Management options for cervical intraepithelial neoplasia

Long-term follow-up of photodynamic therapy of cervical intraepithelial neoplasia grade 2 (CIN2)

BACKGROUND

To determine the long-term efficacy and safety of 5-aminolevulinic acid-based photodynamic therapy (ALA-PDT) for treating cervical intraepithelial neoplasia grade 2 (CIN2) as well as the suitability of ALA-PDT in treating of cervical lesions divided into cervical transformation zone type 3.

METHODS

We included 81 patients diagnosed with CIN2 at the Department of Gynecology of the Affiliated Hospital of Qingdao University with data collected between January 2019 and January 2021 following ALA-PDT. Furthermore, we analyzed the superiority of ALA-PDT in fertility preservation among women of childbearing age based on follow-up data from 11 patients with fertility requirements.

RESULTS

Our findings confirmed the long-term efficacy of ALA-PDT for CIN2 treatment, with an overall efficacy of 95.83 % (23/24) at follow-up of 25-36 months. Moreover, the cervical transformation zone type 3 improvement and human papillomavirus (HPV)-negative efficacy were 69.2 % (18/26) and 82.4 % (14/17), respectively. ALA-PDT is recommended for consenting patients with cervical transformation zone type 3. Additionally, women without primary infertility could experience natural pregnancy and full-term birth of more than one baby following ALA-PDT for CIN2 treatment, with a satisfaction rate of ≈100 %.

CONCLUSIONS

ALA-PDT is recommendable for treating high-grade squamous intraepithelial lesions, especially in patients with fertility requirements.

Factors associated with human papillomavirus persistence after loop electrosurgical excision procedure in patients with cervical squamous intraepithelial lesion

AIM

To seek the high-risk factors of human papillomavirus (HPV) persistence and residual lesion or recurrence after loop electrosurgical excision procedure (LEEP) focus on the predictive value of intraoperative human papilloma virus (IOP-HPV) testing.

METHODS

Intraoperative endocervical sample was obtained with a cytobrush from the remained cervix of 292 patients immediately after LEEP. HPV Genotyping was performed using a polymerase chain reaction technique. All patients followed by HPV genotyping and cytology every 3-6 months. The IOP-HPV testing results and possible risk factors such as age, cytology grade, menopause status, margin involvement, preoperative HPV status, and cervical lesion grade were assessed in predicting persistence of HPV and residual lesion or recurrence after surgery.

RESULTS

There were 61 (20.9%) patients presented persistent HPV infection. Multivariate analyses showed that IOP-HPV positive, post-menopause and preoperative HPV multiplex infection was strongly associated with HPV persistence after LEEP, IOP-HPV positive and post-menopause was also associated with residua or recurrent disease after LEEP.

CONCLUSIONS

IOP-HPV positive, post-menopause, and preoperative HPV multiplex infection are independent predictors of HPV persistence in patients with cervical squamous intraepithelial lesion treated by LEEP. IOP-HPV test is a new approach that may potentially allow for early identification of patients at high risk of HPV persistence and residua or recurrent disease after LEEP, thereby possibly facilitate an attenuated follow-up schedule for negative patients those at low risk of persistent HPV infection.

Evaluation of the effectiveness and safety of photodynamic therapy in the treatment of precancerous diseases of the cervix (neoplasia) associated with the human papillomavirus: A systematic review

This study provides an overview of the effectiveness and safety of PDT for the treatment of HPV-associated precancerous cervical conditions and contains recent findings from relevant research studies. A comprehensive literature search of MEDLINE/PubMed, Cochrane Central Library, and Google Scholar was conducted, including analytic epidemiological studies, and 11 papers were included. The narrative synthesis approach was used to summarize the results of the included studies. Studies were critically appraised using The Joanna Briggs Institute (JBI) tool for assessing the risk of bias. The results of the study demonstrate that CRR for HPV remission ranges from 66.7 % to 92.73 %, whereas for CIN1 it fluctuates from 57.1 % to 83.3 %. The frequency of recurrence of the disease ranged from 3.3 % to 8.9 % during the follow-up period of up to 2 years. Adverse events were observed in 8 (66 %) studies and the most common were cervical stenosis, abdominal pain, vaginal pain, and focal edema. Five types of topical and intravenous applications along with lasers of various wavelengths and intensities were mostly used. However, all studies demonstrated relatively similar results. According to the results, PDT has demonstrated favorable outcomes, but no impressive effect on the treatment of CIN. It should be emphasized, that the effectiveness of PDT for the treatment of HPV-associated CIN may vary depending on some variables, including the kind of PDT agent used, the dosage, duration and frequency of PDT administration, the severity and location of the lesions, and the host immunological response.

The effects of the LaSota strain of oncolytic Newcastle disease virus vaccine on cervical intraepithelial neoplasia Patients-Clinical cohort study

BACKGROUND

Cervical cancer is one of the most common malignancies in women, and its treatment has many side effects. Therefore, in this research, the effects of the LaSota strain of oncolytic Newcastle disease virus vaccine on cervical intraepithelial neoplasia (CIN) patients were investigated.

METHODS

15 patients who met the inclusion criteria and diagnosed as CIN II and CIN III were included in the study. The vaccine was injected inside the cervix (neoplasia site) at increasing doses during 21 days, and they were evaluated for adverse events. NDV antibody titer was measured in 90 days and the levels of ki-67 and p16 proteins were studied by immunohistochemistry. Also, the levels of some important inflammatory cytokines in the serum of CIN patients were measured and finally the patients were evaluated according to the final outcomes and the reduction of tumor lesions.

