Cold-knife conization versus conization by the loop electrosurgical excision procedure: a randomized, prospective study

Advancing Immunotherapies for HPV-Related Cancers: Exploring Novel Vaccine Strategies and the Influence of Tumor Microenvironment

The understanding of the relationship between immunological responses and cancers, especially those related to HPV, has allowed for the study and development of therapeutic vaccines against these neoplasias. There is a growing number of studies about the composition and influence of the tumor microenvironment (TME) in the progression or establishment of the most varied types of cancer. Hence, it has been possible to structure immunotherapy approaches based on therapeutic vaccines that are even more specific and directed to components of TME and the immune response associated with tumors. Among these components are dendritic cells (DCs), which are the main professional antigen-presenting cells (APCs) already studied in therapy strategies for HPV-related cancers. On the other hand, tumor-associated macrophages are also potential targets since the profile present in tumor infiltrates, M1 or M2, influences the prognosis of some types of cancer. These two cell types can be targets for therapy or immunomodulation. In this context, our review aims to provide an overview of immunotherapy strategies for HPV-positive tumors, such as cervical and head and neck cancers, pointing to TME immune cells as promising targets for these approaches. This review also explores the potential of immunotherapy in cancer treatment, including checkpoint inhibitors, cytokine immunotherapies, immunotherapy vaccines, and cell therapies. Furthermore, it highlights the importance of understanding the TME and its effect on the design and achievement of immunotherapeutic methods.

How endocervicoscopy can impact obstetric outcomes in women undergoing LEEP for CIN2 + : a retrospective cohort analysis

PURPOSE

To assess the impact of preoperative endocervicoscopy on obstetric outcomes and complications in women undergoing LEEP for CIN2 + .

METHODS

This was a retrospective cohort study carried out between October 2012 and April 2018. All women had undergone cervical length measurement at T0 (before LEEP), T1 (6 months after LEEP), and T2 (at 20 weeks of pregnancy) through transvaginal ultrasound examination after LEEP for CIN2 + . A total of 528 patients fulfilled our inclusion criteria and contributed to the final analysis: 288 had undergone endocervicoscopy before the excisional procedure (Group A), while the remaining 240 (Group B) did not.

RESULTS

Patients who did not undergo endocervicoscopy showed a greater amount of tissue excised at LEEP compared to those of Group A (6.7% vs 31.9% in Group A and B, p < 0.01, respectively). A statistically relevant difference was detected in the lesion margins involvement: negative in 93.8% in Group A compared to 65.6% in Group B. The cervicometry before the treatment resulted in similar between the two groups, while a statistically significant difference was noted after 6 months (37.5 ± 2.9 mm in Group A vs 35.1 ± 3.8 mm in Group B, p < 0.01) and at 20th week pregnancy (36.9 ± 5.3 mm in Group A vs 33.5 ± 5.6 mm in Group B, p < 0.01). The number of pregnancies after LEEP as well as the difference in the elapsed time (in months) did not result in a statistical significance between the two groups. The threatened preterm labor (TPL) and the threatened miscarriage showed a statistically significant difference in incidence between the two groups (4,2% and 4.2% in Group A vs 15.3% and 25% in Group B, p < 0.01, respectively).

CONCLUSION

Endocervicoscopy reduces the size of the LEEP sample and in particular its depth, saving healthy cervical tissue, and guarantees the total eradication of the lesion as the resection margins are negative in almost all cases, allowing for a reduction of the rate of TPL and threatened miscarriage in women with CIN2 + , especially with Type 2 or 3 cervical squamocolumnar junction (SCJ).

Positive pathological margins after loop electrosurgical excision procedure - Management and outcome

OBJECTIVE

Pathological involvement of cervical conization margins is a risk factor for recurrence, although management of these patients is controversial. We aimed to define risk factors for positive margins and compare recurrence following additional surgical intervention compared to conservative management.

METHODS

A retrospective study of all conizations at our center between 2010 and 2019. Univariate analysis identified characteristics associated with positive margins. Women were stratified by mode of management comparing three groups (surveillance, repeat conization or hysterectomy) then two groups (surveillance vs. additional surgery). Kaplan Meyer survival curves compared cumulative recurrence stratified by mode of management. Pathological results of subsequent surgical procedures were examined for residual disease.

RESULTS

Of 448 conizations performed, 131 (29.2%) had positive margins which were associated with menopause, high-grade cytology and endocervical gland involvement. Women who underwent surveillance (n = 45) were more likely to be nulliparous, with low-grade histology and less endocervical gland involvement. Women who underwent hysterectomy (n = 61) were more likely to be postmenopausal and parous. Recurrence did not differ significantly in the three-group (p = 0.073) or two-group model (6.4% vs. 7.1% p = 0.869). Kaplan Meyer survival curves depicting cumulative recurrence did not differ significantly in either model (log rank test p = 0.642 for the three-group model, and p = 0.868 for the two-group model). Residual disease was found in 51.6% of hysterectomy specimens and 52.6% of repeat conizations.

CONCLUSION

Surveillance is non-inferior to additional surgery in cases with positive conization margins and constitutes a valid option specifically for younger women at risk of future obstetric complications and those susceptible post-hysterectomy complications.

Treatment Outcomes of Patients With Cervical Intraepithelial Neoplasia or Invasive Carcinoma Who Underwent Loop Electrosurgical Excision Procedure

Background

This study aimed to evaluate the treatment outcomes of cervical intraepithelial neoplasia (CIN) or cancer patients who underwent loop electrosurgical excision procedure (LEEP) in terms of primary outcome and factors associated with persistence/recurrence.

Methods

Patients with CIN or cancer who underwent LEEP from January 2007 to December 2015 were reviewed. Data collected were age, parity, menopausal status, human immunodeficiency virus (HIV) infection, smoking, cervical cytology, histopathology from cervical biopsy and LEEP including margin status, final histopathology, and follow-up data.

Results

The mean age of 385 patients was 41.9 ± 10.8 years (range 18 - 79 years). Majority were multiparous (81.6%) and premenopausal (78.2%). There were 15.3% of patients with HIV infection. The most common cervical cytology was high-grade squamous cell intraepithelial lesion (HSIL, 44.1%), followed by atypical squamous cells of undetermined significance (ACS-US, 21%). Minor complications of bleeding or infection from LEEP were encountered in 7.3%. Among 153 patients (39.7%) who had positive margin(s), 43 underwent second LEEP, whereas 76 had hysterectomy. From all patients, 47 had failure after treatment (12.2%), being either persistence (30 patients; 7.8%) or recurrence (17 patients; 4.4%). Factors associated with persistence or recurrence by multivariate analysis were age ≥ 55 years old, HIV infection, final diagnosis of invasive cancer, and positive endocervical margin or both ecto- and endo- cervical margins.

Conclusions

LEEP had low rate of persistence/recurrence. Age ≥ 55 years old, HIV infection, final diagnosis of cancer, and positive endocervical or both endo- and ecto- surgical margin(s) were significantly associated with persistent or recurrent diseases.

Protective Role of Conization Before Radical Hysterectomy in Early-Stage Cervical Cancer: A Propensity-Score Matching Study

PURPOSE

The purpose of this study was to assess the prognostic role and the perioperative outcomes of conization performed before radical hysterectomy in early-stage cervical carcinoma.

