Clinical management of cervical intraepithelial neoplasia in pregnant and postpartum women

Diagnosis and Management of Cervical Squamous Intraepithelial Lesions in Pregnancy and Postpartum

Perinatal care provides important health care opportunities for many individuals at risk for cervical cancer. Pregnancy does not alter cervical cancer screening regimens. ASCCP risk-based management has a colposcopy threshold of a 4% immediate risk of cervical intraepithelial neoplasia (CIN) 3 or cancer, but the actual risk can be considerably higher based on current and past screening results. Improving cervical cancer outcomes with diagnosis during pregnancy rather than postpartum and facilitating further evaluation and treatment postpartum for lesser lesions are the perinatal management goals. Although colposcopy indications are unchanged in pregnancy, some individuals with lower risk of CIN 2-3 and reliable access to postpartum evaluation may defer colposcopy until after delivery. Cervical intraepithelial neoplasia diagnosed in pregnancy tends to be stable, with frequent regression postpartum, though this is not universal. Colposcopic inspection during pregnancy can be challenging. Although biopsies in pregnancy are subjectively associated with increased bleeding, they do not increase complications. Endocervical curettage and expedited treatment are unacceptable. Treatment of CIN 2-3 in pregnancy is not recommended. Excisional biopsies in pregnancy are reserved for suspicion of malignancy that cannot be confirmed by colposcopic biopsy and when excisional biopsy results would alter oncologic or pregnancy care. Surveillance of high-grade lesions in pregnancy uses human papillomavirus-based testing, cytology, and colposcopy, with biopsy of worsening lesions every 12-24 weeks from diagnosis until postpartum evaluation. Mode of delivery does not definitively affect persistence of CIN postpartum. Postpartum care may involve a full colposcopic evaluation or expedited excisional procedure if indicated.

Optimising cervical cancer screening during pregnancy: a study of liquid-based cytology and HPV DNA co-test

This study assessed the efficacy of ThinPrep cytologic test and human papillomavirus (HPV) co-test in cervical cancer screening during pregnancy. A cohort of 8,712 pregnant women from Ren Ji Hospital participated in the study. Among them, 601 (6.90%) tested positive for high-risk HPV (HR-HPV) and 38 (0.44%) exhibited abnormal cytology results (ASCUS+). Following positive HR-HPV findings, 423 patients underwent colposcopy, and 114 individuals suspected of having high-grade squamous intraepithelial lesion and cervical cancer (HSIL+) underwent cervical biopsy. Histological examination revealed 60 cases of normal pathology (52.63%), 35 cases of low-grade squamous intraepithelial lesion (30.70%), 17 cases of HSIL (14.91%), and 2 cases of cervical cancer (1.75%). The incidence of HSIL+ in HPV 16/18 group was significantly higher than that in non-HPV16/18 group (10.53% vs. 6.14%, P < 0.05). Subsequent evaluation of the clinical performance of cytology alone, primary HPV screening, and co-testing for HSIL+ detection revealed that the HSIL+ detection rate was lowest with cytology alone. These findings suggest that HPV testing, either alone or combined with cytology, presents an efficient screening strategy for pregnant women, underscoring the potential for improved sensitivity in cervical cancer screening during pregnancy. The significantly higher incidence of HSIL+ in the HPV16/18 group emphasizes the importance of genotype-specific considerations.

HPV E6/E7 mRNA combined with thin-prep cytology test for the diagnosis of residual/recurrence after loop electrosurgical excision procedure in patients with cervical intraepithelial neoplasia

To evaluate the diagnostic value of combining HPV E6/E7 mRNA testing with Thin-Prep cytology (TCT) for residual/recurrence detection, a total of 289 patients who underwent loop electrosurgical excision procedure (LEEP) for high-grade cervical lesions were included. Patients were followed up at different time points, and residual/recurrent lesions were confirmed through vaginoscopy. TCT, HPV-DNA, and HPV E6/E7 mRNA tests were conducted. Diagnostic performance, including sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, was assessed. Among the patients, 76 cases showed residual lesions/recurrence, while 213 cases showed no residual/recurrence. Positive margins in the cervical-vaginal and cervical canal areas were associated with a higher risk of residual/recurrence. The combined HPV E6/E7 mRNA and TCT test showed higher diagnostic efficacy than individual tests at 6-, 12-, and 24-months follow-up. The combined test consistently demonstrated higher specificity and sensitivity, with significantly larger area under the curve (AUC) values compared to the individual tests.