RESULTS

Only in the first dose of vaccine some patients showed flu-like symptoms. The accumulation of NDV antibodies started on the 7th day of the study and increased until the 90th day. Administration of LaSota vaccine had no significant effect on the expressions of Ki-67 and p16 proteins. Nevertheless, a decrease in the serum levels of Il-1β was observed in patients after the administration of the vaccine, but the serum levels of both Il-2 and INF-γ upregulated significantly. Also, vaccine administration had no significant effect in reducing CIN grades and lesions.

CONCLUSIONS

In general, we concluded that LaSota strain of NDV vaccine has no therapeutic effectiveness in CIN patients.

Efficacy and safety of therapeutic HPV vaccines to treat CIN 2/CIN 3 lesions: a systematic review and meta-analysis of phase II/III clinical trials

OBJECTIVES

We aim to assess the efficacy and safety of therapeutic human papillomavirus (HPV) vaccines to treat cervical intraepithelial neoplasia of grade 2 or 3 (CIN 2/3).

DESIGN

Systematic review and meta-analysis, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

DATA SOURCES

PubMed, Embase, Web of Science, Global Index Medicus and CENTRAL Cochrane were searched up to 31 January 2022.

ELIGIBILITY CRITERIA

Phase II/III randomised controlled trials (RCTs) and single-arm studies reporting the efficacy of therapeutic vaccines to achieve regression of CIN 2/3 lesions were included. Studies evaluating only safety and side effects of the vaccine were excluded.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and evaluated study quality. A random-effect model was used to pool the proportions of regression and/or HPV clearance.

RESULTS

12 trials met the inclusion criteria. Out of 734 women (all studies considered) receiving therapeutic HPV vaccine for CIN 2/3, 414 regressed to normal/CIN 1 with an overall proportion of regression of 0.54 (95% CI 0.39 to 0.69) for vaccinated group; 166 women (from five RCTs) receiving placebo only achieving a pooled normal/CIN 1 regression of 0.27 (95% CI 0.20 to 0.34). When including only the five two-arm studies, the regression proportion for the 410 vaccine group participants was higher than that of the 166 control group participants (relative risk (RR) 1.52; 95% CI 1.14 to 2.04). The pooled proportion of high-risk human papillomavirus (hrHPV) clearance was 0.42 (95% CI 0.32 to 0.52) in the vaccine group (six studies with a total of 357 participants) and 0.17 (95% CI 0.11 to 0.26) in the control group (three RCTs with a total of 104 participants). Based on these three RCTs, the hrHPV clearance was significantly higher in the vaccinated group (250 participants) compared with the control group (RR 2.03; 95% CI 1.30 to 3.16). Similar results were found regarding HPV 16/18 clearance. No significant unsolicited adverse events have been consistently reported.

CONCLUSIONS

The efficacy of the therapeutic vaccines in the treatment of CIN 2/3 was modest. Implementation issues such as feasibility, acceptability, adoption and cost-effectiveness need to be further studied.

PROSPERO REGISTRATION NUMBER

CRD42022307418.

Outcome after loop electrosurgical excision procedure for cervical high-grade squamous intraepithelial lesion

OBJECTIVE

The dilemma in treating cervical high-grade squamous intraepithelial lesion (HSIL) is how to achieve complete excision to minimize the risk of cervical cancer while sparing the anatomy of the cervix and its ability to function during pregnancy. The optimal management for positive margins after excisional treatment is still controversial. This study was conducted to determine the clinical and histologic predictors of residual/recurrent HSIL and assess the outcome of women with positive margin.

MATERIALS AND METHODS

This retrospective cohort study included 386 women who had excisional treatment for HSIL during 1st January 2012 to 31st December 2015 in a university-affiliated hospital.

RESULTS

Overall, 212 (54.9%) women had negative margins and 155 (40.2%) had positive margins. The cumulative rate of residual/recurrent HSIL at 2 and 5 years was 15.7% and 16.8% respectively in positive margins and 1.8% and 5.0% respectively in negative margins (p < 0.001). Of women who had residual/recurrent HSIL, significantly more women had positive margins compared to negative margins (74.1% vs 25.9%, p = 0.001). Positive margin was significantly associated with higher rate of subsequent abnormal cervical smear (48.2% vs 28.9%, p < 0.001), requiring further colposcopy (32.1% vs 14.4%, p < 0.001) and further treatment for SIL (7.5% vs 4.8%, p < 0.001) compared to negative margin.

CONCLUSION

Most women (85%) with positive margin went without residual/recurrent HSIL, of which the option of close surveillance with cytology is reasonable. Repeat excision may be considered in selected women with positive margin, endocervical glandular involvement and those who are older or unable to comply with follow-up.

Topical 5-Aminolevulinic Acid Photodynamic Therapy for Cervical High-Grade Squamous Intraepithelial Lesions

OBJECTIVE

To evaluate the efficacy of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) in the treatment of high-grade squamous intraepithelial lesions of the cervix (HSIL).

METHODS

This retrospective study included 22 female patients with histologically confirmed HSIL and high-risk human papillomavirus (HR-HPV) infections. Patients were treated with ALA-PDT once a week for a total of 6 times. All patients had a follow-up period of 3 months and 6 months. The assessment of effectiveness of ALA-PDT was performed by ThinPrep cytology test (TCT), HPV DNA assay, HPV E6/E7 mRNA examination, colposcopy, biopsy, and immunohistochemistry detection.

RESULTS

Three months after 5-ALA PDT, the histologic disappearance rate was 81.82% (18/22), while the HPV clearance rate was 54.55% (12/22). At the 6 months checkpoint, the HSIL disappearance rate was 90.91% (20/22) and the HPV clearance rate was 86.36% (19/22). Before PDT, 68.18% of patients (15/22) were confirmed with TCT abnormalities, while only one patient (1/22, 4.55%) was abnormal in the TCT test at 6 months checkpoint. All participants were found HPV E6/E7 mRNA positive initially, while the HPV E6/E7 mRNA negative rate was 90.91% (20/22) at 6 months checkpoint. Additionally, we found a significant difference of the expression of CD4+ & CD8+ T cells and HPV E6 & E7 proteins before ALA-PDT and at 3 months follow-up (P < 0.01). No severe side effects were seen.