METHODS

This multicenter, retrospective observational cohort study included patients with FIGO 2009 stage IB1 cervical carcinoma treated with radical hysterectomy between June 2004 and June 2019. Patients were divided into two groups according to conization before radical surgery. One-to-one case-control matching was used to adjust the baseline characteristics.

RESULTS

A total of 332 patients were included after propensity matching (166, 50% in each group). Twenty-four of 166 (14.4%) and 142 of 166 (85.6%) conization patients had negative and positive surgical margins on the conization specimen, respectively. No difference in intra- and postoperative complications was noted between the two groups (p = 0.542 and p = 0.180, respectively). Patients undergoing conization before radical hysterectomy received less adjuvant treatment (p < 0.001) and had a better 5-year disease-free survival (DFS) than patients who did not receive conization (89.8% vs. 80.0%, respectively; p = 0.010). No difference in 5-year overall survival (OS) (97.1% vs. 91.4%, respectively; p = 0.114) or recurrence pattern (p = 0.115) was reported between the two groups. Factors independently related to higher risk of recurrence were pathologic tumor diameter >20 mm and no conization before radical hysterectomy (p = 0.011 and p = 0.018, respectively). The only independent variable influencing OS was pathologic tumor diameter >20 mm (p = 0.020).

CONCLUSIONS

Conization before radical hysterectomy was associated with improved DFS and lower probability of receiving adjuvant treatment. No difference in perioperative complications and OS was evident. Tumor diameter >20 mm was found to be the only independent risk factor affecting OS in both groups.

Loop electrosurgical excision procedure combined with cold coagulation for cervical intraepithelial neoplasia and adenocarcinoma in-situ: a feasible treatment with a low risk of residual/recurrent disease

Objective

This study was performed to evaluate the significance of positive resection margins (RMs) with the loop electrosurgical excision procedure combined with cold coagulation (LEEP with CC) as a definitive treatment for patients with cervical intraepithelial neoplasia (CIN) and adenocarcinoma in-situ.

Methods

We retrospectively reviewed 467 patients who underwent LEEP with CC. A right-angled triangular loop in a single pass followed by a CC (120 °C) to the cone bed for 10 to 20 s was used. Pathology reports and clinical data were obtained and evaluated.

Results

Histopathology evaluation of LEEP tissue samples revealed the presence of CIN 1 in 69, CIN 2/3 in 366, AIS in 5 and invasive carcinoma in 16 (microinvasive squamous cell carcinoma (SCC) and invasive SCC, 13 and 3) patients. Margins were positive in 66 (14.5%) cases: 0 in CIN 1, 54 in CIN 2/3 (12.4%), 1 in AIS (20.0%) and 11 in microinvasive/invasive SCC (68.8%). Although 54 CIN2/3 patients with positive RMs did not undergo additional treatment, 1 of these (1.9%) was confirmed to have residual CIN3 at the first follow-up. Two of 8 (25.0%) microinvasive SCC patients with positive RMs were confirmed to have residual diseases (1 microinvasive SCC and 1 invasive SCC) after hysterectomy. Four out of 360 (1 positive RM, 3 negative RM) CIN cases recurred during the study period.

Conclusions

These results suggest that CIN patients with positive RMs after LEEP with CC may be followed up without additional treatment.

Efficacy and safety of cryotherapy, cold cone or thermocoagulation compared to LEEP as a therapy for cervical intraepithelial neoplasia: Systematic review

OBJECTIVES

To determine the efficacy and safety of the use of cryotherapy, cold knife or thermocoagulation compared to Loop Electrosurgical Excision Procedure (LEEP) for the treatment of cervical intraepithelial neoplasia.

METHODS

Systematic review with meta-analysis of randomized controlled trials in women with cervical intraepithelial neoplasia undergoing treatment with cryotherapy, cold knife, or thermo-coagulation compared with LEEP, to estimate its efficacy and safety. The search was conducted on MEDLINE/PUBMED, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus, until September 2018.

RESULTS

The total of 72 studies were identified, of which only 8 studies met the inclusion criteria. The treatment of CIN with cold knife decreases the risk of residual disease compared with LEEP (RR, 0.54, 95%CI, 0.30-0.96, p = 0.04). The management of premalignant lesions with cryotherapy, compared with LEEP, increases the risk of disease recurrence by 86% (RR, 1.86, 95%CI, 1.16-2.97, p = 0.01), increases the risk of infections (RR, 1.17, 95%CI, 1.08-1.28, p < 0.001) and reduces the risk of minor bleeding by 51% (RR, 0.49, 95%CI) %, 0.40-0.59, p ≤ 0.001).

CONCLUSIONS

The treatment of premalignant lesions of cervical cancer with cold knife reduces the risk of residual disease. Nevertheless, cryotherapy reduces the risk of minor bleeding in the 24 hours after treatment and increases the risk of recurrence of disease and infections.

Human Papillomavirus Detection by Hybrid Capture II and Residual or Recurrent High-Grade Squamous Cervical Intraepithelial Neoplasia after Large Loop Excision of the Transformation Zone (LLETZ)

Aims and background

The purpose of this study was to assess the association between highly-oncogenic types HPV DNA detection by Hybrid Capture II (HCII) and residual or recurrent high-grade cervical intraepithelial neoplasia (CIN 2 or 3) during the follow-up of women submitted to large loop excision of the transformation zone (LLETZ).

Study design

In this cohort study, 94 women submitted to LLETZ because of CIN 2 or 3 between March 2001 and September 2002 were followed up twice yearly until September 2003. Follow-up visits consisted of an interview regarding clinical, social and demographic characteristics complemented with gynecological examination with specimen collection for Pap test and HCII and colposcopy. Eighty-one patients attended the first visit (mean 4.8 months, range 3-6) and 75 the second visit (mean 10.9 months, range 7-17 months). McNemar's test to assess the variation of HPV DNA detection following LLETZ, odds ratios (OR) to evaluate the correlation between HPV DNA positivity and residual/recurrent CIN during follow-up, and logistic regression to assess the risk of residual/recurrent CIN were used.

Results

There was a strong and significant reduction in HPV detection after LLETZ ( P <0.001). HPV DNA detection was correlated with residual/recurrent CIN at the first (OR = 103.4; 95% CI 5.5 to 1961.2) and second (OR = 12.7; 95% CI 1.1 to 345.5) follow-up visits. Multivariate analysis showed HPV persistence as a stand-alone risk factor for residual/recurrent CIN (OR = 50.3; 95% CI 3.8 to 663.1).

Conclusions

High risk HPV DNA detection decreased substantially after CIN treatment with LLETZ, but HPV persistence was strongly correlated with residual/recurrent CIN.

Role of Close Endocervical Margin in Treatment Failure After Cervical Excision for Cervical Intraepithelial Neoplasia: A Retrospective Study

CONTEXT.—

A significant negative trend in length of cone excision has been observed in recent years, leading to a higher percentage of positive endocervical excision margin and close (<1 mm) negative endocervical margin cases.

OBJECTIVE.—

To evaluate the rate of disease persistence and recurrence after cervical excision for cervical intraepithelial neoplasia in relation to a close (<1 mm), negative, or positive endocervical margin.

DESIGN.—

We retrospectively analyzed a cohort of patients with cervical intraepithelial neoplasia having a carbon dioxide laser cervical excision performed by the same operator. We evaluated the rate of positive follow-up in relation to the status of endocervical margin.

