Residual lesions in uterine specimens after loop electrosurgical excision procedure in patients with CIN

A predictive model for residual lesions after LEEP surgery in CIN III patients

Background and aims

The residual lesions after Loop Electrosurgical Excision Procedure (LEEP) contributes to poor prognosis in patients with Cervical Intraepithelial Neoplasia Grade 3 (CIN3). The aim of this study is to establish an effective clinical predictive model for residual lesions in CIN3 patients after LEEP.

Methods

A retrospective analysis was performed on 436 CIN3 patients who underwent total hysterectomy within 3 months after LEEP. Based on the post-hysterectomy pathologic, the patients were divided into the no residual group and residual group. Clinical parameters were compared between the two groups, and univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for residual lesions in CIN3 patients after LEEP. Using R software, a nomogram model was established and its effectiveness was evaluated using calibration plots.

Results

There were 178 cases in the residual group and 258 cases in the no residual group. The two groups had no significant difference in general characteristics (p > 0.05). It was found that Post-LEEP follow-up HPV, Post-LEEP follow-up TCT, and the Gland involvement were independent risk factors for residual lesions in CIN3 patients after LEEP (all p < 0.05). The consistency index (C-index) of the nomogram model for predicting residual lesions was 0.975 (0.962-0.988).

Conclusion

The Post-LEEP follow-up HPV, Post-LEEP follow-up TCT, and Gland involvement are independent risk factors related to residual tissue after LEEP surgery in CIN3 patients. The constructed nomogram can effectively predict the presence of residual tissue after LEEP surgery in CIN3 patients and has good practical value.

2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia

This guideline provides evidence-based guidance on the risk-based management of cervical dysplasia in the colposcopy setting in the context of primary HPV-based screening and HPV testing in colposcopy. Colposcopy management of special populations is also discussed. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC) and the Canadian Partnership Against Cancer (CPAC). The literature informing these guidelines was obtained through a systematic review of the relevant literature via a multi-step search process led by information specialists. The literature was reviewed up to June 2021 with manual searches of relevant national guidelines and more recent publications. Quality of the evidence and strength of recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include gynecologists, colposcopists, screening programs and healthcare facilities. Implementation of the recommendations is intended to promote equitable and standardized care for all people undergoing colposcopy in Canada. The risk-based approach aims to improve personalized care and reduce over-/under-treatment in colposcopy.

Endocervical curettage for diagnosing high-grade squamous intraepithelial lesions or worse in women with type 3 transformation zone lesions: a retrospective, observational study

BACKGROUND

This study aimed to assess the value of endocervical curettage (ECC) in detecting high-grade squamous intraepithelial lesion or worse (HSIL+) in women with type 3 transformation zone (TZ3) lesions, and to identify the clinical characteristics of patients with TZ3 lesions who benefit most from ECC.

METHODS

This retrospective, multicenter study included 1,905 women with TZ3 lesions who attended cervical screening in one of seven tertiary hospitals in China between January 2020 and November 2021. All participants had received abnormal results and had been referred to colposcopy. Risk factors were identified through univariate and multifactorial logistic analyses.

RESULTS

In total, 20.5% (n = 391) of HSIL+ cases with TZ3 lesions had been diagnosed with biopsy and ECC. ECC detected 0.8% (n = 15) HSIL+ cases otherwise missed by biopsy alone. Multivariate analysis identified four factors which influenced detection performance. The probability of detecting HSIL+ with ECC is 2.653 (95% confidence interval [CI] 1.009-6.977) times greater in women aged 40-49 years and 2.545 (95% CI 0.965-6.716) times greater for those aged 50 years and older compared to those younger than 30 years. The probability of ASC-H (atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion) and HSIL cytologies were respectively 2.415 (95% CI 1.213-4.808) and 2.933 (95% CI 1.648-5.220) times higher than for NILM (negative for intraepithelial lesion or malignancy). Women with human papillomavirus 16/18 infections were 2.299 (95% CI 0.942-5.613) times more likely to be HSIL+. Precancerous lesions were 35.884 (95% CI 12.214-105.426) times more likely in women who had high-grade colposcopic impressions compared to those with normal impressions.

