without lesions repaired in all patients. Cervicoplasty is a technique which allows to perfume an ease and comfortable hysteroscopic procedure even in patients with unfavorable cervical canal. Due to the widening of the diameter of the cervical canal, intracavitary lesions are removed intact resulting in an optimal pathological evaluation.

A new approach to prevent cervical stenosis in postmenopausal women after loop electrosurgical excision procedure: a randomized controlled trial

To determine whether regular cervical dilatation is effective for preventing cervical stenosis, and to identify the associated risk factors, in postmenopausal women after LEEP. This was a prospective randomized clinical trial in postmenopausal women who underwent LEEP at our hospital between August 2018 and May 2019. Patients who met the study criteria were randomly allocated to three groups: control group (without any intervention), intervention group A (underwent cervical dilatation at the 3^rd, 5^th, and 8^th week after LEEP) and intervention group B (underwent cervical dilatation at the 4^th, 8^th, and 12^th week after LEEP). A colposcopic follow-up examination was conducted at 6 months after LEEP to determine the incidence of cervical stenosis. A total of 404 postmenopausal women were found to be finally eligible for the study. The rate of cervical stenosis in the control group was significantly higher than that in the intervention group, and the rate in group A was significantly lower than that in group B. We found regular dilatation after LEEP in postmenopausal women can prevent cervical stenosis. Further, the 3rd, 5th, and 8th weeks after LEEP are optimal time points. Finally, LEEP frequency and resection depth are significant risk factors and can be used to screen postmenopausal women at risk for cervical stenosis after LEEP.

Post-conization cervical stenosis treated with silicone catheter in microinvasive cervical cancer patient: A case report

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Cervical Cancer patient experienced a Cervical stenosis after conization.

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Cervical stenosis is one of the most frequent complication of conization.

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The use of a silicon urethral catheter into the cervical canal is a resolutive option.

Introduction

Cervical stenosis can represent a hard complication to treat after conization for microinvasive cervical cancer.

Presentation of case

A young woman with cervical stenosis post-trachelectomy for a microinvasive cervical cancer came to our Department. We introduced a silicone catheter of 18 French in cervical canal. The catheter was removed after 20 days.

The procedure was resolutive.

Discussion

Cervical stenosis is one of the most frequent complication of conization. Among the different described techniques proposed in literature, we would here report the successful use of a silicon urethral catheter into the cervical canal.

Conclusion

This method can be an easy and cheap procedure to take in consideration.

Diagnostic excision of the cervix in women over 40 years with human papilloma virus persistency and normal cytology

Objective

Persistent infection with human papillomavirus (HPV) is recognized as the main risk factor of cervical cancer. Investigation via cytology and colposcopy have lower sensitivity than HPV testing in the diagnosis of high-grade cervical intraepithelial neoplasia (CIN2+). Despite normal cytology and colposcopy findings women with persistent HPV infection have an increased risk of CIN2+. The aim of the study was to evaluate the proportion of histologically confirmed CIN2+ in women with persistent HPV infection and normal Pap smears.

Study design

From April 2013 until March 2016 we prospectively recruited 91 women over 40 years with persistent HPV infection without any abnormalities in cytology. Of these, 40 women attended a gynecological examination including an HPV test, Pap smear, endocervical cytology, colposcopy with biopsies and diagnostic loop electrosurgical excision procedure (LEEP). Biopsy and LEEP samples were subjected to histological examination

Results

CIN2+ was verified by histological examination of the LEEP sample in 6/40 (15%) of the women. All the cytological samples were normal and none of the biopsies confirmed CIN2+. Only 19/40 women still had a persistent HPV infection at the study visit. None of the 21/40 women who had cleared their HPV infection at the study visit had CIN2+ in histology of the LEEP sample.

Conclusions

A persistent HPV infection needs to be monitored despite normal Pap smears, since 6/40 (15%) women older than 40 years, was revealed to have an undiagnosed CIN2+ when LEEP was performed. Counseling women regarding the risk of cervical cancer and the expected effect of an eventual LEEP can help them to make an optimal informed choice.

