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Papoutsis D, Underwood M, Parry-Smith W, Tzavara C. Endocervical crypt involvement by high-grade cervical intraepithelial neoplasia and its association with high-grade histopathological recurrence after cervical excision in women with negative excision margins: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:939-948. [PMID: 37821642 PMCID: PMC10867046 DOI: 10.1007/s00404-023-07242-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/20/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND There is a growing body of evidence suggesting that endocervical crypt involvement by high-grade cervical intraepithelial neoplasia (CIN) may represent a risk factor for disease recurrence after cervical treatment. OBJECTIVES To provide a systematic review and meta-analysis on whether endocervical crypt involvement by high-grade CIN on the excised cervical specimen is associated with high-grade histopathological recurrence during the follow-up of women after cervical excisional treatment. SEARCH STRATEGY We searched the Medline, Scopus, Central, and Clinical Trials.gov databases from inception till May 2023. SELECTION CRITERIA Studies that reported on women with a single cervical treatment with any method of excision for CIN2 or CIN3 lesion, negative excision margins, and whose recurrence was defined histopathologically were included. DATA COLLECTION AND ANALYSIS Two reviewers independently evaluated study eligibility. We used the fixed effects model for meta-analysis. MAIN RESULTS There were 4 eligible studies included in the present systematic review that evaluated 1088 women treated with either large loop excision of the transformation zone (LLETZ) or with cold knife conization (CKC). We found no significant association of endocervical crypt involvement by CIN2-3 with high-grade histopathological recurrence at follow-up after cervical excision (OR 1.93; 95% CI 0.51-3.35). The subgroup analysis of women with LLETZ cervical excision showed again no significant association with high-grade histopathological recurrence at follow-up (OR 2.00; 95% CI 0.26-3.74). CONCLUSION Endocervical crypt involvement by high-grade CIN does not seem to be a risk factor for high-grade histopathological recurrence after cervical excision with negative excision margins.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK.
- School of Health Sciences, University of Western Macedonia, 50100, Ptolemaida, Kozani, PC, Greece.
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - Chara Tzavara
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Polterauer S, Reich O, Widschwendter A, Hadjari L, Bogner G, Reinthaller A, Joura E, Trutnovsky G, Ciresa-Koenig A, Ganhoer-Schimboeck J, Boehm I, Berger R, Langthaler E, Aberle SW, Heinze G, Gleiss A, Grimm C. Topical imiquimod compared with conization to treat cervical high-grade squamous intraepithelial lesions: Multicenter, randomized controlled trial. Gynecol Oncol 2022; 165:23-29. [PMID: 35177279 DOI: 10.1016/j.ygyno.2022.01.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In a previous phase II trial, we showed that topical imiquimod (IMQ) therapy is an efficacious treatment for high-grade squamous intraepithelial lesion (HSIL). Aim of the present study was to investigate the non-inferiority of a 16-week topical, self-applied IMQ therapy compared to large loop excision of the transformation zone (LLETZ) in patients diagnosed with HSIL. METHODS Phase III randomized, controlled, multicenter, open trial performed by Austrian Gynecologic Oncology group. Patients with histologically proven cervical intraepithelial neoplasia (CIN)2 (30 years and older) or CIN3 (18 years and older) and satisfactory colposcopy were randomized to topical IMQ treatment or LLETZ. Successful treatment was defined as negative HPV high-risk test result 6 months after start of the treatment. Secondary endpoints were histological outcome and HPV clearance rates. RESULTS Within 3 years 93 patients were randomized, received the allocated treatment and were available for ITT analysis. In the IMQ group negative HPV test at 6 months after treatment start was observed in 22/51 (43.1%) of patients compared to 27/42 (64.3%) in the LLETZ group on ITT analysis (rate difference 21.2%-points, 95% two-sided CI: 0.8 to 39.1). In the IMQ group histologic regression 6 months after treatment was observed in 32/51 (63%) of patients and complete histologic remission was observed in 19/51 (37%) of patients. Complete surgical resection was observed in 84% after LLETZ. CONCLUSION In women with HSIL, IMQ treatment results in lower HPV clearance rates when compared to LLETZ. LLETZ remains the standard for women with HSIL when treatment is required. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01283763, EudraCT number: 2012-004518-32.
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Affiliation(s)
- Stephan Polterauer
- Department of Obstetrics and Gynecology, Division General Gynecology and Gynecologic Oncology, Medical University of Vienna, Vienna, Austria.