CONCLUSIONS

Topical 5-ALA PDT is an effective treatment for cervical HSIL with HR-HPV infection.

Review of the Standard and Advanced Screening, Staging Systems and Treatment Modalities for Cervical Cancer

Simple Summary

This review discusses the timeline and development of the recommended screening tests, diagnosis system, and therapeutics implemented in clinics for precancer and cancer of the uterine cervix. The incorporation of the latest automation, machine learning modules, and state-of-the-art technologies into these aspects are also discussed.

Abstract

Cancer arising from the uterine cervix is the fourth most common cause of cancer death among women worldwide. Almost 90% of cervical cancer mortality has occurred in low- and middle-income countries. One of the major aetiologies contributing to cervical cancer is the persistent infection by the cancer-causing types of the human papillomavirus. The disease is preventable if the premalignant lesion is detected early and managed effectively. In this review, we outlined the standard guidelines that have been introduced and implemented worldwide for decades, including the cytology, the HPV detection and genotyping, and the immunostaining of surrogate markers. In addition, the staging system used to classify the premalignancy and malignancy of the uterine cervix, as well as the safety and efficacy of the various treatment modalities in clinical trials for cervical cancers, are also discussed. In this millennial world, the advancements in computer-aided technology, including robotic modules and artificial intelligence (AI), are also incorporated into the screening, diagnostic, and treatment platforms. These innovations reduce the dependence on specialists and technologists, as well as the work burden and time incurred for sample processing. However, concerns over the practicality of these advancements remain, due to the high cost, lack of flexibility, and the judgment of a trained professional that is currently not replaceable by a machine.

The Effect of Surgeon Volume on the Outcome of Laser Vaporization: A Single-Center Retrospective Study

Although laser vaporization is a popular minimally invasive treatment for cervical intraepithelial neoplasia (CIN), factors influencing CIN recurrence are understudied. Moreover, the effect of surgeon volume on patients’ prognosis after laser vaporization for CIN is unknown. This single-center retrospective study evaluated the predictive value of surgeon volume and patient characteristics for laser vaporization outcomes in women with pathologically confirmed CIN2. Histologically confirmed CIN2 or higher grade after laser vaporization was defined as persistent or recurrent. Various patient characteristics were compared between women with and those without recurrence to examine the predictive factors for laser vaporization. There were 270 patients with a median age of 36 (18–60) years. The median follow-up period was 25 (6–75.5) months and the median period between treatment and persistence or recurrence was 17 (1.5–69) months. The median annual number of procedures for all seven surgeons was 7.8. There were 38 patients (14.1%) with persistent or recurrent lesions—24 had CIN2, 13 had CIN3, and one had adenocarcinoma in situ. Patient age, body mass index, surgeon volume, and history of prior CIN treatment or invasive cervical cancer were not significantly correlated with lesion persistence or recurrence. In conclusion, laser vaporization has comparable success rates and is a feasible treatment for both low- and high-volume surgeons.

Comparison of Expectant and Excisional/Ablative Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) in the Era of HPV Testing

Objective

To investigate conservative and excisional/ablative treatment outcomes for cervical intraepithelial neoplasia grade 2 (CIN2) following introduction of virological test of cure.

Methods

This was a retrospective study of prospectively collected data at a teaching hospital colposcopy unit. 331 sequential biopsy-proved CIN2 cases were involved. CIN2 cases diagnosed between 01/07/2014 and 31/12/2017 were either conservatively managed or treated with excision/ablation and then were followed up until discharge from colposcopy clinic and then using the national cervical cytology database. Outcomes were defined: cytological/histological regression was absence of high-grade CIN on biopsy and/or high-grade dysplasia; virological regression was cytological/histological regression and negative human papillomavirus testing; persistence was biopsy-proven CIN2 and/or moderate dyskaryosis; progression was biopsy-proven CIN3+ and/or severe dyskaryosis.

Results

Median follow-up was 22.6 months (range: 1.9–65.1 months). Among 175 (52.9%) patients initially managed conservatively, 77.3% (133/172) regressed, 13.4% (23/172) persisted, 9.3% (16/172) progressed to CIN3+, and 97 (56.4%) patients achieved virological regression. 156 (47.1%) patients underwent initial excision/ablation, with an 89.4% (110/123) virological cure rate. After discharge, 7 (4.0%) and 3 (1.9%) patients redeveloped CIN in the conservative and treatment groups, respectively, during a median period of 17.2 months.

Conclusion

Conservative management is a reasonable and effective management strategy in appropriately selected women with CIN2. High rates of histological and virological regression should be expected. The previously mentioned data provide useful information for deciding management options.

Histopathological correlation of cervical biopsy and tissue after excision in patients with precancerous lesions of the cervix

INTRODUCTION

Cervical intraepithelial neoplasia (CIN) are precancerous lesion of cervix, with incidence of 1.6 per 1000 for CIN 1 lesion and 1.2 per 1000 for CIN 3 lesion in USA. According to IARC incidence is higher in less developed and developing countries. Taking into account the fact that the sensitivity, specificity and accuracy of Papanicolaou swab and colposcopy vary, the final diagnosis is made by colposcopically guided biopsy and by excisions of the cervix.

AIM OF THE STUDY

Comparing the histopathological findings of cervical biopsy and definitive histopathological findings after cervical excision in precancerous lesions of the cervix in relation to the degree of lesion, age and institution, where the biopsy was performed.