Risk factors for unsatisfactory colposcopy after large loop excision of the transformation zone: The results of a four-year multicenter prospective study

OBJECTIVES

Not being able to completely examine the cervical squamocolummar junction (SCJ) in colposcopy after large loop excision of the transformation zone (LLETZ) is an important issue regarding surveillance, as high-grade cervical intra-epithelial neoplasia recurrence risk is high. This study was conducted in order to identify risk factors for post-LLETZ unsatisfactory colposcopy.

METHODS

This prospective multicenter observational study was performed in nine French University hospitals, with inclusions running from December 2013 to December 2017. All patients scheduled for LLETZ were included and were divided into two groups after the two to four months post-procedure colposcopic examination: a satisfactory and an unsatisfactory post-LLETZ colposcopy group.

RESULTS

In total, 601 cases were analyzed and 71 post-LLETZ colposcopies (12%) were described as unsatisfactory (including 19 cervical stenosis). In a univariate analysis, we only observed a statistically significant increase of the following parameters in the unsatisfactory post-LLETZ group in comparison with the satisfactory post-LLETZ group: parity (2.11 [±1.55] and 1.49 [±1.24] respectively, p < .01), depth of the LLETZ specimen (10.9 mm [±3.37] and 9.76 [±3.79] respectively, p < .01), age (45.9 years [±11.7] and 37.9 [±9.42] respectively, p < .001) and an unsatisfactory pre-LLETZ colposcopy (43 satisfactory pre-LLETZ colposcopies [61%] and 456 [86%] respectively, p < .001). In a stepwise binary logistic regression analysis, only the two latter parameters were found to be independently associated with unsatisfactory post-LLETZ colposcopies.

CONCLUSIONS

Surgeons should consider other therapeutic strategies when contemplating iterative diagnosis-LLETZ in older women with initially invisible SCJ, as an appropriate post-LLETZ surveillance is at higher risk of being impossible to achieve.

Risk Factors of Post-Large Loop Excision of the Transformation Zone Recurrent High-Grade Cervical Intraepithelial Lesion: A Prospective Cohort Study

OBJECTIVE

The aim of the study was to identify the risk factors of post-large loop excision of the transformation zone (LLETZ) recurrent disease and the impact of colposcopic guidance at the time of LLETZ on that risk.

MATERIALS AND METHODS

From December 2013 to July 2014, 204 patients who had undergone LLETZ for the treatment of high-grade intraepithelial lesion with fully visible cervical squamocolumnar junction were included. The use of colposcopy during each procedure was systematically documented. The dimensions and volume of LLETZ specimens were measured at the time of the procedure before formaldehyde fixation. All participants were invited for a follow-up. The primary endpoint was the diagnosis of post-LLETZ recurrent disease defined as the histologic diagnosis of a high-grade cervical intraepithelial lesion.

RESULTS

The median duration of post-LLETZ follow-up was 25.8 months. Recurrent disease was diagnosed in 8 (3.6%) patients. Older than 38 years (adjusted hazard ratio [aHR] = 11.9, 95% CI = 1.6-86.0), history of excisional therapy (aHR = 21.6, 95% CI = 3.5-135.3), and the absence of colposcopy for the guidance of LLETZ (aHR = 6.4, 95% CI = 1.1-37.7) were found to significantly increase the risk of post-LLETZ recurrent disease. The dimensions and volume of the specimen were not found to have any impact. Only positive endocervical margins were identified to significantly increase the risk of post-LLETZ recurrent disease (aHR = 14.4, 95% CI = 2.0-101.1).

CONCLUSIONS

Risk factors of post-LLETZ recurrent disease are older than 38 years, history of excisional therapy, positive endocervical margins, and lack of colposcopic guidance at the time of LLETZ.

