Recurrent high-grade cervical lesion after primary conization is associated with persistent human papillomavirus infection in Norway

Treatment characteristics, HPV genotype distribution and risk of subsequent disease among women with high-grade cervical intraepithelial neoplasia in Europe: A systematic literature review

INTRODUCTION

High-grade cervical intraepithelial neoplasia (CIN), a premalignant lesion of the uterine cervix, is caused by persistent Human Papillomavirus (HPV) infection. CIN can be identified through screening programs and high-grade CIN is usually treated by ablation or excision. This study aimed to summarize the clinical management and outcomes among women with high-grade CIN in Europe.

METHODS

A systematic literature review was conducted to identify treatment methods and their frequency of use, report HPV genotype prevalence and distribution and summarize patterns for subsequent lesions after primary treatment, among women with high-grade CIN in Europe. Embase®, MEDLINE® and Cochrane databases were searched (1st January 2012 to 30th August 2022), along with relevant conference proceedings (2018-2022), inclusive. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant methodology was adopted. Eligibility criteria included non-immunosuppressed female patients with CIN2+ from Europe (published in English).

RESULTS

In total, n = 55 studies were included. CIN excisional therapy was the most received treatment approach (15.8-100 %, loop electrosurgical excision procedure/large loop excision of the transformation zone most common), followed by ablative therapies (1-43.3 %, cold coagulation most common). Other approaches included 'wait and watch' (4.8-52.6 %) and hysterectomy (4.8-16.2 %). HPV positivity rates ranged from 67.8-100 % pre-conization and 4.7-32.8 % post-conization. The most prevalent HPV genotypes reported (both pre- and post-treatment) were HPV16 and HPV18. In patients who received excisional or ablative procedures subsequent CIN was most frequently diagnosed ≤6 months after treatment. The overall rate of subsequent CIN reported was 0.5-20.9 %.

CONCLUSION

Conization and ablation were the most common techniques, however, these procedures were associated with sub-optimal outcomes. Close clinical follow-up is important due to the risk of subsequent CIN or invasive cancer. This review serves as a reference point for the comparison of future treatment patterns as they evolve across Europe, following improved implementation of prophylactic HPV vaccination and screening.

Safety, Efficacy, and Immunogenicity of Therapeutic Vaccines for Patients with High-Grade Cervical Intraepithelial Neoplasia (CIN 2/3) Associated with Human Papillomavirus: A Systematic Review

Despite the knowledge that HPV is responsible for high-grade CIN and cervical cancer, little is known about the use of therapeutic vaccines as a treatment. We aimed to synthesize and critically evaluate the evidence from clinical trials on the safety, efficacy, and immunogenicity of therapeutic vaccines in the treatment of patients with high-grade CIN associated with HPV. A systematic review of clinical trials adhering to the PRISMA 2020 statement in MEDLINE/PubMed, Embase, CENTRAL Cochrane, Web of Science, Scopus, and LILACS was undertaken, with no data or language restrictions. Primary endpoints related to the safety, efficacy, and immunogenicity of these vaccines were assessed by reviewing the adverse/toxic effects associated with the therapeutic vaccine administration via histopathological regression of the lesion and/or regression of the lesion size and via viral clearance and through the immunological response of individuals who received treatment compared to those who did not or before and after receiving the vaccine, respectively. A total of 1184 studies were identified, and 16 met all the criteria. Overall, the therapeutic vaccines were heterogeneous regarding their formulation, dose, intervention protocol, and routes of administration, making a meta-analysis unfeasible. In most studies (n = 15), the vaccines were safe and well tolerated, with clinical efficacy regarding the lesions and histopathological regression or viral clearance. In addition, eleven studies showed favorable immunological responses against HPV, and seven studies showed a positive correlation between immunogenicity and the clinical response, indicating promising results that should be further investigated. In summary, therapeutic vaccines, although urgently needed to avoid progression of CIN 2/3 patients, still present sparse data, requiring greater investments in a well-designed phase III RCT.