O, Moscoso G, Contreras‐Pulache H. Human papillomavirus infections in low-grade squamous intraepithelial lesion in Peruvian pregnant woman: A cross-sectional cytology-based study

Background and Aims

Low-risk human papillomaviruses (HPV) are important in pregnant women because they are risk factors for Condyloma acuminatum and recurrent respiratory papillomatosis in the newborn. On the other hand, HPV may contribute to the development of preneoplastic lesions such as LSIL in pregnant women. We aimed to assess the frequency of HPV infections in low-grade squamous intraepithelial lesion (LSIL) in Peruvian pregnant women.

Methods

A cross-sectional study was conducted from 2011 to 2015 in 84 primiparous- and multiparous pregnant women (mean age: 27 ± 6.3 years). Pregnant women of 18-45 years attending gynecology outpatient department were included for the study. LSIL and HPV (nuclear irregularities, koilocytosis, and cytopathic effect) cellular alterations were reported using the Bethesda System guidelines.

Results

Sixty-four percent had cytological HPV infection (koilocytes and/or pathognomonic signs of infection) and more than a half of pregnant women had a previous Pap test. LSIL was more frequent in multiparous (increased by 12%, p = 0.008), in the second and third trimester (60.7%, p = 0.002), and between the ages of 18 and 30 (42 cases (50%), p = 0.110). This proportion was significatively increased in women with ≥2 sexual partners (39.3%), with an early onset of first intercourse, and from the Rímac Municipality (14.3%) (p < 0.05). The rate of pregnant women with HPV infection increased by 39% between 2011 and 2015 (p = 0.001).

Conclusion

Peruvian pregnant women with LSIL have a high frequency of HPV infections. These young pregnant women (≤30 years of age), with multiple pregnancy, ≥2 sexual partners, and early onset of sexual intercourse were mainly associated with the third trimester HPV infection and LSIL. To detect early lesions of the cervix, it is key to continue monitoring HPV infections with molecular techniques and screening in pregnant women.

Evaluation of FAM19A4/miR124-2 methylation performance in the management of CIN3 diagnosed pregnant women

Pregnant women diagnosed with CIN3 have high regression rates after delivery. Biomarkers are needed to only identify pregnant women with progressive CIN requiring treatment to reduce over referral and overtreatment. In this study we evaluated the performance of the FAM19A4/miR124-2 methylation test for molecular triage on FFPE samples of CIN3+-diagnosed pregnant women with known clinical course over time as well in a cross-sectional setting. In this German multicenter retrospective study biopsy material was collected from pregnant women diagnosed with cervical cancer (n=16), with CIN3 that progressed to cancer during pregnancy (n=7), with CIN3 that regressed to CIN1 or less within 6 months after delivery (n=41), without CIN (n=16), CIN3 covering 3-4 quadrants (n=14) and randomly selected CIN3 (n=41). FAM19A4/miR124-2 methylation analysis was performed blinded on first diagnosis. All pregnant women with cervical cancer and with CIN3 progressing to cancer tested positive for FAM19A4/miR124-2 methylation (100%, 22/22). In the regressing CIN3 group 47.5% and in the group without CIN 21.6% tested methylation positive. High-volume CIN3 and random selected CIN3 were methylation-positive in 91.7% and 82.1%. Methylation levels were significantly higher in progressive CIN3 and cancer compared to the controls (P<0.0005). The likelihood ratio of a negative methylation test (LR-) for progressive CIN3+ was 0 (95%CI:0-0.208). A negative FAM19A4/miR124-2 methylation test can rule out progressive CIN disease in pregnant women diagnosed with CIN3. This can help the clinician by managing these pregnant women with conservative follow-up until after delivery. This article is protected by copyright. All rights reserved.

Preliminary study of the use of E6/E7mRNA detection in screening and triage management of HR-HPV infection during pregnancy

Background

Detection of E6 and E7 mRNA load of high-risk human papillomavirus (HR-HPV) infection during pregnancy was compared with conventional cytopathology and DNA detection by pathological examination as colposcopy to evaluate the application of E6 and E7 mRNA detection in the diagnosis and management in HR-HPV infection for high -grade cervical lesions during pregnancy.

