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Wang Q, Zhou FY, Ding JX. Factors associated with the persistence of human papillomavirus after surgery in patients with cervical cancer. Diagn Microbiol Infect Dis 2024; 108:116201. [PMID: 38340484 DOI: 10.1016/j.diagmicrobio.2024.116201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 01/14/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE To determine the rate of human papillomavirus (HPV) persistence after surgery in patients with cervical cancer, and to analyze the factors associated with HPV persistence and viral load after surgery. METHODS Medical records of women who underwent surgery for treatment of cervical cancer between 1 January 2018 and 30 June 2019 at Obstetrics and Gynecology Hospital of Fudan University in Shanghai, China, were retrospectively analyzed. Patients with persistent HPV infection after 2 years of follow-up were identified. Univariate and multivariate analyses were employed to determine the impact of various factors including patient age, menopausal status, parity, and surgical margin status on HPV persistence. The Wilcoxon test was used to analyze the factors that influenced postoperative HPV viral load. RESULTS Altogether, 607 women were eligible for the final analysis. The persistence rates of HPV at 6 months, 1 year, and 2 years after surgery were 17.3, 13.7, and 10.2 %, respectively. In univariate analysis, the factors that were predictive of the persistence of HPV infection were old age, postmenopausal status, and positive vaginal incision margin with cancer. In multivariate analysis, the significant independent predictive factors were postmenopausal status and positive vaginal incision margin with cancer (P < 0.05, odds ratio (OR) = 2.289, 95 % confidence interval (CI): 1.262-4.150 and OR = 3.271, 95 % CI: 1.253-8.537, respectively). A vaginal lesion with cancer or squamous intraepithelial lesion (SIL) and positive vaginal incision margin influenced HPV viral load at 6 months after surgery (P < 0.05). CONCLUSIONS Postmenopausal patients and those with positive vaginal incision margin with cancer are at an increased risk of HPV persistence after surgical treatment for cervical cancer. Vaginal lesions with cancer or SILs and positive vaginal incision margin are risk factors for high HPV viral load after surgery.
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Affiliation(s)
- Qing Wang
- Department of Gynecology, the Obstetrics and Gynecology Hospital of Fudan University, 419 Fang-xie Road, Shanghai 200011, PR China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, PR China; Zhabei Central Hospital, Jing 'an District, Shanghai, PR China
| | - Fang-Yue Zhou
- Department of Gynecology, the Obstetrics and Gynecology Hospital of Fudan University, 419 Fang-xie Road, Shanghai 200011, PR China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, PR China; International Peace Maternal and Child Health Hospital, Shanghai, PR China
| | - Jing-Xin Ding
- Department of Gynecology, the Obstetrics and Gynecology Hospital of Fudan University, 419 Fang-xie Road, Shanghai 200011, PR China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, PR China.
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Long E, Macdonald MC, Parker VL, Lyon R, Ellis K, Palmer JE. Factors associated with failed 'test of cure' in the NHS Cervical Screening Programme: A retrospective cohort study. Gynecol Oncol 2023; 179:158-163. [PMID: 37988947 DOI: 10.1016/j.ygyno.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To determine predictive factors associated with failed 'test of cure' (TOC) in the NHS Cervical Screening Programme (NHSCSP). METHODS Retrospective cohort study of all patients treated by large loop excision of transformation zone (LLETZ) between 1st April 2014 and 1st April 2019. Those with no documented HPV genotype on referral, no TOC outcome, those having a hysterectomy, chemotherapy and/or radiotherapy were excluded from final analysis. RESULTS Patients referred with a singular HPV genotype of HPV 16, HPV 18, or HPV Other types (HPV O) were significantly more likely to pass TOC than those referred with multiple HPV genotypes (p < 0.0001). Those with HPV genotypes including HPV O were significantly more likely to fail TOC as compared to those with genotypes of solely HPV 16 and/or 18 (p < 0.0001). Patients aged ≥51 years were significantly more likely to fail TOC when compared to all other age groups (p < 0.0001). CONCLUSION Age >51 yrs. and infection with multiple hr-HPV types were predictors of post treatment hr-HPV persistence. Knowledge of HPV genotype both at referral, and following treatment, could allow a more individualised, and patient-centred, approach to both the management and follow up of CIN. HPV genotype should be reported as standard on all cervical screening sample results. The term HPV O should not be utilised and instead actual HPV genotype should be reported. This would enable us to optimise not only future research but would also allow future monitoring of the efficacy of vaccination programmes.