A study on the correlation between the prognosis of HPV infection and lesion recurrence after cervical conization

Introduction

Persistent human papillomavirus infection is an important factor in the development of cervical cancer, which is usually a long process evolving from the development of squamous intraepithelial lesions (SIL), also referred to as cervical intraepithelial neoplasia (CIN). Local treatment of advanced squamous intraepithelial lesions, also regarded as High-Grade Squamous Intraepithelial Lesion, may be effective in preventing cancer.

Objective

To promptly identify high-risk patients with a tendency to recurrence.

Methods

We retrospectively analyzed the clinical data of 300 patients with high-grade squamous intraepithelial lesions of the cervix admitted to the Second Affiliated Hospital of Dalian Medical University from 2019 to 2020 to investigate the relationship between recurrence of cervical lesions and postoperative regression of HPV infection, as well as other related risk factors.

Results

We found that the HPV-negative rates were 81.81, 85.71, and 90.91% at 6, 12, and 24 months, respectively, and the average lesion recurrence rate was 8.16%, with a median time to recurrence of 14 months in patients undergoing CKC for HSIL. The risk of cervical squamous intraepithelial lesions was highest in patients with HPV16. Patients over 61 years of age had the lowest postoperative HPV-negative rate. The conversion rate was significantly lower in patients with multiple HPV genotypes than in those with single HPV infection (p < 0.05). The probability of recurrence was higher in patients with the same HPV infection genotype before and after surgery than in patients with different infection genotypes before and after surgery (p < 0.05).

Conclusion

Combined with the literature review, we believe that patients aged ≥50 years, with ≥3 pregnancies and births, a history of smoking, and consistent genotypes of preoperative and postoperative HPV infection in cervical conization have more HPV re-infection or persistent infection, and that these factors may be high-risk factors for lesion recurrence. For patients with possible potential high-risk factors, we need to carry out individualized follow-up and focused management, take timely and effective management measures, optimize the treatment plan, reduce the recurrence rate, prevent HSIL and cervical cancer, improve the quality of patient's survival, and improve the prognosis.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The prevalence and genotype distribution of human papillomavirus among women in Guangxi, southern China

Background

Human papillomavirus is a primary cause of cervical cancer and genital warts. HPV vaccine can prevent high-grade cervical lesions as well as cervical cancer. The aim of this study was to analyze the prevalence and genotype distribution of human papillomavirus among women in Guangxi before and after the HPV vaccine was approved for use in China.

Methods

From January 2016 to May 2021, 41,140 women were tested for HPV infection. HPV genotyping included 15 high-risk HPV (HR-HPV) and 6 low-risk HPV (LR-HPV) genotypes. Total prevalence, annual trend, and specific age group prevalence and genotype distribution were analyzed.

Results

The overall HPV infection rate was 18.10% among Guangxi women self-referred to clinic for gynecologic problems in southern China. During 2016–2018, the prevalence of HPV infection showed an upward trend, from 18.21% in 2016 to 21.99% in 2018, and later it showed a downward trend, from 18.35% in 2019 to 12.26% in May 2021. Pure HR-HPV genotypes (14.36%) were found in more infections than pure LR-HPV genotypes (2.77%) and mixed genotypes (0.97%). Two peaks of HPV infection were found in the ≤ 25 years (22.94%) and 56–65 years (21.25%) groups. The six most prevalent HR-HPV genotypes were HPV 52 (4.06%), 16 (2.70%), 58 (2.24%), 51 (1.87%), 39 (1.52%), and 53 (1.52%). The three most prevalent LR-HPV genotypes were HPV 6 (1.31%), CP8304 (1.01%), and 11 (0.82%). Infection with a single HR-HPV genotype was the most common type of infection, with an overall infection rate of 12.30%. Infection with two HPV genotypes was the most common multiple HR-HPV infection type, with an infection rate of 2.35%.