CONCLUSIONS

ECC should be performed for patients with ASC-H or HSIL cytologies, human papillomavirus 16/18 infections, and for those with high-grade colposcopic impressions. This will increase the number of HSIL+ cases identified using biopsy by reducing the number of false negatives.

Persistent HPV infection after conization of cervical intraepithelial neoplasia-- a systematic review and meta-analysis

OBJECTIVE

To systematically evaluate several factors of persistent human papillomavirus (HPV) infection following conization in patients with cervical intraepithelial neoplasia (CIN).

METHODS

PubMed, EMBASE and the Cochrane Library were searched from January 1, 1998 to September 10, 2021. Random-effects models for meta-analyses were used and pooled relative risks with 95% confidence intervals were reported. Literature screening, data extraction, and assessment of the risk of bias in the included studies were conducted independently by two researchers. Data analysis was performed with Stata software, version 12.0.

RESULTS

A total of 28 studies were included in this study. Meta-analysis revealed that surgical margin and residual disease were positively correlated with persistent HPV infection after conization. Compared with patients infected with other types of HPV, CIN patients with HPV 16 had a higher persistent infection rate (OR = 1.967, 95% CI (1.232-3.140), P < 0.05).

CONCLUSIONS

CIN patients who are postmenopausal, have positive surgical margins and residual lesions, and are positive for HPV 16 are prone to persistent HPV infection after conization.

The Influence of Intraoperative Ultrasound Monitoring on the Risk of Recurrence and Reoperation in Patients with Hysteromyomectomy

In recent years, with the continuous development and application of minimally invasive methods in China, laparoscopic myomectomy has become the primary method for clinical treatment of uterine fibroids. There is also a high risk of recurrence and reoperation after endoscopic myomectomy. Intraoperative use of ultrasound for auxiliary examination can provide medical staff with spatial information and position information of fibroids and help medical staff to accurately locate the surgical incision. The aim is to investigate the effect of intraoperative ultrasound monitoring on the risk of postoperative recurrence and reoperation in patients undergoing myomectomy. This study retrospectively collected 80 patients who underwent laparoscopic myomectomy in the gynecology department of our hospital from January 2020 to January 2022. According to the different treatment methods, they were divided into a study group and a control group (both n = 40). The control group underwent preoperative ultrasonography and then underwent myomectomy, while the study group underwent both preoperative and intraoperative ultrasonography before undergoing hysterectomy. Myomectomy: all the enrolled patients were followed up by ultrasound after surgery and followed up for 1 year (recheck ultrasound every 3 months). The indicators, postoperative complications, postoperative average diameter of uterine fibroids, postoperative residual rate of uterine fibroids, postoperative recurrence, and reoperation were compared between the two groups. Intraoperative ultrasound monitoring has a significant effect on patients undergoing myomectomy, which can effectively reduce the residual rate of fibroids, completely remove small and deep fibroids, and reduce complications, postoperative recurrence, and reoperation risks. It has good clinical application value.

Long-term outcomes of photodynamic therapy for a positive resection margin after conization for cervical intraepithelial neoplasia grade 3

BACKGROUND

Positive resection margins after conization or loop electrosurgical excision procedure (conization/LEEP) are associated with increased risks of recurrence or residual cervical intraepithelial neoplasia (CIN). Herein, we investigated the long-term outcomes of photodynamic therapy (PDT) for incomplete excision of CIN3.

METHODS

We retrospectively reviewed the medical charts of 73 patients treated with PDT between 2000 and 2011. Patients who underwent conization/LEEP before PDT within 6 months were included. The primary outcomes were the complete response (CR) rate after 1 year and human papillomavirus (HPV) eradication rate at 6 months after PDT.

