Margin status and excision of cervical intraepithelial neoplasia: a review

LLETZ make it simple: Anxiety, pain and treatment outcomes with outpatient large loop excision of the transformation zone under local anaesthesia

BACKGROUND

Large loop excision of the transformation zone (LLETZ) is the preferred treatment for cervical intraepithelial neoplasia due to its effectiveness and ability to be performed in an outpatient setting under local anaesthesia (LA). Although current guidelines recommend that most LLETZ can be performed under LA, there is paucity in clinical data of patients' perspectives of outpatient LLETZ.

AIM

Determining patient acceptability of outpatient LLETZ through assessment of anxiety and pain scores, and comparing treatment outcomes with current standards in terms of margins status, negative histology, short-term morbidity rates and follow-up attendance.

MATERIALS AND METHODS

This study was conducted at a tertiary hospital over two years (2014-2016). Patients undergoing outpatient LLETZ completed a three-part questionnaire (before, immediately after and 4-6 weeks post-procedure).

RESULTS

One hundred and five patients underwent outpatient LLETZ. Mean pain score was 2 (range 0-8). Pre-procedure anxiety was common but most resolved post-procedure. Women who did not have a prior LLETZ discussion were more likely to report moderate-severe anxiety levels pre-procedure, compared with women who did (odds ratio 3.00, 95% CI 1.11-8.09, P = 0.030). There were no differences found in pain scores when comparing pre-procedure anxiety levels, prior discussion of LLETZ or mode of anaesthesia. Specimen margins were involved in 42.9%. No association was found between positive cervical margin status and age, pre-procedure anxiety or post-procedure pain scores. Most patients were satisfied and attended follow-up appointments.

CONCLUSION

Large loop excision of the transformation zone under LA is a well-tolerated procedure with high satisfaction and follow-up rates. Clinicians need to initiate early discussions regarding treatment to minimise procedure-related anxiety.

Outcome after Conization for Cervical Intraepithelial Neoplasia Grade III: Relation with Surgical Margins, Extension to the Crypts and Mitoses

Aims and Background

Factors linked to residual neoplasia and recurrence following conization of the uterine cervix for treating cervical intraepithelial neoplasia grade III (CIN III), such as the surgical margins, extension of CIN into the crypts and the number of mitoses, have been studied with contradictory results. We evaluated patients submitted to conization for CIN III and analyzed the aforementioned factors, relating them to recurrence and residual neoplasia in hysterectomy specimens.

Methods

The surgical specimen of cold-knife conization for CIN III performed in 63 patients (average age, 37.3 ± 9.3 years) was fixed in 4% formaldehyde. The ectocervical and endocervical margins were removed and the cone was cut into fragments perpendicular to the surface of the endocervical mucosa (1 mm thick). One histological section (5 μm thick) was cut from each block and stained with hematoxylin-eosin. We studied the total number of fragments from each cone and affected by CIN, endocervical and ectocervical margins, extension to the crypts, number of mitoses and tripolar mitoses in 100 microscope fields using a 100x objective.

Results

The endocervical margin was involved in 34.9% vs 9.5% (P = 0.001) of ectocervical margins. Recurrence affected 53.8% of cases presenting involved margins versus 12.9% in the cases without involved margins (P = 0.0078). The average interval to recurrence was 3.2 years. CIN was present in 2.5 to 100% (median, 28%) of the cone fragments (median no., 28; range, 7-95). A median of 44.4% and 25% of cone fragments presented CIN with and without recurrence, respectively. Correlation of the number of mitoses with tripolar mitoses and the percentage of fragments involved by CIN with the number of mitoses and tripolar mitoses showed, respectively, P = 0.02, 0.05 and 0.005. A median of 142 mitosis and 4 tripolar mitosis were observed per case with disease recurrence versus 104 and 3 (P = 0.02, 0.6), respectively, when recurrence did not occur. Of 14 patients who underwent hysterectomy after conization (mean, 3.6 ± 3 months afterwards) for endocervical or both margins involved by CIN in the cone specimen, 8 (57.1%) presented CIN III and one (7.1%) microinvasive carcinoma. In 96.8% of the conizations, the CIN extended to the crypts.

Conclusions

Involved margins and mitoses are associated with a greater recurrence rate for CIN. Residual neoplasia in the hysterectomy specimen after an involved margin with conization is frequent.