Conclusions

The cervical HPV infection rate of women in Guangxi is very high, and there is significant age specificity. There is a need to increase HPV vaccination of young people and the screening of middle-aged and elderly people.

Clearance of HR-HPV within one year after focused ultrasound or loop electrosurgical excision procedure in patients with HSIL under 30

OBJECTIVE

To compare the clearance rate of high-risk human papillomavirus (HR-HPV) in patients with a high-grade squamous intraepithelial lesion (HSIL) 12 months after focused ultrasound (FUS) or loop electrosurgical excision procedure (LEEP), and analyze the influencing factors.

METHODS

A retrospective cohort was established in HSIL patients with HR-HPV infection treated with FUS or LEEP from 2015 to 2019. The cohort consisted of 321 patients under 30 years of age, of which 119 patients received FUS and 202 patients received LEEP. The Cox regression model was used to identify the influencing factors for HR-HPV clearance. Kaplan-Meier method was applied to estimate the efficacy of FUS and LEEP in HR-HPV clearance, and the log-rank test was used to compare the efficacy difference between FUS and LEEP.

RESULTS

Multivariate Cox regression analysis showed that both FUS and LEEP were independent influencing factors for HR-HPV clearance. HR-HPV cleared faster in the FUS group than in the LEEP group [the median time to HR-HPV clearance: 6 months in the FUS group (95% CI: 5.492-6.508) and 6 months in the LEEP group (95% CI: 5.734-6.266), p = 0.021]. The HR-HPV clearance rates at 6 and 12 months were 54.6% and 94.1% respectively in the FUS group, and 50.5% and 79. 2%, respectively in the LEEP group (p = 0.001 at 6 months, p = 0.000 at 12 months).

CONCLUSIONS

For HPV-positive HSIL patients under 30, FUS had a better HR-HPV clearance effect than LEEP 1 year after treatment. FUS may be a viable modality for the treatment of young HSIL patients.

Is large loop excision of the transformation zone depth a risk factor for affected endocervical margins?

OBJECTIVE

The aim of the study was to determine if the depth of large loop excision of the transformation zone (LLETZ) is a risk factor for presenting affected endocervical margins.

METHODS

A cross-sectional retrospective study was performed on 353 patients that underwent LLETZ after presenting cervical biopsies with CIN grade 2 and grade 3 or persistent CIN grade 1 at Hospital Universitario Santa Lucía, Cartagena, Spain, from November 2011 to December 2016. Automatized measurement of the LLETZ depth was performed in microns and added to cervical canal extensions when these were performed. Other variables studied in positive endocervical margins were age (under or over 35 years), premenopause/postmenopause, number of affected quadrants, CIN grading, the presence of HPV 16 before LLETZ, parity (nulliparous vs multiparous) and the location where the LLETZ was performed (operating room vs consultation room).

RESULTS

Our multivariant analysis showed that LLETZ depth ≤ 10 mm did not increase the risk in affected endocervical margins (P = 0.366) and no statistically significant difference between the two groups (affected and nonaffected margins) was found. CIN grading and parity did prove a statistically significant association (P = 0.039 and P = 0.011, respectively). Age, menopause, number of affected quadrants, HPV 16 and the location did not show statistical association with positive endocervix margins.

CONCLUSIONS

LLETZ depth equal to or lower than 10 mm was not proven to be a risk factor to have affected endocervical margins after the treatment. Therefore, higher LLETZ depth would not be justified to ensure oncological results.