RESULTS

A total of 34 patients with positive resection margins were finally enrolled. The median patient age was 33 years. Carcinoma in situ was diagnosed in 25 patients and CIN3 in 7 patients. The CR rate was 97.1% after 1 year. Except for one case of a persistent disease, there was no recurrence or newly developed disease during the median follow-up of 84 months (range, 12-224 months). The HPV eradication rate of PDT following conization/LEEP after 6 months was 96.9% (31/32). Photosensitivity was identified in five patients and cervical stenosis in one patient.

CONCLUSIONS

In conclusion, PDT could be an effective therapeutic option for patients with a positive resection margin after conization/LEEP for CIN3. It could reduce the residual or recurrence rate of CIN lesions with tolerable adverse events.

The safety and efficacy of a novel method for treatment of HSIL

PURPOSE

To investigate the efficacy and safety of Nr-CWS on treatment of cervical HSIL.

METHOD

In this observational study, 16 patients were treated with Nr-CWS 1 time every 2 days for 6 times as one-course group (OC group), the other 184 patients were treated with Nr-CWS 1 time every 2 days for 12 times between 2 menstruations as two-course group (TC group). The medical information including age, HPV assay, vaginal-cervical cytology, and the pathological result of biopsy before and after treatment was collected. All patients were followed up at least twice after treatment. The LEEP was performed once the patients with persistent HR-HPV infection and/or abnormal TCT after the second follow-up.

RESULTS

The cytology remission rate of cervical HSIL in OC and TC group was 100.0% and 87.8%, respectively, which were significant higher than the control (25.0%) with the P value of 2.00 × 10^-3 and 2.06 × 10^-4. Furthermore, HPV clearance rate was 87.5% and 70.2% in OC and TC group, respectively, which were significant higher than control (32.4%) with the P value of 2.74 × 10^-4 and 2.18 × 10^-5, respectively. Moreover, the more severe of cytology, the worse effect of HPV clearance for the HPV remission was 75.4%, 68.3%, 67.4%, 65.6% and 64.3% in the negative, LSIL, ASC-US, ASC-H, and HSIL group. 12 patients underwent LEEP after Nr-CWS treatment, 9 (75%) had persistent HSIL and 44.4% cases were found HSIL lesion in the cervical canal. There was no serious adverse reaction observed during treatment and follow-up, four patients were pregnant after treatment and no adverse pregnancy outcomes were observed.

CONCLUSION

Nr-CWS is an effective and safe drug for treatment of cervical HSIL for Chinese women, especially for cases without lesions in cervical canal.

<p>Risk Factors for Residual Disease in Hysterectomy Specimens After Conization in Post-Menopausal Patients with Cervical Intraepithelial Neoplasia Grade 3</p>

Background

Post-menopausal patients with cervical intraepithelial neoplasia (CIN) have a high rate of residual or recurrent lesions after treatment, and their risk for cervical cancer later in life is higher than the general population. Hence, management for this specific group of post-menopausal patients needs more attention.

Objective

The study aimed to identify risk factors associated with the presence of residual disease in hysterectomy specimens in post-menopausal patients with cervical intraepithelial neoplasia grade 3 (CIN 3).

Methods

This study was a retrospective analysis of data from post-menopausal women who had undergone hysterectomy following conization for CIN 3 from 2012 to 2018 at Fujian Maternity and Child Health Hospital. Factors extracted from the database included age, parity, Thinprep cytology results, human papillomavirus (HPV) genotype, biopsy results, pre-cone endocervical curettage (ECC) results, conization method, operating surgeon, cone dimension, margin status and glandular involvement. Univariate and multivariate analyses were performed to identify risk factors associated with residual disease in hysterectomy specimens.

Results

Analysis of data from 129 women was performed. The proportion of residual disease was 43.41% overall. A higher grade according to colposcopy biopsy, abnormal pre-cone ECC results, the cone method (LEEP vs CKC), a cone volume >1.57 cm³, and positive margins in conization specimens were found to be significantly associated with residual lesions on univariable analysis. After multivariate analysis, only an abnormal pre-cone ECC result (odds ratio 3.99; 95% confidence interval (CI) 1.41–11.33; p = 0.009) remained significant.