MATERIALS AND METHODS

The study was retrospective and was conducted on a group of patients who underwent some excision techniques on the cervix after obtaining a histological finding of the cervical biopsy.

RESULTS

In a total sample of 168 patients, a correlation of histopathological analysis of biopsy material and excision techniques was observed in 62.5% (105/168). This correlation was statistically significant (χ² = 5.333, df 1; p = 0.0209). The greater correlation of histopathological material of biopsies and final histopathological material after excisions were obtained in Oncology Institute of Vojvodina (OIV) without statistical significance.

CONCLUSION

A statistically significant accuracy of biopsy was noted in examined group of patients.

The value of MR-based radiomics in identifying residual disease in patients with carcinoma in situ after cervical conization

Carcinoma in situ (CIS) of the uterine cervix is a precursor to cervical carcinoma. However, hysterectomy can be avoided in patients who can be treated by cone biopsy. Previous studies have shown that imaging-based approaches allow for the noninvasive visualization of cervical cancer, and radiomics has high accuracy in classifying cancer and predicting treatment outcome for different cancer types. To develop a magnetic resonance (MR)-based radiomics model for identifying residual disease in patients with CIS after cervical conization. Patients who had CIS after conization and finally underwent hysterectomy were collected to comprise a database to establish an imaging model for predicting the residual status after conization. Then, patients who opted for uterine preservation were classified as high-risk or low-risk patients according to the model. The disease-free survival was compared between the different risk groups using the Kaplan–Meier curve. The model built with the Boruta features outperformed the random forest model. Further validation with patients with uterine preservation showed that the patients classified as high risk were more likely to have tumor recurrence/residual disease in the follow-up period. In conclusion, radiomics can be used to identify residual disease in patients with CIS after cervical conization and could have the potential to predict recurrence in patients who opt for uterine preservation.

Clinical efficacy and mechanism for focused ultrasound (FUS) in the management of cervical intraepithelial neoplasia 1 (CIN1)

Objective: This study was aimed at investigating the clinical efficacy and studying the possible mechanism of FUS applications to treat cervical intraepithelial neoplasia 1 (CIN1).Methods: This was a prospective clinical study, in which 30 patients with CIN1 (28/30 of the patients were HPV positive) were enrolled and treated with FUS therapy by gynecologist. All patients were followed up for 3 months after FUS therapy. Telephone interviews, PAP smear, colposcopic examinations, cervical biopsies and HPVDNA tests were performed to assess the safety and effectiveness of FUS therapy for HPV-positive CIN1. The expression of p16, Ki-67 and Fas in the cervical tissues were examined in order to account for the possible mechanism of FUS therapy for CIN1 with HPV infection.Results: FUS therapy was tolerated well, and no severe complications were observed in any patient. After FUS treatment, twenty-five patients were cured completely, and two cases were improved with the cervical smear results reversed to normal, and three cases remained the same status as before treatment. The total effectiveness rate was 90.00% (27/30). The expression of P16 and Ki-67 in the treated cervical tissues was significantly lower than that before treatment, and the expression of Fas was found up-regulated (all p < .05).Conclusion: FUS therapy appears to be a feasible and effective treatment for patients with HPV positive CIN1. FUS therapy may help to reduce the expression of p16 and Ki-67 and enhance the expression of Fas in the treated cervical tissues to regulate cell proliferation and increase apoptosis, and thus prevent the disease from evolving into high grade lesions.

Advances in therapeutic vaccines for treating human papillomavirus-related cervical intraepithelial neoplasia

AIM

Human papillomavirus (HPV) is the etiologic agent of the majority of cervical intraepithelial lesions (CIN) and cervical cancers. While prophylactic HPV vaccines prevent infections from the main high-risk HPV types associated with cervical cancer, alternative nonsurgical and nonablative therapeutics to treat HPV infection and preinvasive HPV diseases have been experimentally investigated. Therapeutic vaccines are an emerging investigational strategy. This review aims to introduce the results of the main clinical trials on the use of therapeutic vaccines for treating HPV infection and -related CIN, reporting the ongoing studies on this field.

METHODS

Data research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library querying for all articles related to therapeutic vaccines for the treatment of HPV-related CIN. Selection criteria included randomized clinical trials, nonrandomized controlled studies and review articles.

RESULTS

Preliminary data are available on the evaluation of therapeutic vaccines for treating cervical HPV infections and CIN. Despite having in vitro demonstrated to obtain humoral and cytotoxic responses, therapeutic vaccines have not yet clinically demonstrated consistent success; moreover, each class of therapeutic vaccines has advantages and limitations. Early clinical data are available in the literature for these compounds, except for MVA E2, which reached the phase III clinical trial status, obtaining positive clinical outcomes.

CONCLUSION

Despite promising results, to date many obstacles are still present before hypothesize an introduction in the clinical practice within the next years. Further studies will draw a definitive conclusion on the role of therapeutic vaccines in this setting.

Can we predict surgical margin positivity while performing cervical excisional procedures?