Human papillomavirus type specific risk of progression and remission during long-term follow-up of equivocal and low-grade HPV-positive cervical smears

The prevalence of clinically relevant HPV types and their specific risk for progression and regression in women with atypical squamous cells of uncertain significance (ASCUS) and low-grade squamous intraepithelial lesions (LSIL) were studied in a routine screening population. A 4-year cohort of women (n = 820) with ASCUS/LSIL and a positive HPV test in triage were followed for 6-9 years. The progression risks for CIN2+/CIN3+ were determined for single (71.2%) and multiple HPV infections (28.8%). The CIN2+ progression risk for all HPV 16, all HPV 35, single HPV 16 and single HPV 35 infections were 65.3% (95% CI: 59.6-71.0), 64.4% (95% CI: 50.4-78.4), 63.8% (95% CI: 56.2-71.4) and 73.7% (95% CI: 53.9-93.5), respectively. Based on CIN2+ progression risks four main groups were defined; the HPV 16 group, the HPV 31/33/35 group, the HPV 18/45/51/52 group and the HPV 39/56/58/59/66/68 group with progression risks of 65.3% (95% CI: 59.6-71.0), 62.1% (95% CI: 54.8-69.4), 52.6 (95% CI: 45.9-59.3) and 39.5 (95% CI: 33.0-46.0), respectively. In multivariate analyses, women in the age group 40-49 years had an increased risk of CIN2+ progression. As for CIN3+, HPV 16 had a higher progression risk than other HPV risk groups (p < 0.05). In multiple infections only HPV 16 had a significant additive CIN3+ progression risk (p < 0.05) as compared to other HPV risk groups. In summary, HPV types 16 and 35, including the HPV risk group 31/33/35, had a similar CIN2+ progression risk, but only HPV 16 had a higher risk for CIN3+ progression.

The Value of Partial HPV Genotyping After Conization of Cervical Dysplasias

INTRODUCTION

In this retrospective study partial genotyping of human papilloma viruses (HPV) using the Abbott RealTime HighRisk HPV Test (RealTime) was compared with simple HPV detection (Qiagen Hybrid Capture 2 Test; hc2) for recurrence prediction at the first follow-up examination after conization of cervical intraepithelial neoplasia (CIN).

METHODS

144 women who had undergone conization for CIN between January 2007 and December 2013 were included. HPV status was determined preoperatively and at first follow-up using hc2 in 103 women and RealTime in 41 women. Recurrent or persistent CIN was assumed when CIN2+ was confirmed histologically or on comparable cytology findings.

RESULTS

Of the 144 women with complete data 12 (8.3%) had a recurrence after conization. HPV persistence at follow-up correlated significantly with recurrence (hc2: p = 0.003; RealTime: p = 0.003) and both sensitivity and specificity were high (hc2 = 100 and 78.4% respectively; RealTime = 75.0 and 83.9%). Whereas isolated HPV testing had a relatively low positive predictive value for recurrence (hc2 16%; RealTime 54.5%), this rose to 80% with HPV 16 detection at follow-up.

CONCLUSION

At follow-up after conization of CIN the combination of high risk HPV detection and partial genotyping of HPV 16 constitutes excellent diagnostic criteria for recurrence/persistence of CIN.

Predictors for recurrent/persistent high-grade intraepithelial lesions and cervical stenosis after therapeutic conization: a retrospective analysis of 522 cases

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.

HPV-Testing in Follow-up of Patients Treated for CIN2+ Lesions

Persistent positivity of HPV-DNA testing is considered a prognostic index of recurrent disease in patients treated for CIN2+. HPV detection, and particularly genotyping, has an adequate high rate of sensitivity and specificity (along with an optimal reproducibility), for accurately predicting treatment failure, allowing for an intensified monitoring activity. Conversely, women with a negative HPV-test 6 months after therapy have a very low risk for residual/recurrent disease, which leads to a more individualized follow-up schedule, allowing for a gradual return to the normal screening scheme. HPV testing should be routinely included (with or without cytology) in post-treatment follow-up of CIN2+ patients for early detection of recurrence and cancer progression. HPV genotyping methods, as a biological indicator of persistent disease, could be more suitable for a predictive role and risk stratification (particularly in the case of HPV 16/18 persistence) than pooled HPV-based testing. However, it is necessary to be aware of the performance of the system, adhering to strict standardization of the process and quality assurance criteria.