Conclusion

The rate of residual lesions in uterine specimens was high regardless of the cone margin status in post-menopausal women with CIN 3. Risk-based strategies are needed to identify patients who have abnormal pre-cone ECC results, and definitive treatment with hysterectomy should be considered in post-menopausal patients with an elevated risk for residual lesions.

An Abnormal Precone Endocervical Curettage Result Is an Independent Risk Factor for Positive Margins in Conization Specimens

OBJECTIVE

This study aimed to identify risk factors associated with the presence of positive surgical margins in cervical conization specimens.

METHODS

This study is a retrospective analysis of data from women who had undergone conization for cervical intraepithelial neoplasia (CIN) from 2012 to 2018 at Fujian Maternity and Child Health Hospital. Factors extracted from the database included age, gravidity, parity, menopausal status, precone Thinprep cytology test, human papillomavirus (HPV) test, precone biopsy, precone endocervical curettage (ECC) result, conization method, operating surgeon, cone dimension, and pathology of the conization specimen, including grade of CIN, margin status and glandular involvement. Univariate and multivariate analyses were performed to identify risk factors associated with positive margins.

RESULTS

Data from 495 women were analysed. The proportion of positive margins was 24.85% overall, which varied according to the conization method (27.22% for loop electrosurgical excision procedure vs. 18.52% for cold-knife conization, p = 0.047) and was increased as the severity of the treated lesion increased (10.07% for CIN2 vs. 30.62% for CIN3, p < 0.001). HPV-16 genotype infection, abnormal precone ECC result, higher grade of biopsy, larger cone length and volume, and glandular involvement were significantly associated with positive margins on univariable analysis. After logistic regression analysis, only an abnormal precone ECC result (odds ratio 1.952; 95% confidence interval 1.037-3.676; p = 0.038) remained significant.

CONCLUSIONS

In the present study, an abnormal precone ECC result was identified as an independent risk factor for positive margins in cervical conization specimens. More aggressive treatment may be considered in patients with abnormal precone ECC results in clinical practice.

Value of endocervical curettage in follow-up for patients with cervical intraepithelial neoplasia stage 2+ after loop electrosurgical excision

OBJECTIVE

To assess the value of endocervical curettage (ECC) during follow-up for patients with cervical intraepithelial neoplasia (CIN2+) after loop electrosurgical excision procedures (LEEP) and to explore risk factors for positive ECC during this evaluation.

METHODS

There were 383 CIN2+ patients in the one-step method group who underwent LEEP and were prospectively followed up using ECC as a routine strategy, with colposcopy and liquid-based cytology (LCT) + human papilloma virus (HPV) co-testing performed. The finding were then compared with those from 1041 patients in the retrospective database who underwent colposcopy unless LCT and/or HPV screening was abnormal, and ECC was performed depending on colposcopy images (two-step method group). The two groups were matched using propensity score matching analysis for further statistical comparisons.

RESULTS

In total, 383 pairs of patients from both groups were matched. The persistent/recurrent CIN2+ cases were 20 and 21, respectively (P > .05). However, 47 persistent/recurrent CIN1 cases were detected in the one-step method group; this number was significantly higher than that detected in the two-step method group (P < .05). High-risk factors for positive ECC during follow-up included positive ECC before treatment (odds ratio [OR]: 1.670), involved margins (OR: 1.239), and HPV infection and abnormal LCT during follow-up (ORs: 3.130 and 2.637).

CONCLUSIONS

ECC can detect early recurrent lesions after LEEP in patients with CIN2+ and can offset the limitation of colposcopy and co-testing resulting from LEEP. For patients with positive ECC before LEEP, involved margins, HPV infection, and abnormal LCT after treatment, ECC should be included in the follow-up strategy.