Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization

The objective of this work is to assess the 5-year outcomes of patients undergoing conization for high-grade cervical lesions that simultaneously present as risk factors in the persistence of HPV infection and the positivity of surgical resection margins. This is a retrospective study evaluating patients undergoing conization for high-grade cervical lesions. All patients included had both positive surgical margins and experienced HPV persistence at 6 months. Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). The charts of 2966 patients undergoing conization were reviewed. Among the whole population, 163 (5.5%) patients met the inclusion criteria, being at high risk due to the presence of positive surgical margins and experiencing HPV persistence. Of 163 patients included, 17 (10.4%) patients developed a CIN2+ recurrence during the 5-year follow-up. Via univariate analyses, diagnosis of CIN3 instead of CIN2 (HR: 4.88 (95%CI: 1.10, 12.41); p = 0.035) and positive endocervical instead of ectocervical margins (HR: 6.44 (95%CI: 2.80, 9.65); p < 0.001) were associated with increased risk of persistence/recurrence. Via multivariate analyses, only positive endocervical instead of ectocervical margins (HR: 4.56 (95%CI: 1.23, 7.95); p = 0.021) were associated with worse outcomes. In this high-risk group, positive endocervical margins is the main risk factor predicting 5-year recurrence.

High-risk HPV-positive and -negative high-grade cervical dysplasia: Analysis of 5-year outcomes

OBJECTIVE

To evaluate the outcomes of high-risk (HR) HPV-positive and -negative women affected by high-grade cervical dysplasia.

METHODS

This is a retrospective multi-institutional study. Medical records of consecutive patients with high-grade cervical dysplasia undergoing conization between 2010 and 2014 were retrieved. All patients included had at least 5 years of follow-up. A propensity-score matching was adopted in order to reduce the presence of confounding factors between groups. Kaplan-Meir and Cox hazard models were used to estimate 5-year outcomes.

RESULTS

Overall, data of 2966 women, affected by high-grade cervical dysplasia were reviewed. The study population included 1478 (85%) and 260 (15%) women affected by HR-HPV-positive and HR-HPV-negative high-grade cervical dysplasia. The prevalence of CIN2 and CIN3 among the HR-HPV-positive and -negative cohort was similar (p = 0.315). Patients with HR-HPV-positive high-grade cervical dysplasia were at higher risk of 5-year recurrence (after primary conization) that HR-HPV-negative patients (p < 0.001, log-rank test). Via multivariate analysis, HR-HPV-negative women were at low risk of recurrence (HR: 1.69 (95%CI: 1.05, 4.80); p = 0.018, Cox Hazard model). A propensity-score matched comparison was carried out in order to reduce biases that are related to the retrospective study design. In comparison to HR-HPV-negative patients, thosewith HR-HPV-positive CIN3 was associate with a 8-fold increase in the risk of recurrence (p < 0.001, log-rank test).

CONCLUSIONS

HR-HPV-negative high-grade cervical dysplasia is not uncommon, accounting for 15% of our study population. Those patients experience more favorable outcomes than patients with documented HR-HPV infection(s). Further prospective studies are needed to corroborate our data.

Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser Conization: A 5-year follow-up study

OBJECTIVE

Conization aims to remove pre-neoplastic lesions of the uterine cervix. Several techniques for conization have been compared, but evidence regarding the most effective therapeutic option is scant. Here, we aimed to compare the recurrence rate following laser conization and loop electrosurgical excision procedure (LEEP) in patients with high-grade cervical dysplasia (HSIL/CIN2+).

METHODS

This is a retrospective multi-institutional study. Medical records of consecutive patients with HSIL/CIN2+ undergoing conization between 2010 and 2014 were retrieved. A propensity-score matching (PSM) was applied in order to reduce allocation bias. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models.

RESULTS

Overall, 2966 patients had conization over the study period, including 567 (20%) and 2399 (80%) patients having laser conization and LEEP, respectively. Looking at predictors of recurrence, diagnosis of CIN3 (HR:3.80 (95%CI:2.01,7.21); p < 0.001) and HPV persistence (HR:1.81 (95%CI:1.11,2.96); p < 0.001) correlated with an increased risk of recurrence. After applying a PSM we selected 500 patients undergoing laser conization and 1000 undergoing LEEP. Patients undergoing LEEP were at higher risk of having positive surgical margins in comparison to patients undergoing laser conization (11.2% vs. 4.2%). The risk of having persistence of HPV was similar between the two groups (15.0% vs. 11.6%;p = 0.256). Five-year recurrence rate was 8.1% and 4% after LEEP and laser conization, respectively (p = 0.023). HPV persistence was the only factor associated with [5-]year recurrence after both laser conization (p = 0.003) and LEEP (p = 0.001).

CONCLUSIONS

HPV persistence is the only factor associated with an increased risk of recurrence after either laser conization or LEEP. Owing to the lack of data regarding obstetrical outcomes, we are not able to assess the best therapeutic option for women with cervical dysplasia.

Amniopatch, a repairing technique for premature rupture of amniotic membranes in second trimester

Rupture of the amniotic sac complicates approximately 0.8-1% of amniocentesis procedures carried out between the 15th and 18th gestational weeks. Spontaneous PROM during the second and third trimester is, however, more frequent. In both cases the rate of fetal morbidity and mortality are very high. Infusion of an autolologous platelet concentrate followed by cryoprecipitates (amniopatch) restore the amnio-corial link interrupted by the iatrogenic trauma, thus making the amniotic repair processes even more effective. Five cases of premature membrane rupture in pregnancies ranging from 17 to 23 weeks have been treated with complete closure of the rupture and restoration of a normal amount of amniotic fluid in two cases and incomplete in the other three cases. Neonatal outcome, in accordance to the gestational stage reached by the patient, was good in three cases (41,32 and 27 weeks), complicated by brain hemorrage in the fourth and an abortion in fifth case. Amniopatch is able to physiologically facilitate this process and significantly prolong the pregnancy, improving neonatal outcome.

Use of an endolaparoscopic probe in conservative management of Fallopian pregnancy

The incidence of extrauterine pregnancy has shown an increasing trend, exceeding one out of every 100 term pregnancies. This has resulted in the development of more and more conservative surgical treatments in order to retain the fertility of women. The use of operative laparoscopy has led to progress being made in this direction, due to reduced tissue trauma and a reduction in the number of peritoneal adhesions. Tubal isthmic pregnancies tend to cause an irregular increase in the size of the whole tube, which causes problems for pinpointing the exact site of the ectopic implantation. It is often necessary to make a longitudinal incision in the tubal wall to identify the chorionic tissue and remove it completely. In an attempt to avoid this unnecessarily extensive surgery, we used an echographic sector probe under laparoscopic control to locate the exact area of the ectopic implantation. We found it was possible to remove the villous tissue through a very short and precise cut in the tubal wall which facilitated the drainage of the lumen and reduced the bleeding normally associated with more extensive tubal surgery. Hysterosalpingographic follow-up studies after 2 months showed good tubal recanalization.