RESULTS.—

We found a higher percentage of positivity at follow-up and recurrence rate between 13 and 24 months in patients with positive margin than for patients with negative or close endocervical margin (P = .005 and P = .006, respectively), with no difference between negative and close margin (7.0% versus 8.3%, P = .89, and 1.2% versus 0%, P = .83, respectively).

CONCLUSIONS.—

Women with close and negative endocervical margin presented similar risk of positivity at long-term follow-up, disease persistence, and recurrence between 13 and 24 months, so the histopathologic report of a free endocervical margin less than 1 mm should not categorize the patient as being at increased risk of treatment failure. Therefore, the only information that the pathologist should report is the state of the margin (positive or negative), regardless of the negative endocervical margin length.

Overcoming the Challenging Cervix: Identification and Techniques to Access the Uterine Cavity

Importance

Cervical stenosis is a challenging clinical entity that requires prompt identification and management in order to avoid iatrogenic injury at the time of endocervical canal cannulation.

Objective

The aim of this study was to identify cervical stenosis and discuss associated etiologies, risk factors, and review medical and surgical approaches for overcoming cervical stenosis.

Evidence Acquisition

Computerized searches of MEDLINE and PubMed were conducted using the key words "cervix", "cervical stenosis," "embryo transfer," "hysteroscopy complications," "misoprostol," and "ultrasound." References from identified sources were manually searched to allow for a thorough review. Data from relevant sources were compiled to create this review.

Results

Transcervical access to the uterine cavity is frequently required for procedures such as hysteroscopy, dilation and curettage, endometrial biopsy, sonohysterogram, hysterosalpingogram, intrauterine insemination, embryo transfer in those undergoing in vitro fertilization, and insertion of intrauterine devices. These procedures can become complicated when difficult cannulation of the endocervical canal is encountered. Management strategies include preprocedural use of cervical-ripening agents or osmotic dilators, ultrasound guidance, no-touch vaginoscopy, manual dilatation, and hysteroscopic resection of the obstructed endocervical canal.

Conclusions and Relevance

Cervical stenosis is associated with iatrogenic complications that can result in significant patient morbidity. In patients undergoing in vitro fertilization, difficult embryo transfer is associated with lower pregnancy rates. The clinician should carefully consider the patient's menopausal status, risk factors, and symptoms in order to anticipate difficult navigation of the endocervical canal. Various medical and surgical management strategies, including hysteroscopic resection, can be used to overcome the stenotic cervix.

Increase in the cervical length after the loop electrosurgical excision procedure for grade III cervical intraepithelial neoplasia

This study aimed to determine whether the cervical length increases over a period of six months, after the loop electrosurgical excision procedure (LEEP) for grade III cervical intraepithelial neoplasia (CIN), and to identify the factors associated with an increase in the cervical length. We retrospectively reviewed the medical records of 183 patients who underwent the LEEP between April 2011 and March 2014, at the Department of Gynaecology, Kyosai Hospital. Transvaginal ultrasonography was performed at two, three and six months after the LEEP, and the mean increase in the cervical length between two and three months, two and six months, and three and six months were 2.07, 5.23 and 2.92 mm, respectively. The increase in the cervical length was not associated with age, gravidity, parity and the width of CIN. In conclusion, the cervical length may increase gradually over a period of six months after the LEEP.

[Evaluation of satisfaction after in-office conization under local anesthesia]

OBJECTIVES

Treating cervical intraepithelial neoplasia is essential in cervix carcinoma prevention and conization is the standard treatment. In the current medical and economic context, which advocates the simplification of procedures, loop excision conization is well adapted to an in-office procedure. Therefore, we evaluated the patient satisfaction after an in-office conization.

METHOD

We conducted an observational study at the Besançon University Medical Centre. Between November 2013 and October 2014, all patients treated by an in-office conization were included. Global satisfaction of patient was retrospectively collected by answering a telephone questionnaire.

RESULTS

Seventy patients were treated by in-office conization and answered the questionnaire. Global satisfaction was 88.6%. Moreover, 75.7% of patients declared to have felt no pain or moderate pain during the conization. Most of the patients (91.4%) would advise this in-office care to their relatives. The rate of positive margins for dysplasia was 31.4% and postoperative haemorrhage occurred in 7.1%.

CONCLUSION

In this context of medical care cost reduction, conization seems to be perfectly adapted to in-office surgery. It was also found to be well accepted by patients without raising neither positive margins rate nor postoperative haemorrhage risk.

Meta-analysis of cold-knife conization versus loop electrosurgical excision procedure for cervical intraepithelial neoplasia

Objective

This meta-analysis aimed to compare the superiority of loop electrosurgical excision procedure (LEEP) or large loop excision of the transformation zone (LLETZ) versus cold-knife conization (CKC) in the surgical treatment of cervical intraepithelial neoplasia (CIN).

Methods

Systematic searches were performed in the MEDLINE, EMBASE, Cochrane databases, and the China National Knowledge Infrastructure Databases to identify all potential articles involving patients with CIN treated with LEEP/LLETZ or CKC published up to February 2016. Risk ratios (RRs) or weighted mean difference (MD) with a 95% confidence interval (95% CI) were calculated.

Results

Seven randomized controlled trials, one prospective cohort study, and twelve retrospective cohort studies were included in this meta-analysis. There were no significant differences following LEEP/LLETZ compared with CKC in recurrence rate (RR =1.75, 95% CI =0.99–3.11, P=0.06), positive margin rate (RR =1.45; 95% CI =0.85–2.49, P=0.17), residual disease rate (RR =1.15, 95% CI =0.73–1.81, P=0.48), secondary hemorrhage (RR =1.16, 95% CI =0.74–1.81; P=0.46), or cervical stenosis. Moreover, subgroup analyses based on randomized trials also revealed that no statistical significance was observed in the above outcomes. However, women treated with CKC had a significantly deeper cervical cone than those treated with LLETZ/LEEP (MD =−5.71, 95% CI =−7.45 to −3.96; P<0.001).

Conclusion

LEEP/LLETZ is as effective as CKC with regard to recurrence rate, positive margin rate, residual disease rate, secondary hemorrhage, and cervical stenosis for the surgical treatment of CIN. Further large-scale studies are needed to confirm our findings.

Systematic reviews and meta-analyses of benefits and harms of cryotherapy, LEEP, and cold knife conization to treat cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) stage 2-3 is a premalignant lesion that can progress to cervical cancer in 10-20 years if untreated.

OBJECTIVES

To conduct systematic reviews of randomized and nonrandomized studies for effects of cryotherapy, loop electrosurgical excision procedure (LEEP), and cold knife conization (CKC) as treatment for CIN 2-3.

SEARCH STRATEGY

Medline, Embase, and other databases were searched to February 2012 for benefits, and to July 2012 for harms. Additionally, experts were contacted. Keywords for CIN, cervical cancer, and the treatments were used.

SELECTION CRITERIA

Studies of nonpregnant women 18 years or older not previously treated for CIN were included.

DATA COLLECTION AND ANALYSIS

Two investigators independently screened and collected data. Relative risks and proportions were calculated and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

Recurrence rate was 5.3% 12 months after cryotherapy or LEEP, and 1.4% after CKC. There seemed to be little or no differences in frequency of complications after LEEP or cryotherapy, but they occurred more often after CKC. Evidence suggests premature delivery is most common with CKC, but it also occurs after LEEP and cryotherapy.