Factors That Influence Surgical Margin State in Patients Undergoing Cold Knife Conization - A Single Center Experience

AIM

To evaluate the factors that influence the surgical margin state in patients undergoing cold knife conization at the University Clinic of Gynecology and Obstetrics in Skopje, Republic of Macedonia Materials and methods: We have retrospectively analyzed the medical records of all patients that underwent a cold knife conization at our Clinic in 2015. We cross-referenced the surgical margin state with the histopathological diagnosis (LSIL, HSIL or micro-invasive/invasive cancer), menopausal status of the patients, number of pregnancies, surgeon experience, operating time and cone depth. The data was analyzed with the Chi square test, Fisher's exact test for categorical data and Student's T test for continuous data and univariate and multivariate logistical regressions were performed.

RESULTS

A total of 246 medical records have neen analyzed, out of which 29 (11.79%) patients had LSIL, 194 (78.86%) had HSIL and 23 (9.34%) patients suffered micro-invasive/invasive cervical cancer. The surgical margins were positive in 78 (31.7%) of the patients. The average age of the patients was 41.13 and 35 (14.23%) of the patients were menopausal. The multivariate logistic regression identified preoperative forceps biopsy of micro-invasive SCC, HSIL or higher cone specimen histology and shorter cone depth as independent predictors of surgical margin involvement in patients undergoing cold knife conization.

CONCLUSION

In the current study, we have found no association between the inherent characteristics of the patient and the surgeon and the surgical margin state after a CKC. The most important predictors for positive margins were the severity of the lesion and the cone depth.

Pap Smear Combined with HPV Testing: A Reasonable Tool for Women with High-grade Cervical Intraepithelial Neoplasia Treated by LEEP

BACKGROUND

To evaluate HPV testing by Hybrid Capture II (HCII) in conjunction with cytology in detecting the residual/recurrence disease after treatment of high-grade cervical intraepithelial neoplasia (CIN II-III) with loop electrosurgical excision procedure (LEEP).

MATERIALS AND METHODS

A retrospective review of 158 patients with histologically confirmed CIN II-III who underwent LEEP between January 2011 and October 2012 was conducted. Post-treatment control was scheduled at the 3rd, 6th, 12th and 18th month. All patients were followed up by Pap smear and HR-HPV genotype and viral load testing.

RESULTS

Pre-treatment, HR-HPV DNA, was detected in all specimens of the patients. At follow-up, 25 patients were diagnosed as the residual/recurrent disease during the FU visit, among whom, 16 patients with positive margin: 13 patients (52%) with HR-HPV DNA+/cytology+, 2 patients (8%) with HR-HPV DNA+/cytology-, 1 patient (4%) with cytology+/ HR-HPV DNA-; 9 patients with clean margin--5 patients (55.6%) with HR-HPV DNA+/cytology+; 2 patients (22.2%) with HR- HPV DNA+/cytology-, 2 patients (22.2%) with cytology+/HR-HPV DNA-. None of them persisting HR-HPV DNA-/cytology- with positive or negative margin was identified as the residual/recurrent disease. The majority of residual/recurrent disease was detected at the 12th and 18th month FU, and there was almost no difference in the sensitivity and negative predictive value (NPV) between at the 3rd month and the 6th month FU visits. 14 residual/recurrence disease (14/46:30.4%) had pre-treatment high viral load (>5,000 RUL/PC) and 11 (11/112, 9.8%) with pre-treatment low viral load, P<0.05.

CONCLUSIONS

(1) The persistence HR-HPV DNA is the root cause of the residual/recurrent disease for the women treated for high-grade CIN; the pre-treatment viral load and margin can be seen as the predictor. (2) The FU visit beginning at the 6th month post-treatment and lasting at least 24 months with the combination of cytology and HPV testing. (3) Patients with high pre-treatment HPV load, which is considered as one risk of developing the residual/recurrent disease, should be paid more attention (especially above 500 RUL/PC) to by clinicians.

Quality evaluation of cone biopsy specimens obtained by large loop excision of the transformation zone

Background

Large loop excision of the transformation zone (LLETZ) has been used for the diagnosis and treatment of precancerous cervical lesions, and it is the first choice of treatment in the majority of cervical pathology services. The aim of this study was to evaluate the presence of thermal artifacts, the need for serial sections, the percentage of clear and involved resection margins and the relationship between endocervical gland involvement and the severity of the lesion in samples resected using LLETZ.

Methods

A retrospective study was performed at Santa Casa de Misericordia School of Science (HSCMV), Vitoria, Espirito Santo, Brazil with a sample of 52 histopathology slides from patients submitted to conization because of abnormal cytology findings and a biopsy result of cervical intraepithelial neoplasia (CIN) 2, CIN 3 and adenocarcinoma in situ. Statistical analysis was performed using Student’s t-test.