We designed this study to evaluate any factors associated with positive surgical margin in conisation specimens and to determine the optimal cone size. The medical records of patients who had undergone a loop electrosurgical excision procedure (LEEP), cold-knife conisation (CKC) and needle excision of the transformation zone (NETZ) procedure were reviewed retrospectively. Two hundred and sixty eight women fulfilled the inclusion criteria. Univariate analyses showed that 'postmenopause', 'HSIL on smear', 'previous colposcopic examination revealing HSIL in endocervical curettage (ECC) material and in two or more ectocervical quadrants' and 'managing with LEEP' were significant predictors of surgical margin positivity. Nulliparous patients showed significantly lower rate of surgical margin positivity. 'Postmenopause', 'previous colposcopic examination revealing HSIL in ECC material and in two or more ectocervical quadrants' and 'HSIL on smear' were identified as independent predictors of surgical margin positivity according to multivariate analyses.IMPACT STATEMENTWhat is already known on this subject? Previous studies demonstrated 'menopause', 'Age ≥50', 'managing with LEEP', 'disease involving >2/3 of cervix at visual inspection', 'training level of the surgeon', 'cytology squamous cell carcinoma' and 'mean cone height' as factors associated with positive surgical margin in conisation specimens.What do the results of this study add? In our study, univariate analyses showed that 'postmenopause', 'HSIL on smear', 'previous colposcopic examination revealing HSIL in endocervical curettage material and in two or more ectocervical quadrants' and 'managing with LEEP' were associated with surgical margin positivity. On the other hand, nulliparous women showed significantly lower rate of surgical margin positivity compared with parous women. Multivariate analyses showed that 'postmenopause', 'previous colposcopic examination revealing HSIL in endocervical curettage material and in two or more ectocervical quadrants' and 'HSIL on smear' were independent predictors of surgical margin positivity in conisation specimens.What are the implications of these findings for clinical practice and/or further research? We can predict high-risk patients with regard to surgical margin positivity. Prediction of high-risk patients and management with a tailored approach may help minimise surgical margin positivity rates.

Diagnostic excision of the cervix in women over 40 years with human papilloma virus persistency and normal cytology

Objective

Persistent infection with human papillomavirus (HPV) is recognized as the main risk factor of cervical cancer. Investigation via cytology and colposcopy have lower sensitivity than HPV testing in the diagnosis of high-grade cervical intraepithelial neoplasia (CIN2+). Despite normal cytology and colposcopy findings women with persistent HPV infection have an increased risk of CIN2+. The aim of the study was to evaluate the proportion of histologically confirmed CIN2+ in women with persistent HPV infection and normal Pap smears.

Study design

From April 2013 until March 2016 we prospectively recruited 91 women over 40 years with persistent HPV infection without any abnormalities in cytology. Of these, 40 women attended a gynecological examination including an HPV test, Pap smear, endocervical cytology, colposcopy with biopsies and diagnostic loop electrosurgical excision procedure (LEEP). Biopsy and LEEP samples were subjected to histological examination

Results

CIN2+ was verified by histological examination of the LEEP sample in 6/40 (15%) of the women. All the cytological samples were normal and none of the biopsies confirmed CIN2+. Only 19/40 women still had a persistent HPV infection at the study visit. None of the 21/40 women who had cleared their HPV infection at the study visit had CIN2+ in histology of the LEEP sample.

Conclusions

A persistent HPV infection needs to be monitored despite normal Pap smears, since 6/40 (15%) women older than 40 years, was revealed to have an undiagnosed CIN2+ when LEEP was performed. Counseling women regarding the risk of cervical cancer and the expected effect of an eventual LEEP can help them to make an optimal informed choice.

Long-term observational approach in women with histological diagnosis of cervical low-grade squamous intraepithelial lesion: an Italian multicentric retrospective cohort study

OBJECTIVE

To evaluate the risk of progression to high-grade squamous intraepithelial lesion (HSIL) (CIN2-3) or invasive cancer in women with histopathological diagnosis of low-grade squamous intraepithelial lesion (LSIL) (CIN1), managed in a long-term observational approach up to 5 years.

DESIGN

Retrospective cohort study.

SETTING

Four tertiary referral hospital.

PARTICIPANTS

434 women with adequate colposcopy and complete colposcopic charts were included in the present analysis. Women with glandular lesions on the referral cytology or previous diagnosis of cervical dysplasia or invasive cervical cancer or with synchronous vaginal, or with HIV infection or immunodepression were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main study outcome was the rate of progression to histopathological HSIL (CIN2-3) or invasive cancer at any time during 5 years of follow-up. The possible risk factors were also evaluated. As secondary outcome, we analysed the possible risk factors at the 24-month evaluation for histopathological HSIL (CIN2-3) or invasive cancer progression between 2 and 5 years from initial diagnosis.

RESULTS

A progression to histopathological HSIL (CIN2-3) was found in a total of 32 (7.4%) cases during 5 years of follow-up. A histopathological diagnosis of HSIL (CIN3) was found in four patients (0.9%) and no case of invasive cancer was detected. High-grade cytology at inclusion and the presence of a positive high-risk human papillomavirus (HR-HPV) DNA test at 2 years from inclusion maintained a significant correlation with the risk of histopathological progression to HSIL (CIN2-3).

CONCLUSIONS

The results of our study showed a low rate (7.4%) of histopathological progression to HSIL (CIN2-3) in women with LSIL (CIN1) diagnosis during long-term follow-up up to 5 years. In case of positive HR-HPV DNA test at the 2 years evaluation an excisional treatment could be the preferred choice to prevent progression to HSIL (CIN2-3) in the following years, preferring a continuation of follow-up in case of HR-HPV DNA negative result.

Outcomes of Conservative Management of High Grade Squamous Intraepithelial Lesions in Young Women

OBJECTIVE

The aim of the study was to determine regression rates of cervical intraepithelial neoplasia (CIN) 2 and 3 in women younger than 24 years, followed conservatively for up to 24 months.

MATERIALS AND METHODS

This is a retrospective chart review of colposcopy patients in clinic database based on the following: (1) younger than 24 years at first visit; (2) first visit January 1, 2010, to May 31, 2013, and at least 1 follow-up visit after diagnosis; (3) histologic diagnosis of CIN2+; and (4) optimal conservative management (observation for up to 24 months or to 24 years, whichever occurred first). Patient information and clinical/pathologic data were extracted from charts to examine patient characteristics and treatment outcomes, CIN2+ regression rates, median times to regression for CIN2 versus CIN3 (Kaplan-Meier survival analysis), and predictors of regression (multivariate logistic regression analysis).