CONCLUSIONS

Despite a comprehensive search, there is very low quality evidence and often no evidence for important outcomes, including reproductive outcomes and complications. Studies assessing these outcomes are needed.

The predictive value of human papillomavirus testing for the outcome of patients conservatively treated for stage IA squamous cell cervical carcinoma

BACKGROUND

Although it is hypothesised that human papillomavirus (HPV) testing may have a role in surveillance of patients conservatively treated for stage IA squamous cell cervical carcinoma, research on this topic has been minimal.

OBJECTIVES

To determine: (1) the changes in HPV test result from treatment onward; (2) the time to viral clearance; and (3) the negative predictive value (NPV) and positive predictive value (PPV) of HPV test result for the detection of CIN2 or worse (CIN2+) during follow-up.

STUDY DESIGN

In a multicentre retrospective follow-up study of a consecutive series (1997-2009) of 91 patients, longitudinal outcome measures were estimated as cumulative probabilities using the Kaplan-Meier method.

RESULTS

For patients testing HPV-positive at the first follow-up visit (n=44), the probability of change to negative rose from 0 to 0.78 between 7 and 21 months after treatment. For HPV-negative patients (n=47), the probability of change to positive rose to 0.13 between 9 and 26 months. After a median follow-up of 50 months (range, 2-80), the NPV for CIN2+ was 1.00. The PPV was 0.60 (95% confidence interval, 0.43-0.77) after 26 months. The median time to detection was 5 months.

CONCLUSIONS

If adequately confirmed, these findings would indicate that HPV testing is capable to identify the patients who have had their lesions fully removed, and would make it possible to focus follow-up efforts on a subset of patients at high risk of residual or progressive disease.

Long term outcomes of laser conization for high grade cervical intraepithelial neoplasia in Thai women

AIM

To report long term outcomes of laser conization for high grade cervical intraepithelial neoplasia (CIN) in Thai women.

MATERIALS AND METHODS

A retrospective cohort study was conducted in patients undergoing laser conization due to abnormal cervical cytology suggesting neoplasia during 1989 to 1994 and having follow-up data until December 2010. Conization was performed under colposcopy using a 0.5-mm CO2 laser beam with power density of 18,000-20,000 watts/cm2, and the surgical base was vaporized using a low power defocused beam. The follow-up protocol included cervical cytology and colposcopy. Long term outcome measures were failure rate (persistence and recurrence), post-conization status of transformation zone, and obstetric outcomes.

RESULTS

Of 104 patients undergoing conization, 71 had therapeutic conization for high grade CIN and were followed up for a median time of 115 (range 12-260) months. There was one case of persistent and one of recurrent disease comprising a failure rate of 2.8%. The post treatment transformation zone was well visualized in 68.3% of 63 patients with an intact uterus. Sixteen patients achieved 25 pregnancies; none had second trimester miscarriage. The obstetric outcomes were unremarkable.

CONCLUSIONS

Laser conization under colposcopic visualization for the treatment of high grade CIN in Thai women has a low failure rate of 2.8%. The post-conization transformation zone could not be evaluated completely in approximately 30% of cases; therefore the follow-up protocol should include both cytology and colposcopy. Obstetric outcomes are not adversely affected by this therapeutic procedure.

Loop electrosurgical excision procedure and risk of miscarriage

OBJECTIVE

To evaluate the risk of miscarriage in the subsequent pregnancy after a loop electrosurgical excision procedure (LEEP), also considering time elapsed from LEEP to pregnancy.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Tertiary care university hospitals.

PATIENT(S)

Women who had undergone LEEP from January 2000 to December 2011. Women with histologic assessment of low-grade cervical dysplasia, not requiring subsequent surgical treatment, constituted the control group.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The first pregnancy after the procedure was evaluated, and only women with singleton spontaneous pregnancies were considered. Women with time intervals of <12 months and women with intervals of ≥12 months or more from LEEP to pregnancy were then compared, to identify adjusted odds ratios for miscarriage.

RESULT(S)

In women previously treated with LEEP, a total of 116 cases of miscarriage (18.1%) was reported. The mean time interval from LEEP to pregnancy for women with miscarriage compared with women without miscarriage was significantly shorter (25.1 ± 11.7 months vs. 30.1 ± 13.3 months). A higher rate of miscarriage in women with a LEEP-to-pregnancy interval of <12 months compared with controls emerged (28.2% vs. 13.4%; adjusted odds ratio 2.60, 95% confidence interval 1.57-4.3). No significant difference in the rate of miscarriage in women with a LEEP-to-pregnancy interval of ≥12 months compared with controls emerged.

CONCLUSION(S)

Women with a time interval from LEEP to pregnancy of <12 months are at increased risk for miscarriage.

Loop electrosurgical excision procedure: an effective, inexpensive, and durable teaching model

The effectiveness of simulation training for enhancing operative skills is well established. Here we describe the construction of a simple, low-cost model for teaching the loop electrosurgical excision procedure. Composed of common materials such as polyvinyl chloride pipe and sausages, the simulation model, shown in the accompanying figure, can be easily reproduced by other training programs. In addition, we also present an instructional video that utilizes this model to review loop electrosurgical excision procedure techniques, highlighting important steps in the procedure and briefly addressing challenging situations and common mistakes as well as strategies to prevent them. The video and model can be used in conjunction with a simulation skills laboratory to teach the procedure to students, residents, and new practitioners.

Interval from loop electrosurgical excision procedure to pregnancy and pregnancy outcomes

OBJECTIVE

Previous studies have shown mixed results for pregnancy outcomes after loop electrosurgical excision procedure (LEEP); however, evidence is lacking regarding the pregnancy outcome of spontaneous abortion with respect to time elapsed from LEEP to pregnancy. We investigated risks of spontaneous abortion and preterm birth as they relate to time elapsed from LEEP to pregnancy.

METHODS

A 10-year, multicenter cohort study of women who underwent LEEP was performed between 1996 and 2006. Trained research nurses conducted telephone interviews with all patients to complete data extraction unavailable in charts. Median time from LEEP to pregnancy for spontaneous abortion compared with no spontaneous abortion and preterm birth before 34 and before 37 weeks of gestation compared with term birth were estimated. Patients with time intervals less than 12 months compared with 12 months or more from LEEP to pregnancy were then compared with identify adjusted odds ratios for spontaneous abortion and preterm birth.

RESULTS

Five hundred ninety-six patients met inclusion criteria. Median time from LEEP to pregnancy was significantly shorter for women with a spontaneous abortion (20 months [interquartile range 11.2-40.9] compared with 31 months [interquartile range 18.7-51.2]; P=.01) but did not differ for women with a term birth compared with preterm birth. Women with a time interval less than 12 months compared with 12 months or more were at significantly increased risk for spontaneous abortion (17.9% compared with 4.6%; adjusted odds ratio 5.6; 95% confidence interval 2.5-12.7). No increased risk was identified for preterm birth before 34 weeks of gestation or before 37 weeks of gestation.

CONCLUSION

Women with a shorter time interval from LEEP to pregnancy are at increased risk for spontaneous abortion but not preterm birth.

LEVEL OF EVIDENCE

: II.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to November 2012). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

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.