Results

Serial sections were required to confirm diagnosis in four of 52 cases. Thermal artifacts were present in all cases, with grade I being the most common (94.2% of cases). Clear margins were found in 96.2% of cases. No association was found between glandular involvement and CIN 1 (P > 0.05); however, there was an association with CIN 2 and CIN 3 (P < 0.05).

Conclusion

The amount of excised tissue was sufficient, thermal artifacts were slight, resection margins were clear in most of cases, and a possible association was found between glandular involvement and the severity of the lesion.

Minimal cold knife conization height for high-grade cervical squamous intraepithelial lesion treatment

OBJECTIVES

To assess the relationship between cold-knife conization specimen height, cervical intraepithelial neoplasia (CIN II/III) size and endocervical margin involvement by CIN II/II.

STUDY DESIGN

A cross-sectional study was performed. Cold knife cone specimens with a diagnosis of CIN II/III were selected. Epidemiological data and pathology reports were obtained through a chart review. All samples from each cone specimen showing CIN II/III and the squamocolumnar junction were selected. Cone height (mean ± standard deviation), intraepithelial lesion size, and size of endocervical surgical margins were measured.

RESULTS

Four hundred and forty-seven samples were analyzed from 97 cone specimens. Section size ranged from 3.4 to 29.7 mm, tumor size from 0.3 to 17.5mm, and tumor distance from the endocervical margin, from 0.0 to 22.0mm. Age and parity were similar in the positive vs. negative margin groups (37.6 ± 10.0 years vs. 37.7 ± 11.9 years respectively, p=0.952, and 2.2 ± 1.7 births vs. 2.6 ± 1.9 births respectively, p=0.804), whereas cone height (22.4 ± 6.9 mm vs. 17.1 ± 5.6mm, p=0.013) and tumor size (6.12 ± 3.25 mm vs. 10.6 ± 4.45 mm, p<0.001) were significantly different in negative vs. positive margin groups respectively.

CONCLUSIONS

Use of cone height to identify the likelihood of negative margins enables better estimation of the risk-benefit ratio of greater risks of bleeding, stenosis, and obstetric complications (cervical incompetence) versus greater risks of residual and recurrent disease.

Risk factors for cervical intraepithelial neoplasia recurrence after conization: a 10-year study

OBJECTIVE

To evaluate the risk factors potentially involved in the development of cervical intraepithelial neoplasia (CIN) recurrence after cervical conization in a long-term follow-up period.

STUDY DESIGN

Consecutive patients with histologically proven CIN who had undergone either cold knife conization or a loop electrosurgical excision procedure were enrolled and scheduled for serial follow-up examinations over a 10-year period. Data were stored in a digital database. Multivariate analysis was performed to identify factors for recurrence.

RESULTS

Between January 1999 and December 2009, 282 patients fulfilled the inclusion criteria and were included in the final statistical analysis. After a median follow-up of 26.7 months (range 6-100), 64 (22.7%) women developed histologically confirmed recurrence. The 2-year recurrence-free survival was 83.7% and 66.7% for women with negative and positive margins, respectively (p=0.008). The 5-year recurrence-free survival was 75.4% and 50.3% for patients with negative and positive margins, respectively (p=0.0004). Positive surgical margin was the most important independent predictor of recurrence [HR 2.5 (95%CI 1.5-4.5), p=0.0007; Wald 11.338]. After multinomial logistic regression the indication for conization based on persistent CIN1 was the only independent predictor for negative margin [OR 0.3 (95%CI 0.1-0.7), p=0.008].

CONCLUSIONS

Our study demonstrated that the surgical margin status represents the most important predictor for CIN recurrence after conization. After excisional therapy, close follow-up is mandatory for the early detection of recurrent disease. The identification of risk factors for recurrence may guide clinical decision-making on expectant management versus re-intervention.

Number of fragments, margin status and thermal artifacts of conized specimens from LLETZ surgery to treat cervical intraepithelial neoplasia

CONTEXT AND OBJECTIVE

Large loop excision of the transformation zone (LLETZ) is a nontraumatic cut and coagulation method with several advantages, but it induces thermal artifacts in the cut region. The aim here was to assess the correlations of age, number of fragments, lesion grade and degree of thermal artifacts with margin quality in conized specimens from LLETZ for cervical intraepithelial neoplasia (CIN).

DESIGN AND SETTING

Cross-sectional study at Universidade Federal de São Paulo (Unifesp).

METHODS

The records and histopathology findings of 118 women who underwent LLETZ between 1999 and 2007 were reviewed. Age, number of fragments, lesion grade, degree of thermal artifacts and margin quality were assessed.