RESULTS

A total of 154 women met criteria. The most severe histological diagnoses were CIN2 in 99 (64.3%), CIN3 in 51 (33.1%), and adenocarcinoma in situ in 4 (2.6%). Adenocarcinoma in situ was immediately treated. In follow-up, CIN2 regressed to CIN1 or negative in 74 women (74.7%)-median time to regression, 10.8 months. Cervical intraepithelial neoplasia 3 regressed in 11 women (21.6%)-median time to regression not reached (last follow-up censored at 52.7 months). Cervical intraepithelial neoplasia 2 on biopsy, low grade referral Pap, and younger age predicted regression. Overall, 49 women (31.8%) were treated.

CONCLUSIONS

Conservative management should continue to be recommended to young women with CIN2. Rigorous retention mechanisms are required to ensure that these women return for follow-up.

A Large Retrospective Study of 12714 Cases of LEEP Conization Focusing on Cervical Cancer That Colposcopy-Directed Biopsy Failed to Detect

Punch biopsy is important in the diagnosis of cervical cancer. However, it may fail to detect early cervical cancers. A retrospective study was performed in the largest academic women's hospital in China to demonstrate cervical cancer that colposcopy-directed biopsy failed to detect. Methods. Patients who were diagnosed with high-grade squamous intraepithelial lesion (HSIL), adenocarcinoma in situ (AIS), and persistent low-grade squamous intraepithelial lesion (LSIL) via colposcopy-directed biopsy and had further undergone loop electrosurgical excision procedure (LEEP) conization were included. These procedures were performed at Obstetrics and Gynecology Hospital of Fudan University from July 1, 2013, to December 31, 2016. In total, 5.98% (760/12714) of patients who underwent conization were diagnosed with invasive cervical cancer. Persistent LSIL (0.24%), HSIL (6.37%), and AIS (24.31%) were detected cancer by conization. Histological subtypes included squamous cell carcinoma (92.0%), adenocarcinoma (5.1%), adenosquamous carcinoma (1.8%), adenoid basal type carcinoma (0.9%), and small cell neuroendocrine carcinoma (0.1%). Cytology reports consisted of HSIL (45.4%), atypical squamous cells of undetermined significance (ASC-US) (16.1%), and LSIL (11.6%), and atypical squamous cells cannot exclude HSIL (ASC-H) (9.3%), squamous cell carcinoma (0.9%), AGC (atypical glandular cells, 0.9%), AIS (0.4%), and NILM (negative for intraepithelial lesion or malignancy, 15.4%). The sensitivity of high-risk human papillomavirus (hrHPV) screening (96.4%) was significantly higher than that of cytology (84.6%) (P < 0.01), with sensitivity of cotesting at 99.8% and a ratio of double-negative results at 0.2%. The sensitivity of cytology and hrHPV screening of different cervical cancer histologic subtypes was also demonstrated. In this large retrospective study, we systematically reported the cytology, hrHPV, pathology, and stages of cervical cancer that colposcopy-directed biopsy failed to detect.

Secondary prevention of cervical cancer

Cervical cancer affects women in their reproductive ages. Screening is an important secondary prevention strategy. The long process of carcinogenic transformation from human papillomavirus (HPV) infection to invasive cancer provides ample opportunities to detect the disease at a stage when treatment is highly effective. Suitable screening tests are cytology, visual inspection after acetic acid application and HPV detection tests. Evidence of effectiveness of the tests to reduce cervical cancer mortality and the cost-effectiveness of screening programs have been demonstrated. Cervical intraepithelial neoplasia grade 2 and grade 3 are the high-grade cervical cancer precursors and need to be treated. Treatment is safe and effective with ablative or excisional techniques. The World Health Organization recommends screening women at least once in a lifetime between 30 and 49 years of age and ensuring effective treatment of the detected abnormalities. Combination of HPV vaccination and population-based screening will be instrumental in eliminating cervical cancer.

Nanomechanical Characteristics of Cervical Cancer and Cervical Intraepithelial Neoplasia Revealed by Atomic Force Microscopy

Background

Understanding the biological features and developmental progress of cervical cancer is crucial for disease prevention. This study aimed to determine the nanomechanical signatures of cervical samples, ranging from cervicitis to cervical carcinomas, and to investigate the underlying mechanisms.

Material/Methods

Forty-five cervical biopsies at various pathological stages were subjected to atomic force microscopy (AFM) measurements. Cdc42 and collagen I were quantified using immunohistochemical staining to investigate their relationship with nanomechanical properties of cervical cancers and premalignant lesions.

Results

We found that the lower elasticity peaks (LEPs) in the high-grade squamous intraepithelial lesion (HSIL) group (21.24±3.83 kPa) and higher elasticity peaks (HEPs) in the cancer group (81.23±8.82 kPa) were upshifted compared with the control group (LEP at 8.51±0.18 kPa and HEP at 44.07±3.54 kPa). Furthermore, compared with the control [29.51±13.61 for cell division cycle 42 (Cdc42) expression and 28.61±17.65 for collagen I expression], immunohistochemical staining verified a significant increase of Cdc42 in the HSIL group (50.57±23.85) and collagen I (56.09±25.70) in the cancer group. In addition, using the Pearson correlation coefficient, Cdc42 expression tended to be positively correlated with LEP locations (r=0.63, P=0.012), while collagen I expression displayed a strong and positive correlation with HEP positions (r=0.88, P<0.001).

Conclusions

The nanomechanical properties of HSIL and cancer biopsies show unique features compared with controls, and these alterations are probably due to changes in cytoskeleton and extracellular matrix contents.