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Affiliation(s)
- Emma Long
- ST7 Obstetrics & Gynaecology, Sub-Specialty Trainee Gynaecological Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Madeleine C Macdonald
- Consultant Gynaecological Oncologist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Victoria L Parker
- NIHR Clinical Lecturer in Obstetrics and Gynaecology, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK.
| | - Rachel Lyon
- Clinical Nurse Specialist - Colposcopy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kay Ellis
- Cervical Screening Programme Lead, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Cervical Screening Programme Lead, North East Yorkshire Cervical Screening Centre, Gateshead, UK
| | - Julia E Palmer
- Consultant Gynaecological Oncologist, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Zhang Y, Ni Z, Wei T, Liu Q. Persistent HPV infection after conization of cervical intraepithelial neoplasia-- a systematic review and meta-analysis. BMC Womens Health 2023; 23:216. [PMID: 37138261 PMCID: PMC10155368 DOI: 10.1186/s12905-023-02360-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 04/15/2023] [Indexed: 05/05/2023] Open
Abstract
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.
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Affiliation(s)
- Yueyang Zhang
- Department of Medical Laboratory, Public Health Clinical Center of Chengdu, Chengdu, China
| | - Zhiwen Ni
- Department of Radiology, Chengdu First People's Hospital, Chengdu, China
| | - Ting Wei
- Department of Medical Laboratory, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Qingsong Liu
- Department of Medical Laboratory, Public Health Clinical Center of Chengdu, Chengdu, China.
- Department of Prenatal Diagnosis, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, 1617#, Riyue Avenue, Qingyang District, 611731, Chengdu, China.
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Giannini A, Di Donato V, Sopracordevole F, Ciavattini A, Ghelardi A, Vizza E, D’Oria O, Simoncini T, Plotti F, Casarin J, Golia D’Augè T, Cuccu I, Serati M, Pinelli C, Bergamini A, Gardella B, Dell’Acqua A, Monti E, Vercellini P, D’Ippolito G, Aguzzoli L, Dario Mandato V, Giannella L, Scaffa C, Ditto A, Falcone F, Borghi C, Malzoni M, Di Giovanni A, Salerno MG, Liberale V, Contino B, Donfrancesco C, Desiato M, Perrone AM, De Iaco P, Ferrero S, Sarpietro G, Matarazzo MG, Cianci A, Cianci S, Bosio S, Ruisi S, Mosca L, Tinelli R, De Vincenzo R, Zannoni GF, Ferrandina G, Petrillo M, Capobianco G, Carlea A, Zullo F, Muschiato B, Palomba S, Greggi S, Spinillo A, Ghezzi F, Colacurci N, Angioli R, Benedetti Panici P, Muzii L, Scambia G, Raspagliesi F, Bogani G. Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization. Vaccines (Basel) 2023; 11:698. [PMID: 36992282 PMCID: PMC10051663 DOI: 10.3390/vaccines11030698] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023] Open
Abstract
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.
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Affiliation(s)
- Andrea Giannini
- Department of Gynecological, Obstetrical and Urological Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (A.G.); (V.D.D.); (T.G.D.); (I.C.); (P.B.P.); (L.M.)
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (A.G.); (V.D.D.); (T.G.D.); (I.C.); (P.B.P.); (L.M.)
| | - Francesco Sopracordevole
- Gynecological Oncology Unit, Centro di Riferimento Oncologico-National Cancer Institute, 33081 Aviano, Italy;
| | - Andrea Ciavattini
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60126 Ancona, Italy; (A.C.); (L.G.)
| | - Alessandro Ghelardi
- Azienda Usl Toscana Nord-Ovest, UOC Ostetricia e Ginecologia, Ospedale Apuane, 54100 Massa, Italy;
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy;
| | - Ottavia D’Oria
- Department of Woman’s and Child’s Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (O.D.); (M.G.S.)
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Francesco Plotti
- Department of Obstetrics and Gynecology, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.P.); (R.A.)
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, ‘Filippo Del Ponte’ Hospital, University of Insubria, 21100 Varese, Italy; (J.C.)
| | - Tullio Golia D’Augè
- Department of Gynecological, Obstetrical and Urological Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (A.G.); (V.D.D.); (T.G.D.); (I.C.); (P.B.P.); (L.M.)
| | - Ilaria Cuccu
- Department of Gynecological, Obstetrical and Urological Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (A.G.); (V.D.D.); (T.G.D.); (I.C.); (P.B.P.); (L.M.)