Prospective Comparison of Loop Excision under Colposcopic Guidance versus Vitom Guidance

Background: Aim of the study was to compare the quality of loop excision using a colposcope with results using the VITOM system. Results compared included cervical volume removed, intra- and postoperative complications, and positive resection margins. Methods: A total of 200 patients with histologically confirmed high-grade cervical premalignant lesions, persistent atypical cytological results and/or suspicious colposcopic findings, and cytological and histological discrepancies were included in the study. In transformation zone type 1 (T1) only a superficial cone biopsy was done, in zones type 2 and 3 (T2 and T3) a superficial outside cone biopsy or a deeper inside cone biopsy were done respectively, followed by endocervical curettage. Volume of removed tissue, complications, and positive resection margins were compared for the colposcopy and the VITOM groups. Findings: Demographic and reproductive features were similar between groups. In the VITOM group 49 % of patients had zone T1, 30 % had zone T2, and 21 % had zone T3. In the group of patients managed by colposcopy, 48, 45, and 7 % of patients had zone T1, T2 and T3 zone, respectively (p < 0.01). A "top hat" procedure was done in 65 % of patients in the VITOM group and in 38 % of patients in the colposcopy group (p < 0.05). Mean volume of removed cervical tissue measured was similar, with 1.2 cm³ measured in the VITOM group and 1.14 cm³ in the colposcopy group (p > 0.05). There were no significant differences in the type of procedure or the mean volume of removed tissue. Results were similar for both groups with respect to positive resection margins and complications. Conclusion: VITOM is a safe and reliable system. Results using the VITOM system are comparable to those obtained with conventional colposcopy. The potential advantage of VITOM is the broader availability of endoscopic systems in the operating theatre.

Minimal cold knife conization height for high-grade cervical squamous intraepithelial lesion treatment

OBJECTIVES

To assess the relationship between cold-knife conization specimen height, cervical intraepithelial neoplasia (CIN II/III) size and endocervical margin involvement by CIN II/II.

STUDY DESIGN

A cross-sectional study was performed. Cold knife cone specimens with a diagnosis of CIN II/III were selected. Epidemiological data and pathology reports were obtained through a chart review. All samples from each cone specimen showing CIN II/III and the squamocolumnar junction were selected. Cone height (mean ± standard deviation), intraepithelial lesion size, and size of endocervical surgical margins were measured.

RESULTS

Four hundred and forty-seven samples were analyzed from 97 cone specimens. Section size ranged from 3.4 to 29.7 mm, tumor size from 0.3 to 17.5mm, and tumor distance from the endocervical margin, from 0.0 to 22.0mm. Age and parity were similar in the positive vs. negative margin groups (37.6 ± 10.0 years vs. 37.7 ± 11.9 years respectively, p=0.952, and 2.2 ± 1.7 births vs. 2.6 ± 1.9 births respectively, p=0.804), whereas cone height (22.4 ± 6.9 mm vs. 17.1 ± 5.6mm, p=0.013) and tumor size (6.12 ± 3.25 mm vs. 10.6 ± 4.45 mm, p<0.001) were significantly different in negative vs. positive margin groups respectively.

CONCLUSIONS

Use of cone height to identify the likelihood of negative margins enables better estimation of the risk-benefit ratio of greater risks of bleeding, stenosis, and obstetric complications (cervical incompetence) versus greater risks of residual and recurrent disease.

A novel training model for the loop electrosurgical excision procedure: an innovative replica helped workshop participants improve their LEEP

We wanted to evaluate the feasibility and effect of a hands-on loop electrosurgical excision procedure (LEEP) 2.5-day intensive surgical skills workshop, using a novel training model on porcine tissue. Hands-on simulation-based training was conducted to emphasize colposcopy, local anesthesia, uterine cervix and vulva punch biopsy, LEEP, and complication management. Performance of 51 participants' technical skills was assessed before and after training completion. LEEP performance was significantly better after completion of the training (P < .001). Before and after training mean scores (SD) of 18.0 (3.5) and 23.4 (2.1) were assessed. Multivariate analysis revealed that the training effects were independent of previous surgical expertise. The LEEP workshop was feasible and effective and we recommend implementing hands-on LEEP training into gynecology training programs.

Number of fragments, margin status and thermal artifacts of conized specimens from LLETZ surgery to treat cervical intraepithelial neoplasia

CONTEXT AND OBJECTIVE

Large loop excision of the transformation zone (LLETZ) is a nontraumatic cut and coagulation method with several advantages, but it induces thermal artifacts in the cut region. The aim here was to assess the correlations of age, number of fragments, lesion grade and degree of thermal artifacts with margin quality in conized specimens from LLETZ for cervical intraepithelial neoplasia (CIN).

DESIGN AND SETTING

Cross-sectional study at Universidade Federal de São Paulo (Unifesp).

METHODS

The records and histopathology findings of 118 women who underwent LLETZ between 1999 and 2007 were reviewed. Age, number of fragments, lesion grade, degree of thermal artifacts and margin quality were assessed.

RESULTS

The patients' mean age was 27.14 years; 63.6% had been diagnosed with CIN II and 36.4% with CIN III. The lesion was removed as a single fragment in 79.6% of the cases. The margins were free from intraepithelial neoplasia in 85.6% and compromised in the endocervical margin in 6.8%. Fragment damage due to artifacts occurred in 2.5%. Severe artifacts occurred in 22.8%. Women aged 30 years or over presented more cases of CIN III (P < 0.0004). Neoplastic compromising of surgical margins and severe artifacts occurred more often in cases in which two or more fragments were removed, and in patients aged 30 years or over.

CONCLUSION

CIN III in women aged 30 or over, when removed in two or more fragments during LLETZ, presented a greater number of compromised margins and greater severity of thermal artifacts.

Fertility-sparing treatment in younger women with adenocarcinoma in situ of the cervix

OBJECTIVE

For women who have completed childbearing, the treatment of choice for adenocarcinoma in situ (ACIS) of the cervix is hysterectomy. In women who desire future fertility, however, conservative therapy is an acceptable alternative. In this study we compare the outcomes for young women who underwent loop conization or were treated with cold knife conization.

METHODS

We performed a retrospective analysis in 112 patients with ACIS, age 30 or younger, treated with cold knife conization or loop conization between 1998 and 2010. Decision to perform office loop conization was based on the size of the cervix and the colposcopic lesion. Main outcomes were negative margins after the procedure and recurrence of ACIS.

RESULTS

Fifty-eight patients (52%) were treated with cold knife conization and 54 (48%) underwent loop conization. The odds ratio for cold knife conization to achieve negative cone margins compared with loop conization was 1.4 (95% CI 0.6-3.5). We observed no difference in residual or recurrent ACIS between patients treated with loop conization versus cold knife conization.

CONCLUSIONS

In select young patients who desire future fertility, loop conization and cold knife conization have equivalent rates of negative margins and negative follow-up. For optimal results, patients must have a lesion which can be removed in one pass of a loop, confirmed by expert colposcopy. Loop excision should be considered the treatment of choice in this specific group of patients.

Cervical conization and the risk of preterm delivery

The current body of literature concerning cervical conization and its effect on subsequent pregnancy outcome is conflicting. Depending on the type of conization procedure that is examined and the quality of the control group, the results and conclusions vary widely. Because treatment for cervical intraepithelial neoplasia is commonplace among women of reproductive age, it is imperative that practitioners have an understanding of the issues surrounding the treatment. Therefore, this review will summarize the published literature that addresses excisional procedures of the uterine cervix and the risk of preterm delivery in subsequent pregnancies and provide reasonable treatment recommendations for women with cervical abnormalities and a desire for future fertility.