RESULTS

The patients' mean age was 27.14 years; 63.6% had been diagnosed with CIN II and 36.4% with CIN III. The lesion was removed as a single fragment in 79.6% of the cases. The margins were free from intraepithelial neoplasia in 85.6% and compromised in the endocervical margin in 6.8%. Fragment damage due to artifacts occurred in 2.5%. Severe artifacts occurred in 22.8%. Women aged 30 years or over presented more cases of CIN III (P < 0.0004). Neoplastic compromising of surgical margins and severe artifacts occurred more often in cases in which two or more fragments were removed, and in patients aged 30 years or over.

CONCLUSION

CIN III in women aged 30 or over, when removed in two or more fragments during LLETZ, presented a greater number of compromised margins and greater severity of thermal artifacts.

Multiple levels on LLETZ biopsies do not contribute to patient management

AIM

Cervical large loop excision of the transformation zone (LLETZ) specimens are performed both to treat and to diagnose or exclude cervical pre-neoplasia. Examination of these specimens forms a significant part of the routine histological work load of the pathologist, yet histological confirmation of squamous intraepithelial lesion (SIL) or completeness of excision, does not alter the treatment of SIL. When the LLETZ procedure is done, the treatment is complete, the dysplasia having been subject to excision as well as diathermy during the procedure.

METHOD

In this study, records of 1139 women who underwent LLETZ treatment for SIL were examined. The grade of SIL present and the margin status were extracted from histology reports and linked to post-LLETZ follow-up cytology and histology, for a period of 2 years.

RESULTS

SIL recurrence in women with high grade (HG-SIL), low grade SIL (LG-SIL) and normal LLETZ biopsy results was not significantly different. There was no significant difference between the recurrence rates of HG-SIL and LG-SIL with SIL at margins compared to SIL clear of margins.

DISCUSSION

Pathologists spend significant time examining multiple levels of LLETZ biopsies, grading SIL, determining margins and trying to find SIL in 'normal' LLETZ biopsies. None of this affects the subsequent follow-up. The most useful data the pathologist can provide is whether invasion is present or not. Pathological effort should be directed to examining multiple levels of those with HG-SIL to find invasion, rather than spending time looking at multiple levels of normal or LG-SIL LLETZ biopsies.

Follow-up of screening patients conservatively treated for cervical intraepithelial neoplasia grade 2–3

OBJECTIVES

To evaluate the frequency and correlates of non-adherence to follow-up among patients conservatively treated for CIN2-3.

STUDY DESIGN

Study population comprised 1560 patients aged 25-64 years from a screening programme in northern Italy. The regional standard protocol was used as a reference. Multinomial logistic regression analysis was used to estimate the odds ratio probability of a patient being lost to follow-up (no check-ups within 27 months of treatment) or incompletely followed-up (1-3 negative check-ups) versus having 4 negative check-ups.

RESULTS

Three hundred twenty-six patients (21%) were lost to follow-up, 678 (43%) were incompletely followed-up, 352 (23%) presented for 4 negative check-ups and 204 (13%) were diagnosed with persistent disease. The probability of no or incomplete follow-up was greater for patients who lived in the urban district, who were treated in private settings (versus screening centres), who exhibited a visibile squamocolumnar junction on pre-treatment colposcopy, who were treated with cold knife excision and local destructive therapy (versus loop diathermy excision), and whose surgical specimens had positive excision margins.

CONCLUSIONS

Adherence to the reference protocol was poor. Factors involved in follow-up failures require greater clinical attention.

High-grade squamous intraepithelial lesion (CIN 2 and 3) excised with negative margins by loop electrosurgical excision procedure: the significance of CIN 1 at the margins of excision