Methods

From January 2014 to June 2019, 1,058 pregnant women of childbearing age who were filed for regular obstetrics in the Department of Obstetrics and Gynecology, Xuanwu Hospital of Capital Medical University, were separately assessed using cervical liquid-based cytology and HPV DNA detection. If the results were abnormal, colposcopy was performed as a follow-up. The presence of HR-HPV E6/E7 mRNA fragments was detected through the HR-HPV E6/E7 mRNA test, and monitored at the same time as colposcopy. The diagnostic efficacy of the HR-HPV DNA test versus the HR-HPV E6/E7 mRNA test for high-grade cervical lesions during pregnancy was compared.

Results

The positive rate of HR-HPV E6/E7 mRNA detection in the overall cervical intraepithelial neoplasia (CIN) and above during pregnancy was lower than that with HR-HPV DNA detection, and there was a significant statistical difference between the two methods. In CIN I and normal or inflammatory results, the positive rate of HR-HPV E6/E7 mRNA detection was lower than that of HR-HPV DNA detection, while in the results of CIN II and CIN III, the positive rate of the two was not significantly different. HR-HPV E6/E7 mRNA detection is the same as HR-HPV DNA detection, both of which increased with the severity of cervical lesions, and the positive rate increased. In cases of maintenance or progression of cervical lesions, the positive rate of HR-HPV E6/E7 mRNA detection during pregnancy can reach 81.8%. High-grade cervical lesions during pregnancy had a higher rate of reversal to a lower level after delivery.

Conclusions

The results suggested that the use of HR-HPV E6/E7 mRNA detection in cases of positive HR-HPV DNA detection can significantly improve the diagnostic specificity of CIN II and above high-grade cervical lesions.

Natural history of histologically confirmed high-grade cervical intraepithelial neoplasia during pregnancy: meta-analysis

OBJECTIVES

This study aimed to conduct a meta-analysis of estimates of the natural history of high-grade cervical intraepithelial neoplasia (CIN) during pregnancy.

SETTING

Studies examining the clinical courses of histologically confirmed high-grade CIN during pregnancy.

PARTICIPANTS

We searched PubMed, Web of Science and Embase for eligible studies. Studies were included if they reported the data regarding the natural history of histologically confirmed high-grade CIN during pregnancy. Final estimates were from the meta-analysis of 10 eligible studies.

PRIMARY OUTCOME MEASURES

The regression rate, persistence rate and progression rate of histologically proven untreated high-grade CIN during pregnancy.

RESULTS

A total of 10 original studies were included in this meta-analysis. During pregnancy, the regression rate, persistence rate and progression rate of high-grade CIN were 40% (95% CI 35% to 45%), 59% (95% CI 54% to 64%) and 1% (95% CI 0% to 2%), respectively. There was moderate heterogeneity among the studies. The results of the subgroup meta-analysis show that the pooled rates of regression and persistence during pregnancy were 59% (95% CI 54% to 65%) and 40% (95% CI 35% to 45%) for CIN2, and 29% (95% CI 25% to 33%) and 70% (95% CI 65% to 73%) for CIN3.

CONCLUSIONS

During pregnancy, the majority of histologically confirmed high-grade CIN would be persistent or regressed to lower grade CIN or normal. However, it is still worth noting that a small percentage of high-grade CIN would progress to cervical cancer during pregnancy.

Management and outcome of cervical cancer diagnosed in pregnancy

BACKGROUND

Cervical cancer is the third most common gynecologic malignancy in the United States. Approximately 1-3% of cervical cancers will be diagnosed in pregnant and peripartum women; optimal management in the setting of pregnancy is not always clear.

OBJECTIVE

We sought to describe the management of patients with cervical cancer diagnosed in pregnancy and compare their outcomes to nonpregnant women with similar baseline characteristics.

STUDY DESIGN

We conducted a retrospective chart review of all patients diagnosed with cervical cancer in pregnancy and matched them 1:2 with contemporaneous nonpregnant women of the same age diagnosed with cervical cancer of the same stage. Patients were identified using International Classification of Diseases, Ninth Revision codes and the Dana-Farber/Massachusetts General Hospital Cancer Registry. Data were analyzed using Stata, Version 10.1 (College Station, TX).