Initial observation of CIN2 does not appear to reduce quality of life in women under 25 years of age

BACKGROUND

Although the patient perspective is implicit in the practice of medicine, research evaluating this remains scarce. In a climate where clinicians and policy-makers constantly strive to achieve more patient-centred models of care, this omission warrants attention.

AIM

To assess health-related quality of life (HrQoL) in women under 25 years of age with cervical intra-epithelial neoplasia grade 2 (CIN2) receiving conservative management (colposcopy follow-up, with treatment if necessary) compared with those receiving immediate excisional treatment with large loop excision of the transformation zone (LLETZ).

METHODS

An observational study evaluating HrQoL was conducted at Christchurch Women's Hospital, New Zealand. Women undergoing conservative management for CIN2 were compared with those undergoing immediate excisional treatment in an age-matched sample. The Short Form Health Survey 12 version 2 (SF-12v2) was used to evaluate HrQoL. Secondary outcomes of anxiety and sexual function were also assessed.

RESULTS

One hundred and four women with CIN2 participated in the study. Of these, 63 (60%) received conservative management and 41 (40%) received immediate excisional treatment with LLETZ. We found no significant difference in HrQoL between the groups in a multivariate regression analysis adjusted for parity, smoking and socioeconomic status. There were also no significant differences in sexual function or anxiety.

CONCLUSION

We found no difference in HrQoL by management strategy. Conservative management of CIN2 in women under 25 is unlikely to have an adverse impact on self-reported HrQoL, anxiety or sexual functioning compared with conventional management.

Health economic evaluation of Human Papillomavirus vaccines in women from Venezuela by a lifetime Markov cohort model

Background

Cervical cancer (CC) and genital warts (GW) are a significant public health issue in Venezuela. Our objective was to assess the cost-effectiveness of the two available vaccines, bivalent and quadrivalent, against Human Papillomavirus (HPV) in Venezuelan girls in order to inform decision-makers.

Methods

A previously published Markov cohort model, informed by the best available evidence, was adapted to the Venezuelan context to evaluate the effects of vaccination on health and healthcare costs from the perspective of the healthcare payer in an 11-year-old girls cohort of 264,489. Costs and quality-adjusted life years (QALYs) were discounted at 5%. Eight scenarios were analyzed to depict the cost-effectiveness under alternative vaccine prices, exchange rates and dosing schemes. Deterministic and probabilistic sensitivity analyses were performed.

Results

Compared to screening only, the bivalent and quadrivalent vaccines were cost-saving in all scenarios, avoiding 2,310 and 2,143 deaths, 4,781 and 4,431 CCs up to 18,459 GW for the quadrivalent vaccine and gaining 4,486 and 4,395 discounted QALYs respectively. For both vaccines, the main determinants of variations in the incremental costs-effectiveness ratio after running deterministic and probabilistic sensitivity analyses were transition probabilities, vaccine and cancer-treatment costs and HPV 16 and 18 distribution in CC cases. When comparing vaccines, none of them was consistently more cost-effective than the other. In sensitivity analyses, for these comparisons, the main determinants were GW incidence, the level of cross-protection and, for some scenarios, vaccines costs.

Conclusions

Immunization with the bivalent or quadrivalent HPV vaccines showed to be cost-saving or cost-effective in Venezuela, falling below the threshold of one Gross Domestic Product (GDP) per capita (104,404 VEF) per QALY gained. Deterministic and probabilistic sensitivity analyses confirmed the robustness of these results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4064-7) contains supplementary material, which is available to authorized users.

Expression of Sialyl Lewis a, Sialyl Lewis x, Lewis y, Gal-3, Gal-7, STMN1 and p16 in cervical dysplasia

AIM

Cervical intraepithelial neoplasia (CIN) is commonly divided into three grades. Guidelines increasingly recommend surgery only in CIN 3 lesions. We investigated markers to evaluate differences in CIN 2 and 3 lesions as well as possible predictors for regression/progression in CIN 2 lesions.

MATERIALS & METHODS

Biopsies (n = 128) of healthy cervical tissue and CIN 1-3 were stained for Sialyl Lewis a, Sialyl Lewis x, Lewis y, Gal-3, Gal-7, STMN1 and p16.

RESULTS

We observed significant differences between CIN 2 and 3 lesions for Sialyl Lewis a, Sialyl Lewis x, Gal-3, Gal-7, STMN1 and p16. Expression of Sialyl Lewis a was significantly higher in CIN 2 patients who progressed during follow-up.

CONCLUSION

Significant differences in marker expression support the differentiation of CIN 2 and 3. Lewis a may help to predict progression/regression in CIN 2 patients.

Optimal cone size to predict positive surgical margins after cold knife conization (CKC) and the risk factors for residual disease

OBJECTIVE

To determine the optimal cone size to achieve a reliable sensitivity and specificity for clear surgical margins after cold knife conization (CKC).

MATERIAL AND METHODS

The medical reports of patients who had high-grade cervical intraepithelial lesions, carcinoma in situ, or stage 1A1 microinvasive carcinoma in their CKC specimens between June 2008 and January 2015 were reviewed retrospectively.

RESULTS

In total, 315 women fulfilled the inclusion criteria. The mean age of the patients was 40.7 years. The conization results were microinvasive carcinoma and high-grade squamous lesion (HSIL) for 8 and 307 patients, respectively. Ninety-nine patients had positive surgical margins. Eighty-one patients with positive cone margins underwent the repeat excisional procedure and 35 of them showed residual disease. In the univariate analyses, the patient age, menopausal status, and mean cone height parameters showed statistically significant differences between the patients with positive and negative margins. Also, residual disease was associated with the menopausal status and age of the patients.

CONCLUSION

There is no optimal cone depth that is applicable for all patients. The most important predictors for positive margins are the menopausal status of the patient and that more than two quadrants are involved. However, the menopausal status and age of the patients were still predictors for residual disease.