The significance of cervical intraepithelial neoplasia grades 2 or 3 (CIN 2-3) at the margin of a loop electrosurgical excision procedure (LEEP) specimen as a predictor of recurrent or persistent disease is relatively controversial. Most studies have found the presence of high-grade dysplasia at the margins in this setting to be an adverse parameter. However, the significance of an isolated finding of CIN 1 at the surgical margins of LEEP specimens has not been rigorously studied. Herein, we evaluate the significance of finding CIN 1 at one or more margins of a LEEP specimen when these margins are negative for CIN 2-3. Consecutive LEEP specimens with a CIN 2-3 diagnosis (and whose margins were negative for the latter) were retrieved, and their slides were reviewed. The cases were classified as to whether CIN 1 was present at the margins. Follow-up cytologic and histologic data were compared between patients with and without CIN 1 at the margin. For patients with multiple follow-up samples, only the most severe abnormality (1 sample per patient) was counted. Seventy-three cases were evaluated, with CIN 1 present at the margin in 59 (81%, group 1) and absent in 14 (19%, group 2). Follow-up cytologic information was available in 60 patients, with a median follow-up of 19 months. The cytologic follow-up of groups 1 and 2 patients were not significantly different regarding the diagnostic frequency of any one of the Bethesda 2001 diagnostic categories (P > .05 for all, Fisher exact and chi(2) tests). Of the 33 patients who received a cervical biopsy and/or endocervical curettage during the follow-up period, 29 belonged to group 1 and 4 to group 2. The distribution of "negative" CIN 1 and CIN 2-3 diagnoses for group 1 were 16 (55%) of 29, 7 (24%) of 29, and 6 (21%) of 29, respectively. Parallel figures for group 2 were 2 (50%) of 4, 2 (50%) of 4, and 0 (0%) of 4, respectively. Although CIN 2-3 was more frequent in group 1, none of the comparisons attained statistical significance. The current study is a small single-institution study, whose findings should not be extrapolated to cold-knife conizations, and need to be confirmed in larger data sets. However, our preliminary analysis suggests that the isolated presence of CIN 1 at the margin of a LEEP specimen, whose margins are otherwise negative, lacks adverse prognostic significance.

Dysplastic endocervical curettings: a predictor of cervical squamous cell carcinoma

OBJECTIVE

To identify parameters associated with the presence or development of invasive cervical cancer among patients who underwent cold knife conization (CKC) following loop electrocautery excision procedure (LEEP) revealing positive endocervical curettings for stage 3 cervical intraepithelial neoplasia (CIN III).

STUDY DESIGN

Patients who underwent CKC following LEEP with endocervical curettings indicating CIN III were observed retrospectively.

RESULTS

Of 146 patients identified, 133 (91.1%) had residual CIN on their cone biopsy; 23 (15.8%) had invasive cervical carcinoma. Patients with residual CIN III, ectocervical and endocervical margins with CIN, and positive endocervical curettings on cone biopsy were more likely to harbor or develop invasive cervical carcinoma.

CONCLUSION

Patients with CIN III on endocervical curettage at the time of LEEP procedure are at high risk for harboring residual cervical dysplasia or micros-invasive carcinoma, or developing carcinoma in the future. Residual CIN III, ectocervical or endocervical margins positive for CIN, and/or positive endocervical curettings on CKC subsequent to LEEP with positive endocervical curettings for CIN III all indicate a higher likelihood of harboring or developing cervical carcinoma.

Human Papillomavirus Testing Following Loop Electrosurgical Excision Procedure Identifies Women at Risk for Posttreatment Cervical Intraepithelial Neoplasia Grade 2 or 3 Disease

BACKGROUND

Loop electrosurgical excision procedure (LEEP) is the predominant treatment for cervical intraepithelial neoplasia grade 2 or 3 (CIN2+) in the United States, yet following treatment approximately 10% of women are diagnosed again with CIN2+, necessitating close follow-up of such patients.

METHODS

Surveillance strategies using cytology and/or human papillomavirus (HPV) testing were compared among women who underwent LEEP (n = 610) in the Atypical Squamous Cells of Undetermined Significance (ASCUS) Low-Grade Squamous Intraepithelial Lesion (LSIL) Triage Study. Cervical specimens, collected at 6-month visits for 2 years, were used for cytology, Hybrid Capture 2 (HC2) detection of carcinogenic HPVs, and PCR for genotyping of carcinogenic and noncarcinogenic HPV types. At exit, women had colposcopy for safety and disease ascertainment.

RESULTS

At the visit post-LEEP (median time: 4.5 months after LEEP), 36.9% [95% confidence interval (95% CI), 32.7-41.1%] of women were positive for carcinogenic HPV by PCR and 33.7% (95% CI, 29.7-37.9) had ASCUS or more severe (ASCUS+) cytology. The overall 2-year cumulative incidence of histologically confirmed posttreatment CIN2+ was 7.0%; this could be further stratified by the HPV risk category detected at the 6-month visit after LEEP. The 2-year risk associated with HPV16 positivity was 37.0%, significantly higher than for other carcinogenic HPV types (10.8%, P < 0.001), noncarcinogenic types (1.5%, P < 0.001), or testing HPV negative (0%). Post-LEEP cytology (using a positive threshold of ASCUS+) was 78.1% (95% CI, 60.0-90.7%) sensitive for detection of posttreatment CIN2+. By comparison, PCR for carcinogenic HPV and combination testing (using a positive result from carcinogenic HPV testing or cytology as the test threshold with HPV-negative ASCUS not referred) were significantly more sensitive (96.9% for each, P = 0.03); HC2 alone was nonsignificantly more sensitive (90.6%, P = 0.3). Specificity was similar for ASCUS+ cytology (69.1%, 95% CI, 64.6-73.3%) and PCR for carcinogenic HPV (67.1%, P = 0.5), yet was lower for HC2 (63.8%, P = 0.048) and combination testing (62.9%, P = 0.02).