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, ‘Filippo Del Ponte’ Hospital, University of Insubria, 21100 Varese, Italy; (J.C.)
| | - Ciro Pinelli
- Ospedale di Circolo Fondazione Macchi, 21100 Varese, Italy (F.G.)
| | - Alice Bergamini
- Department of Obstetrics and Gynecology, IRCCS Ospedale San Raffaele, 20100 Milano, Italy;
| | - Barbara Gardella
- IRCCS S. Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy; (B.G.); (A.S.)
| | - Andrea Dell’Acqua
- Gynaecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.D.); (E.M.); (P.V.)
| | - Ermelinda Monti
- Gynaecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.D.); (E.M.); (P.V.)
| | - Paolo Vercellini
- Gynaecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (A.D.); (E.M.); (P.V.)
| | - Giovanni D’Ippolito
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42019 Scandiano, Italy; (G.D.); (L.A.); (V.D.M.)
| | - Lorenzo Aguzzoli
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42019 Scandiano, Italy; (G.D.); (L.A.); (V.D.M.)
| | - Vincenzo Dario Mandato
- Division of Obstetrics and Gynecology, Cesare Magati Hospital, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42019 Scandiano, Italy; (G.D.); (L.A.); (V.D.M.)
| | - Luca Giannella
- Woman’s Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, 60126 Ancona, Italy; (A.C.); (L.G.)
| | - Cono Scaffa
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy; (C.S.); (F.F.); (S.G.)
| | - Antonino Ditto
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milan, Italy; (A.D.); (F.R.)
| | - Francesca Falcone
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy; (C.S.); (F.F.); (S.G.)
| | - Chiara Borghi
- Department of Obstetrics and Gynecology, S. Anna University Hospital, 44121 Ferrara, Italy;
| | - Mario Malzoni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecological Surgery, 83100 Avellino, Italy; (M.M.); (A.D.G.)
| | - Alessandra Di Giovanni
- Endoscopica Malzoni, Center for Advanced Endoscopic Gynecological Surgery, 83100 Avellino, Italy; (M.M.); (A.D.G.)
| | - Maria Giovanna Salerno
- Department of Woman’s and Child’s Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (O.D.); (M.G.S.)
| | - Viola Liberale
- Department of Obstetrics and Gynecology, Ospedale Maria Vittoria, 10144 Torino, Italy; (V.L.); (B.C.)
| | - Biagio Contino
- Department of Obstetrics and Gynecology, Ospedale Maria Vittoria, 10144 Torino, Italy; (V.L.); (B.C.)
| | - Cristina Donfrancesco
- Department of Obstetrics and Gynecology, Azienda ASL Frosinone, Ospedale S Trinità di Sora, 03039 Sora, Italy; (C.D.); (M.D.)
| | - Michele Desiato
- Department of Obstetrics and Gynecology, Azienda ASL Frosinone, Ospedale S Trinità di Sora, 03039 Sora, Italy; (C.D.); (M.D.)
| | - Anna Myriam Perrone
- Gynecologic Oncology Unit, Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy; (A.M.P.); (P.D.I.)
| | - Pierandrea De Iaco
- Gynecologic Oncology Unit, Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy; (A.M.P.); (P.D.I.)
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, 16132 Genova, Italy
| | - Giuseppe Sarpietro
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy; (G.S.); (M.G.M.); (A.C.)
| | - Maria G. Matarazzo
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy; (G.S.); (M.G.M.); (A.C.)
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic University of Catania, Via S. Sofia 78, 95124 Catania, Italy; (G.S.); (M.G.M.); (A.C.)
| | - Stefano Cianci
- Department of Gynecologic Oncology, Università degli Studi di Messina, Policlinico G. Martino, 98122 Messina, Italy;
| | - Sara Bosio
- San Paolo Hospital, Università degli Studi di Milano, 20142 Milan, Italy; (S.B.); (S.R.)
| | - Simona Ruisi
- San Paolo Hospital, Università degli Studi di Milano, 20142 Milan, Italy; (S.B.); (S.R.)
| | - Lavinia Mosca
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (L.M.); (N.C.)
| | - Raffaele Tinelli
- Department of Obstetrics and Gynecology, “Valle d’Itria” Hospital, Martina Franca, Via San Francesco da Paola, 74015 Taranto, Italy;
| | - Rosa De Vincenzo
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (R.D.V.); (G.F.Z.); (G.F.); (G.S.)
| | - Gian Franco Zannoni
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (R.D.V.); (G.F.Z.); (G.F.); (G.S.)
| | - Gabriella Ferrandina
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (R.D.V.); (G.F.Z.); (G.F.); (G.S.)
| | - Marco Petrillo
- Gynecologic and Obstetric Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (M.P.); (G.C.)
| | - Giampiero Capobianco
- Gynecologic and Obstetric Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy; (M.P.); (G.C.)
| | - Annunziata Carlea
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (A.C.); (F.Z.)