Shimodaira-Taniguchi conization method: its utility and reliability

INTRODUCTION

Introduced in 1992, the Shimodaira-Taniguchi conization procedure addresses the disadvantages of the loop electrosurgical excision procedure by relying on a high frequency current of 150 W and a triangular probe with a 0.25-mm linear excision electrode to extract a single informative specimen. We conducted a retrospective study to evaluate Shimodaira-Taniguchi conization as a conservative therapy for cervical intraepithelial neoplasia (CIN) and microinvasive cancer of the cervix.

METHODS

Subjects were 455 patients who underwent Shimodaira-Taniguchi conization for CIN, carcinoma in situ, adenocarcinoma in situ, or stage IA microinvasive cervical carcinoma at our hospital from January 2005 to December 2008. Patient follow-up ranged from 13 to 60 months. Clinical data were obtained and evaluated.

RESULTS

Mean operation time was 11 minutes, and average blood loss was 9.9 mL. Margins were positive in 178 (39.1%) cases. Postsurgical complications occurred in 61 patients, with secondary hemorrhage occurring in 46 patients. None required transfusion. None were lost to follow-up, and there was no disease-related death. Disease recurred in 6 (1.3%) patients: 4 with a positive excision margin and 2 with a negative margin. Cervical stenosis occurred in 15 (3.3%) patients, 3 of whom suffered cervical obstruction, including 1 with dysmenorrhea who underwent hysterectomy. In most cases (n = 357, 78%), a single adequate specimen was extracted.

CONCLUSIONS

As a conservative treatment for CIN and microinvasive cervical cancer, Shimodaira-Taniguchi conization is useful. It is easy, provides adequate histologic specimens (often singular), and results in few postoperative complications.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to April 2009). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

Loop electrosurgical excision procedure to treat cervical stenosis at the time of surgical abortion

Cervical stenosis can act as a barrier to the uterine cavity for surgical abortion. We present a case in which a loop electrosurgical excision procedure (LEEP) was performed during a surgical abortion to overcome a stenotic cervix. We also discuss risk factors for cervical stenosis, and other methods of treating stenosis which have been reported in the literature.

Factors influencing the choice between cold knife conization and loop electrosurgical excisional procedure for the treatment of cervical intraepithelial neoplasia

AIM

To determine whether cold knife conization (CKC) or loop electrosurgical excisional procedure (LEEP) is the better option for the treatment of cervical intraepithelial neoplasia (CIN) under specific circumstances.

METHODS

We retrospectively reviewed the medical records of patients who underwent CKC or LEEP for the treatment of CIN. The proportion of non-negative surgical margins between the two treatment groups was calculated based on their age, parity, previous mode of delivery, and grade of CIN. The Student's t-test and multivariate logistic regression analysis were used to find the better option for the treatment of CIN under the specific circumstances.

RESULTS

A total of 118 patients were enrolled in the study. Between the two treatment groups, there was no significant difference in the overall proportion of non-negative surgical margins (P > 0.05). The grade of CIN, the previous mode of delivery, and parity did not affect the surgical margin status. The CKC treatment group had a significantly lower incidence of non-negative surgical margins than the LEEP treatment group (14.3% vs. 52.6%, respectively; P < 0.05) in the patients >45 years of age. Based on multivariate analyses, LEEP was identified as a significant risk factor for non-negative surgical margins in the patients >45 years of age. Of the 11 patients with non-negative surgical margins who underwent a secondary procedure within 6 months of the initial CKC or LEEP, five patients (45.5%) had residual CIN II and III.

CONCLUSIONS

In patients >45 years of age, CKC is the preferred treatment for CIN.

Routine follow-up intervals in patients with high-grade squamous intraepithelial lesions (HSIL) and free excision margins can safely be increased in the first two years after Large Loop Excision of the Transformation Zone (LLETZ)

OBJECTIVE

To assess the compliance of HSIL patients to the national Dutch routine follow-up protocol in the first 2 years after LLETZ and to determine if based on the status of excision margins, follow-up intervals could be modified.

METHODS

A prospective cohort study was performed in patients, referred because of an abnormal Pap smear between 1996 and 2004 and treated for HSIL with LLETZ. The Dutch national routine follow-up protocol orders a Pap smear after 6, 12 and 24 months, respectively. Follow-up results were completed by using PALGA, the nationwide network and registry of histo- and cytopathology in the Netherlands. To assess compliance to the follow-up protocol, adequate follow-up was defined as three cervical smears taken after 6 (+/-3), 12 (+/-3) and 24 (+/-3) months, respectively.

RESULTS

Compliance to the first 2 years follow-up protocol declined from 86.2% to 64.8% to 51.2% for first, second and third follow-up cervical smears, respectively. Patients with involved excision margins had a three times higher overall risk of developing a subsequent HSIL after LLETZ as compared to patients with free excision margins (HR: 3.2, 95% CI=1.3-7.9, p=0.01). Risk for diagnosing HSIL during the first 12 months of follow-up for patients with free excision margins was only 1%.

CONCLUSIONS

Compliance to the Dutch national routine follow-up protocol in HSIL patients after LLETZ is only moderate. For HSIL patients with free excision margins after LLETZ the first cytological follow-up interval can safely be increased to 12 months.

Overcoming the challenging cervix: techniques to access the uterine cavity

OBJECTIVE

To identify cervical stenosis and review medical, surgical, and radiological modalities to access the uterine cavity.

MATERIALS AND METHODS

Computerized searches of Medline and PubMed from 1996 to 2005 were conducted using the key words "cervix," "cervical ripening," and "cervical stenosis." References from identified publications were manually searched and cross-referenced to identify additional relevant articles. We review relevant techniques on how to access the uterine cavity when cervical stenosis is encountered.

RESULTS

Many gynecologic procedures require uncomplicated access through the cervix to access the uterine cavity, including hysteroscopy, dilation and curettage, sonohysterogram, hysterosalpingogram, endometrial biopsy, and embryo transfer for in vitro fertilization. These procedures can be quite complicated when a cervix is obstructed. Management techniques described include the medical use of misoprostol and laminaria, intraoperative ultrasound guidance, and operative creation of a new passage. Additionally, techniques for bypassing the obstructed cervix and preventing cervical stenosis have been described.

CONCLUSIONS

Cervical stenosis can result in iatrogenic complications. Preoperative identification, cervical ripening agents, osmotic dilators, and the use of ultrasound guidance are useful in overcoming cervical stenosis. It is also key to identify those at risk for cervical stenosis and implement preventative techniques as needed.

Compliance After Loop Electrosurgical Excision Procedure or Cold Knife Cone Biopsy

OBJECTIVE

To examine rates and predictors of compliance with follow-up recommendations in low-income women from a county hospital clinic undergoing loop electrosurgical excision procedure (LEEP) and cone knife cone biopsy.

METHODS

A retrospective cohort study of 135 patients who underwent LEEP or cold knife cone biopsy was performed. Demographic data, results of cytology, colposcopy biopsy, excision specimen pathology, and indication for the LEEP or cold knife cone biopsy were collected. Compliance was determined by whether the patient adhered to the recommended follow-up within 1 year from the date of the procedure. Multivariable analysis was performed by using logistic regression.