Development of endometrioma after cervical conization

The association between cervical conization and subsequent development of endometriosis is uncertain. The objective of this study was to estimate the incidence rate of ovarian endometrioma after cervical conization and to determine factors associated with the development of endometrioma. One hundred forty-two patients who underwent cervical conization at the University of Tokyo Hospital between January 2006 and December 2013 were included in the study. Their medical records were retrospectively studied until April 2015. The incidence rate of postconization endometrioma was calculated. Patients' characteristics (age, parity, preoperative and postoperative diagnosis and observation period) were analyzed. Six patients developed endometrioma after the cervical conization, and the incidence rate of endometrioma among patients who underwent cervical conization was 10.8 per 1000 person-year (95%CI 3.6-20.5). Patients' age, percent of nulliparous, postoperative diagnosis and observation period were not associated with the development of postconization endometrioma. A preoperative diagnosis with invasive cancer (p < 0.05) was significantly associated with the development of postconization endometrioma. The incidence rate of endometrioma among patients who underwent cervical conization in the current study was higher than that reported population.

Predictors for recurrent/persistent high-grade intraepithelial lesions and cervical stenosis after therapeutic conization: a retrospective analysis of 522 cases

OBJECTIVE

The objective of the study is to identify the risk factors associated with recurrent/persistent disease and cervical stenosis after conization.

METHODS

Five hundred twenty-two (522) cases of high-grade intraepithelial lesions treated by conization were retrospectively reviewed. Risk factors associated with recurrent/persistent disease were analyzed by univariate and multivariate analysis using a Cox hazard regression model. Factors that could potentially affect the risk of cervical stenosis were examined by univariate and by multivariate analysis using the χ ² test and logistic regression, respectively.

RESULTS

Recurrent/persistent diseases and cervical stenosis occurred in 4.8% and 5.4% of the patients, respectively. Age ≥46 years [hazard ratio (HR) 3.6, 95% CI 1.36-10.3, p = 0.0092] and surgical margin involvement (HR 13.44, 95% CI 5.07-46.37, p < 0.001) were independent predictors for recurrent/persistent diseases. Age ≥46 years [odds ratio (OR) 4.27, 95% CI 1.88-10.07, p < 0.001] and shortened interval after childbirth to conization (within 12 months) (OR 5.42, 95% CI 1.42-17.41, p = 0.016) were independent risk factors for cervical stenosis.

CONCLUSION

Elderly patients (aged ≥46 years) are at high risk of recurrence and cervical stenosis, which may lead to unsatisfactory follow-up. Subsequent hysterectomy is beneficial to patients aged 46 or older with surgical margin involvement. Clinicians should recognize the possibility of cervical stenosis after conization during the breastfeeding period, leading to secondary infertility or hematometra.

Levonorgestrel-releasing intrauterine system placement for severe uterine cervical stenosis after conization: two case reports

Background

Several approaches for treating severe uterine cervical stenosis after conization for cervical intraepithelial neoplasia have been reported; yet, the condition can still be difficult to treat successfully.

Case presentation

We performed uterine cervical dilation surgery in two patients with severe stenosis, followed by insertion of the levonorgestrel-releasing intrauterine system, which is used for dysmenorrhea or endometriosis-related pain because of its strong progesterone activity. Patient 1 was a 34-year-old Japanese woman who was diagnosed with dysmenorrhea caused by recurrent uterine cervical stenosis and hematometra after laser conization. Patient 2 was a 44-year-old Japanese woman who developed dysmenorrhea and prolonged menstruation caused by uterine cervical stenosis without hematometra. After providing informed consent, they underwent cervical dilation surgery followed by insertion of the levonorgestrel-releasing intrauterine system. After treatment, their symptoms immediately improved, and after removal of their devices, they remained asymptomatic.

Conclusions

To the best of our knowledge, this is the first report to confirm the usefulness and easy applicability of the levonorgestrel-releasing intrauterine system for uterine cervical stenosis. Although we had success with the method, this study of two patients is preliminary. Further study with larger numbers of patients is necessary to confirm the usefulness of our technique.