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (A.C.); (F.Z.)
| | | | - Stefano Palomba
- Unit of Obstetrics and Gynecology, GOM of Reggio Calabria & University ‘Magna Graecia’ of Catanzaro, 88100 Catanzaro, Italy;
| | - Stefano Greggi
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy; (C.S.); (F.F.); (S.G.)
| | - Arsenio Spinillo
- IRCCS S. Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy; (B.G.); (A.S.)
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, ‘Filippo Del Ponte’ Hospital, University of Insubria, 21100 Varese, Italy; (J.C.)
- Ospedale di Circolo Fondazione Macchi, 21100 Varese, Italy (F.G.)
| | - Nicola Colacurci
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (L.M.); (N.C.)
| | - Roberto Angioli
- Department of Obstetrics and Gynecology, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.P.); (R.A.)
| | - Pierluigi Benedetti Panici
- Department of Gynecological, Obstetrical and Urological Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (A.G.); (V.D.D.); (T.G.D.); (I.C.); (P.B.P.); (L.M.)
| | - Ludovico Muzii
- Department of Gynecological, Obstetrical and Urological Sciences, “Sapienza” University of Rome, 00161 Rome, Italy; (A.G.); (V.D.D.); (T.G.D.); (I.C.); (P.B.P.); (L.M.)
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la Salute Della Donna e del Bambino e Della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (R.D.V.); (G.F.Z.); (G.F.); (G.S.)
| | - Francesco Raspagliesi
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milan, Italy; (A.D.); (F.R.)
| | - Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, 20133 Milan, Italy; (A.D.); (F.R.)
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Oncologic and obstetric outcomes after conization for adenocarcinoma in situ or stage IA1 cervical cancer. Sci Rep 2020; 10:19920. [PMID: 33199765 PMCID: PMC7669853 DOI: 10.1038/s41598-020-75512-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/16/2020] [Indexed: 01/23/2023] Open
Abstract
This study aims to reveal the risk factors associated with recurrence or new-onset high-grade squamous intraepithelial lesions (HSILs) or more severe lesions (HSILs +) and analyze obstetrical outcomes in patients with adenocarcinoma in situ (AIS) or stage IA1 cervical cancer patients after conization. A retrospective cohort study was developed from January 1, 2002, and July 1, 2018, in a single center, where all patients with AIS or stage IA1 cervical cancer who accepted conization for primary surgery were reviewed and followed up until July 1, 2019, for the pathological findings of HSILs + and obstetric outcomes. Two hundred and seventeen patients were identified, including 114 cases of AIS, 76 cases of stage IA1 squamous cell carcinoma (SCC) and 27 cases of stage IA1 adenocarcinoma (ADC). A total of 88 (40.6%) patients had an intact uterus without radiotherapy. Five patients experienced HSIL+ recurrence. The cumulative 3-, 5- and 10-year incidence rates of HSILs + were 1.0%, 1.5% and 2.0%, respectively. No significant risk factors, including primary disease, margin status and hysterectomy, were associated with recurrence. Twenty (66.7%) of 30 patients who attempted pregnancy had 23 successful pregnancies, which result in 7 miscarriages, 16 live births and 5 preterm births. Age at conization was the only independent risk factor associated with pregnancy, live births and preterm births. In conclusion, conization is safe for young women with AIS, stage IA1 SCC and ADC who desire future fertility, and the associated HSIL recurrence rate is low. Increased age significantly lowered the conception or live birth rate.