CONCLUSION

Women who tested positive after LEEP for carcinogenic HPV types, especially HPV16, had high risk of subsequent CIN2+. HPV-based detection methods, alone or in combination with cytology, may be useful to incorporate in post-LEEP management strategies.

Management of cervical premalignant lesions

Management of cervical preneoplasia starts with an abnormal smear result. The use of the Bethesda system is recommended. The management of patients with low-grade abnormal smear results varies around the world. Patients with atypical squamous cells on cytology are recommended to be subclassified into atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells where high-grade squamous intra-epithelial lesions (HSIL) cannot be excluded (ASCH) groups. While patients with ASCUS can be followed with cytology or colposcopy, the risk of having cervical intra-epithelial neoplasia (CIN) is higher in patients with ASCH. Such patients, as well as those with low-grade squamous intra-epithelial lesions on cytology, should be referred for colposcopy to ensure that diagnosis and treatment in CIN is detected. Patients with HSIL should be referred promptly for colposcopic assessment. This should, usually at the same clinic visit, be followed by large loop excision of the transformation zone (LLETZ). Although this is effective treatment, around 15% of patients will have persistent/recurrent disease on cytological follow-up. Patients with positive human papillomavirus DNA tests at follow-up seem to have a considerably higher risk of recurrent preneoplasia than those who have negative tests. Patients over 50 years of age have much higher recurrence risks than younger patients. These factors impact on second-line treatment and follow-up schedules. An important benefit of conservative treatment for CIN with LLETZ is retention of fertility. LLETZ is associated with an increased risk of preterm prelabour rupture of membranes and preterm birth, but not with other adverse pregnancy outcome measures. Conservative excisional management of adenocarcinoma in situ by LLETZ or cold knife cone biopsy is not reported to be as effective as that of CIN, with high risk of residual and recurrent disease at follow-up. Conversely, LLETZ may be acceptable treatment for micro-invasive squamous carcinoma if the excision margins are free of disease and there is no evidence of lymphovascular involvement. The ability to detect and treat premalignant lesions on the cervix reversed the natural history of cervical cancer. Methods of conservative treatment that evolved over decades have been proven safe and effective, allowing retention of fertility. Good clinical guidelines have been developed for most clinical scenarios while some uncertainties persist for other scenarios.

Tools for Post LEEP Surveillance

Recurrences of cervical intraepithelial neoplasia (CIN) as well as invasive cervical carcinoma have been reported to arise following ablative or excisional treatment for cervical intraepithelial neoplasia. This review utilizes MEDLINE and National Library of Medicine's PubMed review of the various screening tools used in follow-up protocols for women treated by loop excision for CIN. Cervical cytology, colposcopy, endocervical curettage and HPV typing have been advocated for use as tools for follow up. Involvement of the surgical margins and the presence of HPV-DNA are associated with higher risks of recurrence and should be taken into consideration. The psychological impact of undergoing colposcopy may affect compliance with follow-up visits and should be dealt with appropriately.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the various tools that can be used for the surveillance of patients after treatment for CIN, to compare the advantages and disadvantages of each surveillance method, and summarize methods to improve compliance with follow-up.

HPV DNA test and Pap smear in detection of residual and recurrent disease following loop electrosurgical excision procedure of high-grade cervical intraepithelial neoplasia

OBJECTIVE

We compared the performance of cervical cytology and HPV DNA test in detection of residual or recurrent disease following the treatment of cervical intraepithelial neoplasia (CIN) 2/3 with loop electrosurgical excision procedure (LEEP).

SUBJECTS AND METHODS

A series of 107 women subjected to LEEP due to histologically confirmed CIN 2/3 between March 2001 and December 2002 were followed-up biannually until January 2004. Follow-up visits consisted of interview and gynecological examination including cervical cytology, hybrid capture II (HCII), and colposcopy. Patients presenting with abnormal colposcopy or high-grade squamous intraepithelial lesion (HSIL) smear were subjected to new excision procedure, and presence of histologically confirmed CIN 2/3 or higher was considered as residual or recurrent disease. Performance indicators were calculated for cytology and HCII assay in detecting residual or recurrent disease.