Recurrence of high-grade cervical abnormalities following conservative management of cervical intraepithelial neoplasia grade 2

OBJECTIVE

Conservative management of cervical intraepithelial neoplasia (CIN) grade 2 in women younger than 25 years may reduce overtreatment. However, long-term efficacy remains uncertain. This retrospective cohort study aimed to determine the rate of recurrence of high-grade abnormalities among young women with a history of CIN 2 that spontaneously regressed within 2 years and compare this with the rate of high-grade abnormality in similar women with an initial diagnosis of CIN 1.

STUDY DESIGN

We identified all women aged younger than 25 years who were diagnosed with CIN 1 or CIN 2 between January 2005 and August 2009 within 2 colposcopy units. Follow-up data from the National Cervical Screening Programme were obtained to identify those women who developed recurrent high-grade lesions before October 2012. Comparisons were made using Cox proportional hazards regression.

RESULTS

A total of 683 women were included: 106 with CIN 2 that spontaneously regressed, 299 with treated CIN 2, and 278 with conservatively managed CIN 1. Median follow-up was 4 years. There was no significant difference in the risk of development of high-grade abnormalities after 2 years between the spontaneously regressing CIN 2 and CIN 1 groups (P = .83). Women with treated CIN 2 had a significantly lower risk of recurrence than women with untreated CIN 2 (P = .01).

CONCLUSION

CIN 2 that has spontaneously regressed appears to behave as a low-grade lesion. This study contributes to the growing body of evidence that careful observation of CIN 2 is an efficacious and appropriate initial management option for women aged younger than 25 years at diagnosis.

Colposcopic management of abnormal cervical cytology and histology

OBJECTIVE

To provide a guideline for managing abnormal cytology results after screening for cervical cancer, to clarify the appropriate algorithms for follow-up after treatment, and to promote the best possible care for women while ensuring efficient use of available resources.

OUTCOMES

Women with abnormal cytology are at risk of developing cervical cancer; appropriate triage and treatment will reduce this risk. This guideline will facilitate implementation of common standards across Canada, moving away from the current trend of individual guidelines in each province and territory.

EVIDENCE

Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in October 2008 using appropriate controlled vocabulary (e.g., colposcopy, cervical dysplasia) and key words (e.g., colposcopy management, CIN, AGC, cervical dysplasia, LEEP, LLETZ, HPV testing, cervical dysplasia triage). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Expert opinion from published peer-reviewed literature and evidence from clinical trials is summarized. Consensus opinion is outlined when evidence is insufficient.

VALUES

The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1).

VALIDATION

This guideline has been reviewed for accuracy from content experts in cytology, pathology, and cervical screening programs. Guideline content was also compared with similar documents from other organizations including the American Society for Colposcopy and Cervical Pathology, the British Society for Colposcopy and Cervical Pathology, and the European Cancer Network.

Efficacy and safety of photodynamic therapy for cervical intraepithelial neoplasia: a systemic review

BACKGROUND

The current treatment of cervical intraepithelial neoplasia (CIN) is primarily based on surgical excision using laser, a loop electrosurgical procedure, or a cold knife technique. Unfortunately, these treatments often lead to obstetrical problems during the subsequent pregnancy, particularly in young women. Photodynamic therapy (PDT), which uses a topical or intravenous photosensitizer (PS) activated by a light source to ablate abnormal tissue, offers a minimally invasive alternative. The purpose of this study was to comprehensively assess the effectiveness and safety of PDT in the treatment of CIN.

METHODS

Following Cochrane guidelines, a comprehensive systematic review of all clinical studies and reports examining the use of PDT for CIN was conducted. Study quality was assessed using the Oxford Levels of Evidence Scale.

RESULTS

The 14 studies included two randomized control trials (RCTs), one case-control study, and 11 case series. Among the 506 patients studied, 472 were included to study the effectiveness of PDT on CIN and 10 were lost to follow-up. An assessment of clinical effectiveness included the response of the lesion to treatment (may include lesion recurrence) reported by all 14 studies. The complete response rate (CRR) of PDT on CIN ranged from 0% to 100%. HPV eradication rate (HER) was reported in seven studies, with rates ranging from 53.4% to 80.0%.

CONCLUSIONS

PDT is a safe and tolerable treatment for CIN. Evidence regarding the efficacy of PDT for CIN is conflicting, which may, in part, be explained by the limited number of controlled comparative clinical trials.

Post-cervical conization outcomes in patients with high-grade intraepithelial lesions

To investigate the rates of residual, recurrent and invasive disease after cervical conization in patients diagnosed with cervical intraepithelial neoplasia (CIN) grades 2/3. A retrospective study was conducted with 274 patients undergoing cervical conization due to diagnosis of CIN 2/3. Cervical conization was done through the Loop Electrosurgical Excision Procedure (LEEP) and Cold Knife Conization. Data related to personal, familial, gynecological, and obstetric antecedents, as well as surgical specimens margins were collected from medical records. The outcome after conization was evaluated, including the time of follow-up and disease recurrence. The outcome after conization was not associated with age of menarche (p = 0.920), age of the first sexual intercourse (p = 0.533), number of parturition (p = 0.063), number of sexual partners (p = 0.328), immunosuppression (p = 0.225), smoking habit (p = 0.193), and conization type (p = 0.198). However, the outcome presented a significant association with age (p < 0.001), pregnancy numbers (p = 0.009), use of hormonal contraception methods (p = 0.016), menopause (p = 0.007), type of margins (p = 0.011), and cone histological results (p = 0.030). The routine control of all patients who had undergone cervical conization is obligate, independently of surgical margins, due to the risk of disease recurrence; the older patients and those with CIN 3 should have a more rigorous follow-up.