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Spinillo A, Dominoni M, Boschi AC, Cesari S, Fiandrino G, Gardella B. The relationship of human papillomavirus infection with endocervical glandular involvement on cone specimens in women with cervical intraepithelial neoplasia. Gynecol Oncol 2020; 159:630-635. [PMID: 33041069 DOI: 10.1016/j.ygyno.2020.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of study was to evaluate the association of endocervical gland involvement (EGI) on histological samples with high risk (HR) human papillomavirus (HPV) infection and with the persistence/recurrence rate of cervical intraepithelial neoplasia (CIN) after treatment. METHODS A total of 1301 subjects who had conization procedures after cervical punch biopsies (533 persistent CIN1, 768 CIN2+ including 20 microinvasive cervical cancer) were enrolled in the study. HPV genotypes were identified using the INNO-LiPA HPV genotyping assay on cervical scraping. Logistic regression and Cox regression analyses were used to evaluate the association of EGI on the persistence/recurrence rate of CIN after treatment. RESULTS The rate of EGI on final histology was 46.3% (602/1301). HPV 16 was the only HR-HPV significantly associated with increasing rates of EGI (231/602 as compared to 211/699, p = 0.002). EGI was also associated with an excess of multiple HR-HPV infections (237/602 as compared with 225/699, p = 0.006). After correction for confounders, the odds ratio of EGI among women infected by HPV 16 was 1.41 (95% CI = 1.12-178). CIN2+ lesions were diagnosed in 40.5% (283/699) of EGI negative subjects and 86.7% (522/602, p < 0.001 compared to negative subjects) of EGI positive subjects.After a median of 25 months of follow-up (IQR = 15-47) of 1090 treated women, the persistence of HPV 16 during follow-up was 38.1% (93/217, p = 0.03 compared to EGI negative) among EGI positive and 32% (58/181) among controls. After corrections for potential confounders, the odds ratio of CIN2+ persistence and or recurrence was higher among EGI positive (OR = 2.35, 95% CI = 1.16-4.77) than negative controls. CONCLUSION EGI on histological samples is associated with increased rates of HPV 16, multiple high risk-HPV infections and CIN2+ lesions. EGI positive subjects also had an increased CIN recurrence/persistence after treatment compared to controls.
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Affiliation(s)
- Arsenio Spinillo
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Mattia Dominoni
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Anna Chiara Boschi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Stefania Cesari
- Department of Pathology, Fondazione IRCCS Policlinico San Matteo, Università of Pavia, Italy
| | - Giacomo Fiandrino
- Department of Pathology, Fondazione IRCCS Policlinico San Matteo, Università of Pavia, Italy
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy.
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Kamio M, Yanazume S, Togami S, Kobayashi H. Association Between Positive Human Papillomavirus Status After Conization and Disease Recurrence in Patients with Cervical Intraepithelial Neoplasia Grade 3. J Obstet Gynaecol India 2020; 71:66-71. [PMID: 33814801 DOI: 10.1007/s13224-020-01368-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022] Open
Abstract
Objective This study aimed to examine the associations of cone margin and human papillomavirus (HPV) status after conization with cytological abnormalities and disease recurrence in patients with cervical intraepithelial neoplasia grade 3 (CIN3). Methods This is a retrospective study of 366 women with CIN3 who underwent conization at Kagoshima University Hospital between 2004 and 2017. Conization was performed using an ultrasonic scalpel. The polymerase chain reaction for detecting HPV genotypes was performed using fresh cervical cell samples. We examined the associations of margin status and HPV status after conization with cytological abnormalities and recurrence. Results Among 224 women with CIN3, 193 (86.2%) underwent HPV genotype testing before conization. The HPV-positive rate was 84.9%. The most common HPV genotypes before conization were HPV 16, 31, 58, 52, 18, 35, and 33. In 191 patients, the uterus was preserved after conization. Sixteen patients had pathologically positive margins, 165 had negative margins, and 10 had unclear margins. There was no significant difference in abnormal cytology and recurrence rate after conization between the three groups. Five patients with positive margins and abnormal cytology during follow-ups were HPV16- or HPV58-positive in the preoperative HPV testing. Of the 191 women, 91 (47.6%) underwent pre- and postoperative HPV genotype testing, among whom 14 (15.4%) were HPV-positive after conization. No significant difference in abnormal cytology based on HPV status after conization was found. The recurrence rate tended to be higher in HPV-positive patients than in HPV-negative patients after conization (21.4% vs. 1.3%, p < 0.05). Three patients with HPV positivity after conization and recurrence during follow-up were HPV16- or HPV58-positive. Conclusions HPV positivity after conization for CIN3 was associated with a high recurrence rate, especially in HPV16- and HPV58-positive patients. HPV58 has not received much attention thus far, but abnormalities in cytology and recurrence may be as likely as those associated with HPV16. Thus, a careful follow-up in such patients is recommended.