RESULTS

A total of 135 patients were included for analysis (81 LEEP and 54 cold knife cone cases). Type of procedure was significant in predicting compliance: 74.1% of cold knife cone patients were compliant compared with 43.2% of LEEP patients (adjusted relative risk 1.64, 95% confidence interval 1.30-1.87). There was a trend for older patients to be more compliant than younger patients in the univariable analyses but not in multivariable analysis. After adjusting for age, LEEP patients were still significantly less compliant than cold knife cone patients. Pathologic indication (severity of disease), race, payor source, and gravidity were not significant predictors of compliance and not included in the multivariable analysis.

CONCLUSION

Compared with LEEP, cold knife cone patients were significantly more compliant with follow-up. Because LEEP is a less invasive in-office procedure, it may convey to patients the idea that their condition is less severe.

LEVEL OF EVIDENCE

II.

A LEEP Cervical Conization Is Rarely Indicated for a Two-Step Discrepancy

OBJECTIVES

The current indications for conization of the cervix include a 2-step discrepancy between cervical cytological and histological findings. We sought to determine the utility of a loop electrocautery excision procedure (LEEP) cone for a 2-step discrepancy.

METHODS

A retrospective institutional review board-approved chart review was performed on all women recommended to undergo a LEEP secondary to a discrepancy between a referral high-grade squamous intraepithelial lesion cytological finding and a subsequent colposcopic biopsy result revealing either normal or cervical intraepithelial neoplasia (CIN) 1 histological finding; CIN 2 was excluded from the study. Statistical analysis was performed using SAS 9 (SAS Institute, Inc, Cary, NC). The results were considered significant if a p value less than or equal to.05 was demonstrated.

RESULTS

Fifty-nine patients received a LEEP for a 2-step discrepancy between cytological and histological findings. Twenty-seven patients had a second pass or LEEP cone. Among the patients with a normal cervical biopsy result and a high-grade cytological finding, 10 (29%) of 34 had normal histological findings, as revealed by LEEP, and 14 (41%) of 34 had CIN 3; 16 (64%) of 25 patients with high-grade cytological finding and CIN 1 biopsy finding had CIN 3, as revealed by LEEP. Compared with patients with an initial normal cervical biopsy result, those with CIN 1 on initial biopsy were more likely to have CIN 3 on their LEEP findings (p =.08). Twenty-seven of 59 patients underwent a LEEP cone surgery; 1 of 27 had CIN 3 finding in the second-pass portion. This was associated with a CIN 3 identified on the first pass and associated with positive margins. The second pass of the LEEP cone failed to demonstrate CIN 96% of the time (p < .0001). Patients with a normal or a CIN 1 finding on the first pass had a normal finding on the second pass in 100% of cases.

CONCLUSIONS

A LEEP cone is rarely indicated for the evaluation of a 2-step discrepancy. A randomized trial of this finding is warranted.

Outcomes after treatment of cervical intraepithelial neoplasia among women with HIV

OBJECTIVE

To describe outcomes after treatment of cervical intraepithelial neoplasia (CIN) in women with HIV.

MATERIALS AND METHODS

Women in two prospective cohort studies, the Women's Interagency HIV Study (WIHS) and the HIV Epidemiology Research Study (HERS), were followed every 6 months after treatment of CIN using human papillomavirus (HPV) testing and cytology with colposcopy as indicated. Identification of CIN or a squamous intraepithelial lesion (SIL) within 6 months was defined as treatment failure and later disease as recurrence.

RESULTS

Follow-up was available for 170 HIV-seropositive and 15 HIV-seronegative women. Treatment failed in 84 (45%) women (79 HIV seropositive and 5 HIV seronegative). Failure was more likely in women with lower CD4 counts (CD4 < 200 cells/microL: odds ratio [OR] = 2.96; 95% CI = 1.4-6.2) and detectable HPV DNA (OR 8.20; 95% CI = 1.8-37.4; p = .01). After successful treatment, recurrence-free probabilities at 1,2, 3, and 5 years were .79, .64, .49, and .34, respectively. HIV-seronegative women were less likely to recur than HIV-seropositive women (p = .03). In multivariable analysis of HIV-positive women, recurrence was more likely among women treated for CIN 2,3 (hazard ratio [HR] = 2.4; 95% CI = 1.4-4.8), those with CD4 count of less than 200 cells/microL (HR = 2.9; 95% CI = 1.3-6.5) and those with HPV after treatment (HR 2.9; 95% CI = 1.4-6.1); oncogenic HPV was more strongly associated with recurrence than nononcogenic HPV (p(trend) = .009). Most failures and recurrences were low grade, but one adenocarcinoma was diagnosed 4.2 years after therapy for CIN 1.

CONCLUSION

Treatment failure and recurrence are common in women with HIV but are usually low grade.

High-grade squamous intraepithelial lesion (CIN 2 and 3) excised with negative margins by loop electrosurgical excision procedure: the significance of CIN 1 at the margins of excision

The significance of cervical intraepithelial neoplasia grades 2 or 3 (CIN 2-3) at the margin of a loop electrosurgical excision procedure (LEEP) specimen as a predictor of recurrent or persistent disease is relatively controversial. Most studies have found the presence of high-grade dysplasia at the margins in this setting to be an adverse parameter. However, the significance of an isolated finding of CIN 1 at the surgical margins of LEEP specimens has not been rigorously studied. Herein, we evaluate the significance of finding CIN 1 at one or more margins of a LEEP specimen when these margins are negative for CIN 2-3. Consecutive LEEP specimens with a CIN 2-3 diagnosis (and whose margins were negative for the latter) were retrieved, and their slides were reviewed. The cases were classified as to whether CIN 1 was present at the margins. Follow-up cytologic and histologic data were compared between patients with and without CIN 1 at the margin. For patients with multiple follow-up samples, only the most severe abnormality (1 sample per patient) was counted. Seventy-three cases were evaluated, with CIN 1 present at the margin in 59 (81%, group 1) and absent in 14 (19%, group 2). Follow-up cytologic information was available in 60 patients, with a median follow-up of 19 months. The cytologic follow-up of groups 1 and 2 patients were not significantly different regarding the diagnostic frequency of any one of the Bethesda 2001 diagnostic categories (P > .05 for all, Fisher exact and chi(2) tests). Of the 33 patients who received a cervical biopsy and/or endocervical curettage during the follow-up period, 29 belonged to group 1 and 4 to group 2. The distribution of "negative" CIN 1 and CIN 2-3 diagnoses for group 1 were 16 (55%) of 29, 7 (24%) of 29, and 6 (21%) of 29, respectively. Parallel figures for group 2 were 2 (50%) of 4, 2 (50%) of 4, and 0 (0%) of 4, respectively. Although CIN 2-3 was more frequent in group 1, none of the comparisons attained statistical significance. The current study is a small single-institution study, whose findings should not be extrapolated to cold-knife conizations, and need to be confirmed in larger data sets. However, our preliminary analysis suggests that the isolated presence of CIN 1 at the margin of a LEEP specimen, whose margins are otherwise negative, lacks adverse prognostic significance.

Preoperative predictors of positive margins after loop electrosurgical excisional procedure–Cone

OBJECTIVE

A LEEP-Cone may not be necessary for all patients with traditional cone indications. This study defines populations where a single pass technique with the LEEP is appropriate.