[Iatrogenic endometriosis during reproductive age: main issues?]

Among endometriotic lesions a small proportion is secondary to various medical activities, and may be considered as iatrogenic. Any medical or surgical procedure increasing the menstrual flow or the retrograde flow bears a potential risk: conization, hydrotubation or copper intra-uterine device. Surgical procedures, by laparotomy or laparoscopic approach, are able to favor transport and cutaneous seeding of endometrial tissue, especially when a hysterotomy has been performed. Diagnosis and treatment of these lesions are today standardized. Few preventive measures are available, besides adequate surgical procedure, but none has been properly evaluated, mainly because these lesions are not frequent.

Treatment of HPV infection-associated cervical condylomata acuminata with 5-aminolevulinic acid-mediated photodynamic therapy

The aim of this study was to investigate the efficacy of 5-aminolaevulinic acid (ALA)-mediated photodynamic therapy (PDT) in treatment of human papillomavirus (HPV)-associated cervical condylomata. A total of 56 patients with cervical and external condylomata lesions were recruited for this open-label study. HPV genotyping of exfoliated cells collected from the cervix and external lesions was performed. Cervical lesions were treated with PDT by applying ALA gel (10%) to the surface of the cervix for 4 h followed by irradiating with a 635 nm laser at 100 J cm(-2). PDT was repeated at 2-week intervals if lesion and HPV infection remained. Patients were followed up for 6-24 months. Genotyping analysis revealed four HPV subtypes (HPV6, 11, 16 and 18). The overall complete remission rate of 1-4 sessions of treatments was 98.2% and the corresponding HPV clearance rate was 83.9%. Ten cases showed complete removal of cervical lesions and HPV infection after a single treatment. Recurrence rate was 3.6%. Adverse effects were minimal and no structural complications were reported. In conclusion, topical ALA PDT is safe and effective for eradicating cervical HPV infection and eliminating condylomata lesion. Its definitive role in treating cervical condylomata deserves further investigation.

Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause

The true value of colposcopy in pregnancy is under debate; the examination may be more difficult depending on the gestation at which a woman presents. Cervical intraepithelial neoplasia does not have an accelerated progression during pregnancy, and treatment is usually deferred until postpartum. The prevalence of cervical intraepithelial neoplasia is greater in women with immune compromise. Those with human immunodeficiency have a higher prevalence, more persistence and less regression of human papillomavirus-related infections. Cervical cancer remains an AIDS-defining illness. Women who have had renal transplants also have a higher risk of developing cervical intraepithelial neoplasia. By contrast, other chronic illnesses that require immunosuppressant therapy do not seem to show this added risk. In young women, human papillomavirus infection is common and cervical intraepithelial neoplasia is also evident, but regression of these lesions is frequent and so conservative review may be appropriate. At the menopause, colposcopy is often unsatisfactory. The use of human papillomavirus testing for triage of low-grade cytological abnormalities may benefit this age group.

Depot medroxyprogesterone acetate: a risk factor for cervical stenosis after loop electrosurgical excisional procedure management of cervical intraepithelial neoplasia?

OBJECTIVES

In our anecdotal experience and sporadically in the literature, gynecologists have observed a connection between patient's use of depot medroxyprogesterone acetate (DMPA) and increased occurrence of cervical stenosis during follow-up after loop electrosurgical excisional procedure (LEEP). We decided to formally examine this association in our clinic population.

MATERIALS AND METHODS

We performed a chart review, enrolling 257 patients and tabulating data on demography, use of hormonal contraceptives, characteristics of the LEEP, and presence or absence of cervical stenosis at 1- and 6-month follow-up evaluations. Univariate tests of association between the independent variables and the dependent variable of cervical stenosis were examined via the chi and Student t tests for discrete and continuous variables, respectively. To characterize the relative importance of independent variables significantly associated with cervical stenosis, logistic regression was performed.