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Affiliation(s)
- Masaki Kamio
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Shintaro Yanazume
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Shinichi Togami
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
| | - Hiroaki Kobayashi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
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Kilic D, Guler T, Atigan A, Avsaroglu E, Karakaya YA, Kaleli I, Kaleli B. Predictors of Human papillomavirus (HPV) persistence after treatment of high grade cervical lesions; does cervical cytology have any prognostic value in primary HPV screening? Ann Diagn Pathol 2020; 49:151626. [PMID: 33011494 DOI: 10.1016/j.anndiagpath.2020.151626] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/21/2020] [Accepted: 09/05/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to determine the factors associated with Human Papillomavirus (HPV) persistence in women undergoing cervical excision for pre-invasive lesions, after they have been referred from a primary HPV screening program. METHODS A retrospective study design involving patients who were treated at a Cervical Disease Screening and Treatment Unit, in a university hospital setting. After initial treatment, cervical HPV infection status was analyzed at the sixth month, first year and then subsequently after the second year. RESULTS Totally, 395 patients who were diagnosed with pre-invasive cervical lesions and who subsequently undergone cervical excision were identified. In the first-year visit after cervical excision, HPV 18 was cleared in almost all (95.8%) cases, followed by HPV 16 (69.9%) and other hrHPV types (65.6%). Available data documented that 88.6% of women reached clearance after the two-year follow-up. Univariate analysis revealed a significantly higher proportion of HPV clearance among women who were younger (p = 0.019), premenopausal (p = 0.002), and who had been found to have a negative cytology result on their initial Pap test (p = 0.018). However, only cervical cytology result remained as the independent predictor of HPV persistence on a multivariate logistic regression (OR 0.43; 95% CI 0.21-0.87; p = 0.019). CONCLUSIONS A low risk of HPV persistence was found among every HPV genotype in women undergoing cervical excision for pre-invasive cervical lesions. Initial cervical cytology result was the only independent predictor of HPV clearance during surveillance, which indicates the prognostic value of Pap test in primary HPV screening.
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Affiliation(s)
- Derya Kilic
- Department of Obstetrics and Gynecology, Pamukkale University Medical School, Denizli, Turkey
| | - Tolga Guler
- Department of Obstetrics and Gynecology, Pamukkale University Medical School, Denizli, Turkey.
| | - Ayhan Atigan
- Department of Obstetrics and Gynecology, Pamukkale University Medical School, Denizli, Turkey
| | - Elif Avsaroglu
- Department of Obstetrics and Gynecology, Pamukkale University Medical School, Denizli, Turkey
| | | | - Ilknur Kaleli
- Department of Microbiology, Pamukkale University Medical School, Denizli, Turkey
| | - Babur Kaleli
- Department of Obstetrics and Gynecology, Pamukkale University Medical School, Denizli, Turkey
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Bhaskaran M, Murali SV, Rajaram B, Krishnasamy S, Devasena CS, Pathak A, Ravi V, Swaminathan K, Ayyappa A, Vedhantham S, Seshachalam A, ArunKumar G. Association of HLA-A, -B, DRB, and DQB Alleles with Persistent HPV-16 Infection in Women from Tamil Nadu, India. Viral Immunol 2019; 32:430-441. [PMID: 31800372 DOI: 10.1089/vim.2019.0094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Women with persistent human papillomavirus (HPV) infections have a high risk of developing cervical cancer (CaCx). HPV-16 alone accounts for more than 60% of CaCx worldwide. Most of the HPV infections are transient and only a subset of women develop persistent HPV-16 infection. Many studies have shown associations of different human leukocyte antigen (HLA) alleles with HPV-mediated CaCx, but there are only a few studies globally that relate to persistent HPV-16 infection. Furthermore, such studies from India are sparse. Hence, we investigated the association of HLA-A, B, DRB, and DQB alleles with persistent HPV-16 infection and HPV-16-positive CaCx in south India (Tamil Nadu). HPV-16 persistent infection was observed in 7% of normal women. A total of 50 women with HPV-16-positive CaCx, 21 women with HPV-16 persistent infection, and 74 HPV-16-negative normal women were recruited for this study. Low-resolution typing of HLA-A, B, DRB, and DQB alleles was performed. HLA-B*44 and DRB1*07 showed a significant association with persistent HPV-16 infection (odds ratio, p-value = 26.3, 0.03 and 4.7, 0.01, respectively). HLA-B*27 and DRB1*12 were significantly associated with both HPV-16+ CaCx and persistent HPV-16 infection (23.8, 0.03; 52.9, 0.01; 9.8, 0.0009; and 13.8, 0.009; respectively). HLA-B*15 showed a negative association with HPV-16-positive CaCx (0.1, 0.01), whereas DRB1*04 exhibited protection to both HPV-16-positive CaCx and persistent HPV-16 infection (0.3, 0.0001 and 0.1, 0.0002, respectively). Thus, we show HLA allelic association with HPV-16 infection in Tamil Nadu. Larger studies on high-resolution HLA typing coupled with HPV-16 genome diversity will offer further insights into host/pathogen genome coevolution.