METHODS

We retrospectively reviewed patients undergoing LEEP-Cone procedures performed at the University of Oklahoma Health Science Center from February of 1994 to July of 2002. Patients include those for LEEP-Cone with traditional excisional indications and those who underwent LEEP-Cone at the operating physician's discretion. Statistical analysis was used to compare preoperative factors with the resultant pathologic results.

RESULTS

A total of 248 women underwent LEEP-Cone. 50.0% (33/66) of the patients with positive margins on the first pass had dysplasia or worse (CIN I-III or CA) in the second pass (top hat), compared to 6.6% (12/182) of the patients with a negative first pass (P < 0.0001). Univariate analysis found CIN III on histology and parity to be predictive of dysplasia in the top hat and two-step discrepancy to predict absence of dysplasia. On multivariate analysis, two-step discrepancy and parity remained predictive. Age >35 was the greatest percentile predictor of dysplasia in the top hat, and 91.5% of women <21 had normal top hat pathology.

CONCLUSION

The retrospective data reported regarding LEEP-Cones reveal increased parity to predict dysplasia in the top hat and two-step discrepancy as a poor predictor of dysplasia in the top hat. Women under 21 years of age should have a single pass LEEP technique. The "top hat" is more appropriate as parity and age increase.

Significance of benign endometrial cells in papanicolaou tests from women aged ≥ 40 years

BACKGROUND

The 2001 Bethesda System recommends reporting benign endometrial cells (BECs) in women aged >or=40 years and considers these women at risk for endometrial pathology. The current study examines the relative risk of hyperplasia or malignancy conferred by the presence versus the absence of BECs in Papanicolaou (Pap) tests of women aged >or=40 years.

METHODS

Women aged >or=40 years represented 29,177 (46.2%) of 63,202 Pap tests obtained over 1 year from a largely suburban screened population. Of these, 866 Pap tests (3%) showed BECs. Over the same 1 year period, 789 women aged >or=40 years had endometrial histologic evaluations between 14 days and 6 months following a Pap test. The Pap tests of 159 women had BECs, and 33 had atypical (n=32) or malignant (n=1) endometrial cells. The 597 remaining women, who had Pap tests without endometrial cells but who had endometrial sampling for other reasons, served as controls.

RESULTS

There were nine endometrial hyperplasias (5.7%) and no adenocarcinomas in the BECs group, whereas 34 hyperplasias (5.7%) and 6 adenocarcinomas (1%) were diagnosed in the controls. These differences were not statistically significant, even after restricting the analysis to women aged >or=50 years or to women known to be postmenopausal.

CONCLUSIONS

The current study found that women aged >or=40 years with BECs in their Pap tests did not have more endometrial hyperplasias or malignancies when compared with women who had endometrial sampling for reasons other than the presence of endometrial cells in a Pap test.

Factors associated with HPV persistence after treatment for high-grade cervical intra-epithelial neoplasia with large loop excision of the transformation zone (LLETZ)

BACKGROUND AND OBJECTIVE

Human Papillomavirus (HPV) persistence after high-grade cervical intra-epithelial neoplasia (CIN) removal may be associated with residual lesions or risk of disease recurrence. Knowledge regarding the factors associated with HPV persistence following CIN treatment is still limited. The main purpose of this longitudinal study was to assess the association between characteristics of the patients and their cervical lesions with high-risk HPV-type persistence, detected by commercially available Hybrid Capture II (HC II), after CIN 2 and 3 treatment with large loop excision of the transformation zone (LLETZ).

STUDY DESIGN

For this cohort study, a total of 94 women submitted to LLETZ between March 2001 and September 2002 were included. Only women with at least one follow-up visit at 6 or 12 months and confirmed CIN 2 or 3 in the cone specimen were considered. In each visit women answered to a questionnaire and undertook Pap smear and HC II specimens collection. McNemar's, chi-square and Fisher tests were used for univariate analysis. Generalized Estimating Equations (GEE) were used for multivariate analysis. All calculations were performed within 95% confidence intervals (95% CI).

RESULTS

Histological evaluation showed 12 (13%) women with CIN, 2 and 82 (87%) with CIN 3 and conization margins were compromised in 27 (29%) cases. Eighty-seven (92%) women showed positive HC II tests prior to LLETZ. Of women initially HPV negative, none had a positive HC II during follow-up. The proportion of positive HPV tests was reduced from 92% to 20%(P < 0.01) at the first visit and to 22% (P < 0.01) at the second visit after LLETZ. Multivariate analysis showed that smoking and age above 35 years (irrespective of margin status) were strongly associated with positive HPV during follow-up.

CONCLUSION

HPV persistence following LLETZ was associated with smoking and with the interaction between age and conization margins.

A Randomized Trial of the Fischer Cone Biopsy Excisor and Loop Electrosurgical Excision Procedure

OBJECTIVE

To compare specimens obtained with the Fischer cone biopsy excisor or loop electrosurgical excision procedure (LEEP) with respect to number of specimens obtained, margin interpretability, adequacy of excision, and ease of use.

METHODS

One hundred eligible patients aged 13 years and older were randomly assigned to treatment with the Fischer cone biopsy excisor or LEEP. Eligibility criteria included: (1) cervical intraepithelial neoplasia (CIN) 2 or 3, (2) persistent CIN 1, or (3) cytologic/histologic discrepancy. Following excision, providers ranked ease of use on a scale of 1 to 10. A pathologist blinded to procedure type analyzed specimens for margin interpretability and adequacy of excision. Before study initiation we calculated that a total of 100 patients would be required to demonstrate a significant difference in the interpretable margin rate of 80% for LEEP and 99% for cone biopsy excisor (power 80%, alpha =.05).

RESULTS

After adjustment for ease of use, lesion size, and degree of neoplasia, the cone biopsy excisor was no more likely to result in a single specimen than LEEP (74% versus 63%, relative risk [RR] 0.93, 95% confidence interval [CI] 0.79 -1.11), to result in a specimen with interpretable margins (65% versus 73%, RR 0.97, 95% CI 0.78-1.22), or to result in a fully excised cervical lesion (72% versus 62% for LEEPs, RR 1.08, 95% CI 0.77-1.52). Providers found their experiences with both Fischer cone biopsy excisor and LEEP cone biopsies to be similar, even after adjustment for year of training and previous experience (RR 0.95, 95% CI 0.72-1.24).

CONCLUSION

The Fischer cone biopsy excisor and LEEP performed similarly with respect to the number of final specimens, margin interpretability, and ease of use.

LEVEL OF EVIDENCE

I

Microinvasive squamous cell cervical carcinoma

Several histologic tumor-related features are the key factors for further treatment planning in microinvasive cervical cancer (MIC) after conization. To better define the indications for conservative treatment of MIC we conducted a literature review for prognostic factors for MIC and we carried out a prospective observational study evaluating most important pathologic factors and the relationships between tumor and edges of the cone and incidence of recurrences. In our experience seven recurrences were observed. Two distinct groups of patients were identified with a clearance lower or higher of 10 and 8 mm for apical and lateral margin respectively. Depth of infiltration and even lymph-vascular involvement have been confirmed as the most important histologic parameters to be evaluated. Apical and lateral clearance of the tumor are significantly correlated with the recurrence rate. If an adequate lateral border of healthy tissue is present on the specimen, conization may be considered as definitive treatment of MIC.