| | - Olaf Reich
- Department of Obstetrics & Gynecology, Medical University of Graz, Austria
| | - Andreas Widschwendter
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Laudia Hadjari
- Department of Gynecology, Ordensklinikum Linz, Linz, Austria
| | - Gerhard Bogner
- Department of Obstetrics and Gynecology (OB/GYN), Paracelsus Medical University, Muellner Hauptstr. 48, A-5020 Salzburg, Austria
| | - Alexander Reinthaller
- Department of Obstetrics and Gynecology, Division General Gynecology and Gynecologic Oncology, Medical University of Vienna, Vienna, Austria
| | - Elmar Joura
- Department of Obstetrics and Gynecology, Division General Gynecology and Gynecologic Oncology, Medical University of Vienna, Vienna, Austria
| | - Gerda Trutnovsky
- Department of Obstetrics & Gynecology, Medical University of Graz, Austria
| | - Alexandra Ciresa-Koenig
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Ina Boehm
- Department of Obstetrics and Gynecology (OB/GYN), Paracelsus Medical University, Muellner Hauptstr. 48, A-5020 Salzburg, Austria
| | - Regina Berger
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Innsbruck, Austria; Department of Obstetrics and Gynecology, Medical University of Innsbruck, Austrian AGO, Innsbruck, Austria
| | - Eva Langthaler
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Stephan W Aberle
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Georg Heinze
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Andreas Gleiss
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Grimm
- Department of Obstetrics and Gynecology, Division General Gynecology and Gynecologic Oncology, Medical University of Vienna, Vienna, Austria
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Shahar D, Bornstein S, Bornstein J. Cervical traction suture technique during large loop excision of the transformation zone increases complete lesion excision. J Gynecol Obstet Hum Reprod 2020; 50:101904. [PMID: 32942052 DOI: 10.1016/j.jogoh.2020.101904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE A surgical technique was developed in the past by our group to reduce the rate of inadvertent complications. It was then seemed that it also increased the rate of complete lesion excision. The objective of the study was to evaluate the effectiveness of a cervical traction suture technique in increasing the prevalence of complete lesion excisions and reducing the incidence of unintended injuries to adjacent tissues during large loop excision of the transformation zone (LLETZ). BASIC PROCEDURES A retrospective cohort study, including all consecutive patients who underwent LLETZ between January 2016 and June 2018, at the outpatient Colposcopy clinic of a general hospital in Galilee Medical Center. We divided patients into two groups based on whether their LLETZ utilized the cervical traction suture technique. We compared these two groups using an independent-samples t test, and we compared the study-specific proportions to those reported in the literature using the proportion test. MAIN FINDINGS A total of 66 patients were included in the analysis; 33 had undergone LLETZ with a traction suture, and 33 had undergone LLETZ without a traction suture. The prevalence of complete lesion excision was 93.3 % among patients undergoing LLETZ with a traction suture and 72.7 % among those without a traction suture (p = 0.04). The incidence of unintentional injuries to adjacent organs was 12.1 % in women with a traction suture and 18.2 % in women without a traction suture (p = 0.73). PRINCIPAL CONCLUSIONS Using a cervical traction suture along with LLETZ can increase the rate of complete lesion excision and may reduce the prevalence of unintended injuries.
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Affiliation(s)
- Dor Shahar
- Department of Obstetrics & Gynecology, Galilee Medical Center and Bar-Ilan University Faculty of Medicine, Nahariya, Israel
| | | | - Jacob Bornstein
- Department of Obstetrics & Gynecology, Galilee Medical Center and Bar-Ilan University Faculty of Medicine, Nahariya, Israel.
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Hakem E, Ibrahim E, Tanyous E, Astbury K, Purandare N. Association between grade of referral smear and high-grade disease among women with biopsy samples showing cervical intraepithelial neoplasia grade 2. Int J Gynaecol Obstet 2017; 140:223-227. [PMID: 29049873 DOI: 10.1002/ijgo.12357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/30/2017] [Accepted: 10/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether the grade of referral smear reflects the frequency of cervical intraepithelial neoplasia (CIN) grade 3 (CIN3) or worse lesions among patients with CIN2 on punch biopsy. METHODS In a retrospective study, data were reviewed from women with a punch biopsy sample showing CIN2 and a known referral smear who underwent large loop excision of the transformation zone (LLETZ) between January 1, 2013, and January 1, 2016, at Galway University Hospital, Ireland. Data were analyzed by patient age (≤30 and >30 years), referral smear (low and high grade), and LLETZ histology (≤CIN2 and ≥CIN3). RESULTS Overall, 264 women were included. LLETZ histology of CIN3 or worse was more common among women with high-grade referral smears (63/144 [43.8%]) than among those with low-grade smears (26/120 [21.7%]; relative risk 2.02, 95% confidence interval 1.37-2.96; P<0.001). Among patients younger than 30 years, underlying CIN3 and above was again more frequent among women with high-grade (44/95 [46.3%]) versus low-grade smears (12/56 [21.4%]; relative risk 2.16, 95% confidence interval 1.25-3.73; P=0.004). No difference was recorded in the older age group. CONCLUSION Although LLETZ can be performed for a CIN2 biopsy and high-grade smear, consideration should be given among young women (<30 years) with low-grade smears whose biopsy histology is incidentally CIN2.
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Affiliation(s)
- Emmanuel Hakem
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
| | - Elzahra Ibrahim
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
| | - Emmanuel Tanyous
- Ministry of Health, General Directorate of Primary Health Care, Central Supervision Unit, Riyadh, Saudi Arabia
| | - Katharine Astbury
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
| | - Nikhil Purandare
- Department of Obstetrics and Gynaecology, University College Hospital Galway, Galway, Ireland
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Koeneman M, Kruitwagen R, Kruse AJ. Clinical applicability of immunotherapy of cervical intraepithelial neoplasia. World J Obstet Gynecol 2016; 5:1-4. [DOI: 10.5317/wjog.v5.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/10/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023] Open
Abstract
Immunotherapy for cervical intraepithelial neoplasia (CIN) has not yet reached clinical applicability, but seems sensible and shows promising preliminary results. One of the most promising forms of immunotherapy for CIN may currently be imiquimod, because of its established role in other human papillomavirus (HPV)-induced genital conditions, its promising treatment efficacy in high-grade CIN, and its off-label availability. Although imiquimod cannot yet replace the current gold standard treatment for CIN [i.e., large loop excision of the transformation zone (LLETZ)] in all patients, it may be considered in subgroups of patients; for example, young women who may wish to become pregnant in the future, or patients with recurrent CIN lesions in whom a second LLETZ is to be avoided. Immunotherapy of CIN could be extended to post-treatment vaccination, in order to prevent new HPV infections and disease recurrence.
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