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Affiliation(s)
- Muthumeenakshi Bhaskaran
- Human Genomics Laboratory, Centre for Research in Infectious Disease (CRID), School of Chemical and Biotechnology, SASTRA Deemed University, Thanjavur, India
| | - Sree Varshini Murali
- Human Genomics Laboratory, Centre for Research in Infectious Disease (CRID), School of Chemical and Biotechnology, SASTRA Deemed University, Thanjavur, India
| | - Barathi Rajaram
- Human Genomics Laboratory, Centre for Research in Infectious Disease (CRID), School of Chemical and Biotechnology, SASTRA Deemed University, Thanjavur, India
| | - Sundar Krishnasamy
- Human Genomics Laboratory, Centre for Research in Infectious Disease (CRID), School of Chemical and Biotechnology, SASTRA Deemed University, Thanjavur, India
| | - C S Devasena
- Department of Obstetrics and Gynaecology, Kovai Medical Centre and Hospital, Coimbatore, India
| | - Atima Pathak
- Department of Obstetrics and Gynaecology, Kovai Medical Centre and Hospital, Coimbatore, India
| | - Vidhya Ravi
- Department of Obstetrics and Gynaecology, K.A.P. Viswanatham, Government Medical College, Tiruchirapalli, India
| | - Krishnan Swaminathan
- Department of Endocrinology, Kovai Medical Centre and Hospital and Research Foundation, Coimbatore, India
| | - Ashok Ayyappa
- Human Genomics Laboratory, Centre for Research in Infectious Disease (CRID), School of Chemical and Biotechnology, SASTRA Deemed University, Thanjavur, India
| | | | - Arun Seshachalam
- Department of Medical Oncology, GVN Hospital Ltd., Tiruchirapalli, India
| | - GaneshPrasad ArunKumar
- Human Genomics Laboratory, Centre for Research in Infectious Disease (CRID), School of Chemical and Biotechnology, SASTRA Deemed University, Thanjavur, India
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Wang Y, Ouyang Y, Su J, Liu J, Cai Q, Xu Q, Bai Z, Cao X. Multicentre, randomised controlled trial of adjuvant chemotherapy in cervical cancer with residual human papilloma virus DNA following primary radiotherapy or chemoradiotherapy: a study protocol. BMJ Open 2019; 9:e028171. [PMID: 31594870 PMCID: PMC6797403 DOI: 10.1136/bmjopen-2018-028171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The role of adjuvant chemotherapy after radical radiotherapy (RT) or chemoradiotherapy (CRT) in cervical cancer awaits further confirmation. Evidences have shown that persistent human papilloma virus (HPV) DNA in exfoliated cell post-RT is a potential biomarker of subclinical residual disease and thus increases the risk of recurrence. In this prospective, multicentre, randomised controlled trial, we will use HPV DNA in exfoliated cell to identify patients with cervical cancer who received definitive RT or CRT with higher risk of relapse for adjuvant chemotherapy. METHODS AND ANALYSIS Eligible patients with histologically confirmed cervical cancer stage IIA2 to IVA of the International Federation of Gynaecology and Obstetrics, adequate organ function and no locoregional disease or distant metastasis after completion of primary treatment will be screened for HPV DNA in exfoliated cell at 1 month post-RT. Patients with undetectable HPV DNA will undergo standard surveillance. Patients with detectable HPV DNA will be randomly assigned to either adjuvant chemotherapy with docetaxel and nedaplatin for four cycles (arm 1) or observation (arm 2). Patients will be stratified for primary treatment (RT vs CRT). The primary endpoint is relapse-free survival. ETHICS AND DISSEMINATION This protocol received a favourable ethical opinion from the Ethics Committee of the Second Affiliated Hospital of Fujian Medical University on 6 February, 2018, (No. 28). The trial results will be published in peer-reviewed journals and presented in conferences. A summary of the findings will be made available to participants. TRIAL REGISTRATION NUMBER ChiCTR-IIR-17012655; Pre-results.