RESULTS

In all, 28 women diagnosed with cervical cancer during pregnancy were identified from 1997 through 2013. The majority were Stage IB1. In all, 25% (7/28) of women terminated the pregnancy; these women were more likely to be diagnosed earlier in pregnancy (10.9 vs 19.7 weeks, P = .006). For those who did not terminate, mean gestational age at delivery was 36.1 weeks. Pregnancy complications were uncommon. Complication rates in pregnant women undergoing radical hysterectomy were similar to those outside of pregnancy. Time to treatment was significantly longer for pregnant women compared to nonpregnant patients (20.8 vs 7.9 weeks, P = .0014) but there was no survival difference between groups (89.3% vs 95.2%, P = .08). Women who underwent gravid radical hysterectomy had significantly higher estimated blood loss than those who had a radical hysterectomy in the postpartum period (2033 vs 425 mL, P = .0064), but operative characteristics were otherwise similar. None of the pregnant women who died delayed treatment due to pregnancy.

CONCLUSION

Gestational age at diagnosis is an important determinant of management of cervical cancer in pregnancy, underscoring the need for expeditious workup of abnormal cervical cytology. Of women who choose to continue the pregnancy, most delivered in the late preterm period without significant obstetric complications. For women undergoing radical hysterectomy in the peripartum period, complication rates are similar to nonpregnant women undergoing this procedure. Women who died were more likely to have advanced stage disease at the time of diagnosis. This information may be useful in counseling women facing the diagnosis of cervical cancer in pregnancy.

Cervical intraepithelial neoplasia in pregnancy: Interference of pregnancy status with p16 and Ki-67 protein expression

To date, there are evidence-based guidelines available for cervical dysplasia diagnosed in pregnancy. Certain functional biomarkers have proven useful in the prediction of regressing and non-regressing cervical intraepithelial neoplasia (CIN) lesions in non-pregnant women. In the present study, Ki-67 and p16 immunostaining were evaluated in different grades of CIN lesions diagnosed in pregnant or non-pregnant women with the aim to identify any differences in order to better understand the behavior of CIN in pregnancy. The current retrospective case-control study included 17 pregnant patients that conceived naturally with first-time onset of CIN occurring at no later than 16 gestational weeks. The control group included 17 non-pregnant patients matched for age, parity and number of previous sexual partners. Exclusion criteria included previous cervical treatment, immunocompromised status, chronic hepatitis B and/or C and cigarette smoking. p16 and Ki-67 protein expression were respectively detected using the CINtec Histology kit and monoclonal antibodies against Ki-67. p16 and Ki-67 staining were analyzed using a classification system based on the distribution of positivity on a semi-quantitative three point-scale. p16 and Ki-67 immune reactivity correlated positively with the grade of epithelial dysplasia in the total cohort of pregnant and non-pregnant patients; expression increased linearly from CIN1 to CIN3. Furthermore, the association between p16 immunostaining and CIN grade was significant in non-pregnant patients but not in pregnant patients. In pregnant patients, positivity for Ki-67 was less intense than in non-pregnant patients. These results appear to suggest that pregnancy status interferes with the expression of cellular proteins involved in cell-cycle regulation and the carcinogenic process induced by high-risk human papilloma virus, exhibiting increased variability in their staining.

Obstetrical prognosis of patients with cervical intraepithelial neoplasia (CIN) after "coin-shaped" conization

PURPOSE

Uterine cervical conization is related to adverse pregnancy outcomes in subsequent pregnancies. To deal with this problem, we started conservative coin-shaped conization for reproductive-aged patients with cervical intraepithelial neoplasia (CIN). Here we report both the obstetrical and oncological impacts of this operation in comparison with the standard cone-shaped resection.

METHODS

A total of 401 women 44 years old or younger were treated in our hospital by CO2 laser conization between 2003 and 2012, and subsequently 50 patients became pregnant. The patients were divided into two groups, a standard cone-shaped conization group (until 2008) and a shallow coin-shaped conization group (beginning in 2008). The pregnancy courses and oncological prognoses of these two groups were studied.

RESULTS

Cone height reduction of about 3 mm was done. However, there were no significant differences between the two groups with regard to the occurrence of oncological complications. In the standard conization group, 18 of the 25 patients delivered at term. In the coin-shaped conization group, 20 of the 25 patients delivered at term. There were no significant differences between the two groups with regard to the occurrence of various obstetrical complications. However, the reduction rate of cervical length over the pregnancy was smaller in the coin-shaped group and the number of patients with a short cervix length of 2 cm or less was smaller in the coin-shaped group.

CONCLUSIONS

Although conservative coin-shaped conization did not markedly improve the obstetrical prognosis, this operative procedure improved the reduction rate of uterine cervical length over the pregnancy without any increase in oncological complications.