RESULTS

Of the 257 charts reviewed, 127 patients (49.4%) completed 1 and 6 months after LEEP follow-up appointments, providing adequate data for analysis. In this population, we observed 25 cases of cervical stenosis, or an overall rate of 19.7%. Of patients using DMPA at the time of LEEP or during the follow-up period, 9 (41.0%) of 22 developed stenosis, whereas of those who did not use DMPA, 16 (15.2%) of 105 developed stenosis, indicating a significant difference (odds ratio = 3.85, 95% CI = 1.41-10.50).

CONCLUSIONS

In our clinic population, use of DMPA was associated with higher rates of development of cervical stenosis, calling for larger studies of the association of DMPA in this LEEP complication.

Cervical stenosis following electrosurgical conization

CONTEXT AND OBJECTIVE

Cervical stenosis is a postoperative complication of procedures for treating preinvasive lesions of the cervix and takes on particular importance due to the clinical repercussions associated with it. Furthermore, it causes limitations in relation to cytological and colposcopic follow-up. The aim here was to assess the incidence of cervical stenosis among a cohort of patients who underwent electrosurgical conization and to identify possible prognostic factors associated with its occurrence.

DESIGN AND SETTING

Retrospective study at Gynecology and Obstetrics Department, Instituto Fernandes Figueira, Rio de Janeiro.

METHODS

This was an observational study among a cohort of patients who underwent electrosurgical conization of the uterine cervix. The possible predictive variables were analyzed as bivariate means between the groups with and without stenosis. We also calculated the incidence density rate ratio for cervical stenosis in relation to each possible predictive variable and the respective confidence intervals (95%). Levels of 5% were considered significant.

RESULTS

274 patients who underwent electrosurgical conization of the uterine cervix with a minimum follow-up period of six months were included. The crude incidence of cervical stenosis was 7.66% and the incidence density was 3.3/1,000 patients-month.

CONCLUSIONS

We did not find associations between the variables for stenosis. However, we observed borderline significance levels relating to hemorrhagic complications before and after the operation (p = 0.089).

PCR detection rates of high risk human papillomavirus DNA in paired self-collected urine and cervical scrapes after laser CO2 conization for high-grade cervical intraepithelial neoplasia

OBJECTIVE

To compare the PCR detection rates of high risk human papillomavirus DNA in self-collected urine and cervical scrapes during follow-up of patients treated for HG-CIN by laser CO2 conization.

PATIENTS AND METHODS

52 women who submitted to laser conization for HG-CIN were enrolled into this prospective follow-up study receiving liquid-based cytology and HR-HPV testing by PCR assay on self-collected urine and cervical scrapes before and at 3, 6 and 12 months after treatment. Diagnostic accuracy and predictive values for treatment failure were evaluated for both urinary and cervical HPV testing and follow-up cytology.

RESULTS

3 cases (5.8%) of recurrent HG-CIN occurred during follow-up. Positive margins and HR-HPV persistence resulted to significant risk factors for recurrence (p=0.01). The overall concordance on HR-HPV detection between paired urine and cervical samples was 96.6% and discord trend between agreement rates during follow-up were excluded by overall fixed-effect index (OR 1.03; 95% CI 0.62-1.70). No difference was observed comparing the three- and six-month cumulative sensitivity and NPV for recurrent disease of urinary and cervical HPV detections, with an increase of 5.6% in specificity associated with urinary testing.

CONCLUSIONS

PCR detection of HR-HPV in paired urine and cervical samples during follow-up revealed an excellent concordance, suggesting a potential equivalent role of the two methods within post-treatment follow-up. In our experience HPV testing on self-collected urine was more sensitive than cytology and more specific than cervical HPV detection to predict treatment failure. Larger studies are needed to definitively establish the role of urine-based HPV testing during follow-up.

Feasibility and outcome of laser CO2conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2conization of the cervix forin situand minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinomain situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.