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Affiliation(s)
- Yanhong Wang
- Radiotherapy Department, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yi Ouyang
- Radiotherapy Department, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jingjing Su
- Radiotherapy Department, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Jing Liu
- Gynecology Department, Fujian Provincial Tumor Hospital, Fuzhou, China
| | - Qunrong Cai
- Radiotherapy Department, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Qin Xu
- Gynecology Department, Fujian Provincial Tumor Hospital, Fuzhou, China
| | - Zhigang Bai
- Radiotherapy Department, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xinping Cao
- Radiotherapy Department, Sun Yat-sen University Cancer Center, Guangzhou, China
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11
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Artificial intelligence estimates the impact of human papillomavirus types in influencing the risk of cervical dysplasia recurrence: progress toward a more personalized approach. Eur J Cancer Prev 2019; 28:81-86. [DOI: 10.1097/cej.0000000000000432] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Fan A, Wang C, Han C, Wang Y, Xue F, Zhang L. Factors affecting residual/recurrent cervical intraepithelial neoplasia after cervical conization with negative margins. J Med Virol 2018; 90:1541-1548. [PMID: 29704442 DOI: 10.1002/jmv.25208] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 04/12/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Aiping Fan
- Department of Gynecology and Obstetrics; Tianjin Medical University General Hospital; Tianjin China
| | - Chen Wang
- Department of Gynecology and Obstetrics; Tianjin Medical University General Hospital; Tianjin China
| | - Cha Han
- Department of Gynecology and Obstetrics; Tianjin Medical University General Hospital; Tianjin China
| | - Yingmei Wang
- Department of Gynecology and Obstetrics; Tianjin Medical University General Hospital; Tianjin China
| | - Fengxia Xue
- Department of Gynecology and Obstetrics; Tianjin Medical University General Hospital; Tianjin China
| | - Liqin Zhang
- Department of Gynecology and Obstetrics; Tianjin Medical University General Hospital; Tianjin China
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Tanaka Y, Ueda Y, Kakuda M, Kubota S, Matsuzaki S, Iwamiya T, Okazawa A, Matsuzaki S, Hashimoto K, Kobayashi E, Mabuchi S, Sawada K, Tomimatsu T, Yoshino K, Kimura T. Predictors for recurrent/persistent high-grade intraepithelial lesions and cervical stenosis after therapeutic conization: a retrospective analysis of 522 cases. Int J Clin Oncol 2017; 22:921-926. [PMID: 28451844 DOI: 10.1007/s10147-017-1124-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 04/11/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the study is to identify the risk factors associated with recurrent/persistent disease and cervical stenosis after conization. METHODS Five hundred twenty-two (522) cases of high-grade intraepithelial lesions treated by conization were retrospectively reviewed. Risk factors associated with recurrent/persistent disease were analyzed by univariate and multivariate analysis using a Cox hazard regression model. Factors that could potentially affect the risk of cervical stenosis were examined by univariate and by multivariate analysis using the χ 2 test and logistic regression, respectively. RESULTS Recurrent/persistent diseases and cervical stenosis occurred in 4.8% and 5.4% of the patients, respectively. Age ≥46 years [hazard ratio (HR) 3.6, 95% CI 1.36-10.3, p = 0.0092] and surgical margin involvement (HR 13.44, 95% CI 5.07-46.37, p < 0.001) were independent predictors for recurrent/persistent diseases. Age ≥46 years [odds ratio (OR) 4.27, 95% CI 1.88-10.07, p < 0.001] and shortened interval after childbirth to conization (within 12 months) (OR 5.42, 95% CI 1.42-17.41, p = 0.016) were independent risk factors for cervical stenosis. CONCLUSION Elderly patients (aged ≥46 years) are at high risk of recurrence and cervical stenosis, which may lead to unsatisfactory follow-up. Subsequent hysterectomy is beneficial to patients aged 46 or older with surgical margin involvement. Clinicians should recognize the possibility of cervical stenosis after conization during the breastfeeding period, leading to secondary infertility or hematometra.
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Affiliation(s)
- Yusuke Tanaka
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yutaka Ueda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Mamoru Kakuda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Satoshi Kubota
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Satoko Matsuzaki
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tadashi Iwamiya
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Akiko Okazawa
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shinya Matsuzaki
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kae Hashimoto
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Eiji Kobayashi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Seiji Mabuchi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kenjiro Sawada
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takuji Tomimatsu
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kiyoshi Yoshino
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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