RESULTS

Eleven (10.2%) women showed residual or recurrent disease during the follow-up. Considering HCII and Pap smear as stand-alone tests, both techniques showed similar sensitivity, detecting 100% of CIN 2/3 at the first follow-up visit. At the second follow-up visit, Pap smear showed better specificity and positive predictive value (PPV) than HCII, and both tests had fairly the same high negative predictive value (NPV) and sensitivity. The combined positive HCII and abnormal cytology had the same sensitivity as each of the tests alone, but specificity and PPV were significantly higher than those of single tests. When only one of the tests was positive, the sensitivity and the NPV of the combination remained the same, but its specificity and PPV were lower than that of the combined two positive tests and that of the individual test, at both follow-up visits.

CONCLUSIONS

Both tests performed well in detecting residual or recurrent disease after LEEP and combination of the tests did not increase sensitivity of the single tests.

Frozen section examination of the endocervical margin of cervical conization specimens

OBJECTIVE

We conducted this retrospective study to determine accuracy of frozen section examination of endocervical margin during cold knife conization.

METHODS

Between June 1993 and June 2001, 310 consecutive patients underwent cervical conization for squamous intraepithelial lesion or stage IA1 cervical cancer. Before 1997, the surgical specimens of 149 patients were processed following a standard pathological procedure (historical group). After 1997, a frozen section of the upper endocervical margin was processed during surgery for 161 patients. If the upper endocervical margin was involved with intraepithelial neoplasia, the surgeon performed a second resection if possible. Results of the frozen section examination were compared with the final diagnoses to determine sensitivity, specificity, and positive and negative predictive values. The usefulness of this procedure was evaluated by comparison of positive margin status rate with the one of the historical control group.

RESULTS

For the diagnosis of intraepithelial neoplasia involving the endocervical margin, the sensitivity, specificity, and positive and negative predictive values of frozen section were 91%, 100%, 100%, and 98%, respectively. Eleven patients had definitive positive endocervical margin in the frozen section group (three false negatives, six patients without additional resection, and two patients with intraepithelial neoplasia involving the upper margin of the additional resection) and 17 patients in the historical group (P =.16).

CONCLUSION

Frozen section examination of the endocervical margin of cervical specimen obtained during cold knife conization is highly accurate. Its clinical relevance has to be demonstrated in a multicenter study.

Traditional management of invasive cervical cancer

Cervical carcinoma is staged clinically by examination and simple radiological procedures. CT and MRI can, however, be used to guide management. Prognosis is best made by tumor size. depth of invasion, parametrial involvement, nodal status, LVSI, and histology. CIN III and CIS can be treated by ablative or excisional procedures. Hysterectomy should not be the primary treatment. Microinvasive (<3 mm) Stage IA cervical carcinoma can be treated conservatively with conization in patients who desire fertility, but the standard of care remains simple hysterectomy. Stages IB and IIA can be treated with either radical hysterectomy or radiation therapy dependent upon the patient's health and preference. Risk factors after radical hysterectomy (eg, bulky tumors, deep invasion, involved nodes or margins. LVSI) might warrant adjuvant radiation therapy. Chemoirradiation is the current standard of care for treatment for Stages IIB, III, and [VA. Some clinicians also use this modality in patients with Stage IB disease who are undergoing radiation as the primary treatment. Locally recurrent disease can be treated with either radiation (after radical hysterectomy) or pelvic exeteration (after primary radiation therapy). Exenteration in appropriately selected patients yields 5-year survival rates up to 82% with low complication rates. Many exenterations are aborted intraoperatively because of distant or unresectable disease, however. The incidence of glandular carcinoma of the cervix is rising, particularly in younger women. Cervical carcinoma detected during pregnancy requires the combined efforts of the gynecologic oncologist and the maternal-fetal medical specialist to determine the timing and method of treatment.

Disease persistence in patients with cervical intraepithelial neoplasia undergoing electrosurgical conization

OBJECTIVE

Cone margin status has been reported to be the most important predictor of residual disease in patients with cervical intraepithelial neoplasia (CIN) undergoing electrosurgical excisional treatment. The primary aim of this study of patients treated with electrosurgical conization was to evaluate the association of cone margin status and other clinical and pathologic factors with the probability of residual disease.

METHODS

The study population comprised 699 patients with at least one follow-up visit within 12 months of conization. Residual disease was defined as a histology diagnosis of CIN within 3 years of conization. Multivariate associations were evaluated with multiple logistic regression analysis.

RESULTS

Attendance to follow-up was 97% for the second visit and 34% for the third visit. Residual disease was detected in a total of 38 patients (5.4%). The detection rate was 3.3% at the first visit, 2.1% at the second visit, and 0.4% at the third visit. An increased probability of residual disease was associated with a referral Pap smear reported as high-grade squamous intraepithelial neoplasia and carcinoma (odds ratio, 2.9; reference category, low-grade squamous intraepithelial neoplasia). A decreased probability was associated with a squamocolumnar junction entirely visible at the first follow-up visit (odds ratio, 0.2; reference category, squamocolumnar junction not visible). Patient age, time period, lesion size, lesion site, grade of CIN, cone width, cone depth, and margin status had no influence.

CONCLUSIONS

The determinants of residual disease in this study differed from those generally reported so far. Factors associated with effectiveness of electrosurgical treatment of CIN need further research.

Management of adenocarcinoma in situ, micro-invasive, and early stage adenocarcinoma of the cervix

The incidence of glandular neoplasms of the uterine cervix has been steadily increasing over the past two decades. Given the fact that these lesions are more difficult to diagnosis and are relatively infrequent, less is known about them compared with their squamous counterparts. In addition, because these lesions tend to arise in women of childbearing age, there is a particular need to understand whether the in-situ and early invasive forms of adenocarcinoma are amenable to conservative treatment measures that spare fertility like their squamous counterparts. Recent publications have addressed the underlying causes of the increasing incidence, the pros and cons of conservative management, and the difficulties in definitively identifying each glandular subtype. The most difficult diagnostic lesions are adenocarcinoma in situ cases and early invasive adenocarcinomas.

Cervical adenocarcinoma in situ: a systematic review of therapeutic options and predictors of persistent or recurrent disease

The incidence of cervical adenocarcinoma in situ is increasing in frequency, and our limited knowledge about this lesion presents the physician with a therapeutic dilemma. Treatment for this lesion has included conservative therapy, large loop excision or cold-knife cone biopsy, or definitive therapy consisting of hysterectomy. But, rates of residual adenocarcinoma in situ after cone biopsy with negative margins vary from 0% to 40%, and residual disease rates as high as 80% have been noted when the margins are positive. Despite these recent data on follow-up after conservative therapy such as cone biopsy, it seems that this method is safe and gaining acceptance by many physicians and patients. However, the short follow-up duration and small number of patients limit the conclusions of many studies. The relative infrequency of this diagnosis has precluded extensive clinical experience with the natural history of this lesion.

Aminolevulinic acid: pharmacological profile and clinical indication

The role of aminolevulinic acid hydrochloride (ALA) in photodynamic therapy (PDT) of in situ neoplasias and tumours of epithelial tumours is steadily increasing and it has been shown to be the drug with most clinical use in PDT. In dermatology, topical PDT with ALA is already postulated to be the treatment of choice for actinic keratoses and superficial basal cell carcinomas. In gastroenterology, pulmonology, uro- and nephrology, neurology and gynaecology ALA has an important role as a photosensitiser not only in the diagnosis of neoplastic tissue but as therapy; first experiences have been made with PDT in these organs. Besides the therapeutic efficacy of this technique, the fluorescence of ALA-induced porphyrins can be effectively used to detect and delineate epithelial and endothelial neoplasms. In dermatology, other indications for ALA-treatment are non-tumoural applications, especially psoriasis, viral-induced diseases, or acne vulgaris. ALA is an effective compound in the diagnosis or therapy of various epithelial and endothelial neoplastic lesions.

Migraine and beyond: cardiovascular therapeutic potential for CGRP modulators

CGRP is a potent vasodilator that has been shown to have a physiological and/or pathological role in neurogenic inflammation, headaches including migraine, thermal injury, circulatory shock, pregnancy and menopause, hypertension and heart failure and is known to be cardioprotective. CGRP is also a positive inotrope and increases heart rate. Clinical trials have shown beneficial effects of the vasodilatory action of CGRP in hypertension, angina, heart failure, Raynaud's disease and venous stasis ulcers. However, the clinical potential of CGRP is limited as it has to be given by infusion and is quickly broken down. Oral long acting CGRP-mimetics may have potential in disorders in which CGRP has been shown to be beneficial. CGRP-mimetics include capsaicin/vanilloid receptor agonists and gene transfer of an adenoviral vector that encodes prepro-CGRP. CGRP inhibitors have therapeutic potential in conditions in which excessive CGRP-mediated vasodilatation is present; neurogenic inflammation, migraine and other headaches, thermal injury, circulatory shock and flushing in menopause. CGRP inhibitors include capsaicin, antagonists at capsaicin/vanilloid receptors, civamide, CGRP receptor antagonists and 5-HT1D-receptor agonists. Drugs that are 5-HT1D-receptor agonists, the 'triptans' are already commonly used in migraine and the first small molecule CGRP antagonist, BIBN4096BS, is under clinical investigation for the treatment of migraine.