Tools for Post LEEP Surveillance

Outcomes of Laser Conization for Cervical Intraepithelial Neoplasia 2-3 and Microinvasive Cervical Cancer

Background

Currently, there is no standardized follow-up protocol for patients who undergo laser conization. Therefore, we retrospectively investigated the clinical outcomes of laser conization in patients with high-grade cervical intraepithelial neoplasia 2-3 (CIN 2-3) and microinvasive squamous cell carcinoma and assessed the risks of residual and recurrent lesions of the cervix uteri.

Methods

The medical and pathological records of 91 patients with CIN 2, 580 with CIN 3 and 73 with microinvasive cervical cancer (MIC) who underwent laser conization between January 2000 and December 2011 were retrospectively reviewed.

Results

Positive margins increased with the extent of disease and were observed in 5.5%, 8.9% and 16.4% patients with CIN 2, CIN 3 and MIC, respectively, while residual or recurrent disease was observed in 0%, 3.2% and 13.6% patients, respectively. Examination of specimens obtained through postconization biopsy or hysterectomy revealed that 1.5% and 20% patients with negative and positive margins, respectively, were diagnosed with residual or recurrent lesions. Among patients who were conservatively managed after conization, seven with CIN 3 exhibited residual or recurrent disease, as evidenced by abnormal cytological findings, within 2 years after conization.

Conclusions

Continuous follow-up by cytology and colposcopy, particularly during the first 2 years after conization, can effectively detect early residual or recurrent disease in CIN 3 and MIC patients, regardless of their margin status.

Cytological follow-up of women older than 50 years with high-grade cervical smear treated by large loop excision

OBJECTIVE

To evaluate cytological surveillance for women older than 50 years, to detect recurrent or residual disease after treatment of cervical intraepithelial neoplasia by loop excision.

MATERIALS AND METHODS

Women undergoing a large loop excision for high-grade squamous intraepithelial lesion or glandular cytological abnormalities during a period of 4 years (2000-2003) were identified from the colposcopy database. Women younger than 50 years or with a history of previous loop excision were excluded. Clinical data, histology, and follow-up cytology results for up to 2 years after treatment were collected.

RESULTS

Eighty-nine patients were identified. Age of the women ranged from 51 to 66 years, with a median of 51.5 years. Thirty-two (36%) had severe dyskaryosis, 53 (60%) had moderate dyskaryosis, and 4 (4%) had glandular abnormalities on cervical cytology before the loop biopsy. Cervical intraepithelial neoplasia (CIN) 2,3 and glandular abnormalities, CIN 1, and no abnormalities were found in 50 (56%), 18 (20%), and 19 (22%) loop specimens, respectively. Invasive disease was found in 2 (2%) cases. They were excluded from further analysis. The lesion was completely excised in 58 (65%) and incompletely excised in 23 (26%) patients. It was not possible to comment on the margin status in 8 (9%) cases. These were excluded from further analysis. Of the 23 women who had margins involved, 8 (35%) had ectocervical, 12 (52%) had endocervical, and 3 (13%) had both margins involved. All women had follow-up cervical smears at the cytology clinic. At 6-month follow-up, 3 patients had persistent CIN and 4 had borderline changes on cervical smears. At 2 years follow-up, 3 patients had high-grade squamous intraepithelial lesion abnormalities, 2 of whom had clear margins at their loop biopsy earlier.Twenty percent of the women with positive endocervical margins on loop excision needed further treatment for residual or persistent disease on follow-up. Overall, 4 (5%) of the 79 patients who had a loop biopsy went on to have cytological abnormalities suggestive of persistent/residual disease needing further treatment.

CONCLUSION

Cytological surveillance for post-loop biopsy follow-up seems to be a good option for detecting residual disease in this high-risk group of patients.

Prediction of recurrent disease by cytology and HPV testing after treatment of cervical intraepithelial neoplasia

OBJECTIVE

To assess the role of human papillomavirus (HPV) testing and cytology as predictors of residual/recurrent disease after treatment of high-grade cervical intraepithelial lesions.

METHODS

One hundred and thirty-eight women with cervical intraepithelial neoplasia (CIN) grade 2/3 lesion on biopsy were included in a prospective follow-up study in Belgium and Nicaragua. All women were treated with loop electrosurgical excision procedure (LEEP) and follow-up visits took place at 6 weeks, 6 months, 1 year and 2 years. During these visits, a Papanicolaou (Pap) smear test was taken, colposcopy was performed and specimens were collected for HPV testing. Cytology, high-risk (HR) HPV presence, persistent HR HPV infection and combinations of these tests at different time points during follow-up were correlated with histologically confirmed residual/recurrent disease.

RESULTS

Thirteen patients (9%) developed residual/recurrent disease during follow-up. Abnormal cytology at 6 weeks after treatment was significantly correlated with residual/recurrent disease. Nine of thirty-seven patients with abnormal cytology at 6 weeks had recurrent disease versus three of seventy with a normal cytology [odds ratio (OR): 7.2; 95% confidence interval (CI): 1.8-28.5; P = 0.003). Sensitivity of this test was 75.0%, specificity 70.5%. Combining abnormal cytology and the presence of HR HPV within the first 6 months after treatment gave the best correlation with residual/recurrent disease: of the 54 women with abnormal cytology and/or HR HPV presence within the first 6 months, 11 developed residual/recurrent disease (OR 10.2; 95% CI: 2.2-48.3). Sensitivity of this combination was 84.6% and specificity 65.0%.

CONCLUSION

Cytology remains the cornerstone in the early follow-up after LEEP for CIN lesions of the cervix. HPV testing can add value as it increases the sensitivity of cytology in concomitant testing within the first 6 months.

PCR detection rates of high risk human papillomavirus DNA in paired self-collected urine and cervical scrapes after laser CO2 conization for high-grade cervical intraepithelial neoplasia

OBJECTIVE

To compare the PCR detection rates of high risk human papillomavirus DNA in self-collected urine and cervical scrapes during follow-up of patients treated for HG-CIN by laser CO2 conization.

PATIENTS AND METHODS

52 women who submitted to laser conization for HG-CIN were enrolled into this prospective follow-up study receiving liquid-based cytology and HR-HPV testing by PCR assay on self-collected urine and cervical scrapes before and at 3, 6 and 12 months after treatment. Diagnostic accuracy and predictive values for treatment failure were evaluated for both urinary and cervical HPV testing and follow-up cytology.

RESULTS

3 cases (5.8%) of recurrent HG-CIN occurred during follow-up. Positive margins and HR-HPV persistence resulted to significant risk factors for recurrence (p=0.01). The overall concordance on HR-HPV detection between paired urine and cervical samples was 96.6% and discord trend between agreement rates during follow-up were excluded by overall fixed-effect index (OR 1.03; 95% CI 0.62-1.70). No difference was observed comparing the three- and six-month cumulative sensitivity and NPV for recurrent disease of urinary and cervical HPV detections, with an increase of 5.6% in specificity associated with urinary testing.

CONCLUSIONS

PCR detection of HR-HPV in paired urine and cervical samples during follow-up revealed an excellent concordance, suggesting a potential equivalent role of the two methods within post-treatment follow-up. In our experience HPV testing on self-collected urine was more sensitive than cytology and more specific than cervical HPV detection to predict treatment failure. Larger studies are needed to definitively establish the role of urine-based HPV testing during follow-up.

2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ

OBJECTIVE

To provide updated consensus guidelines for the management of women with cervical intraepithelial neoplasia (CIN) or adenocarcinoma in situ (AIS).

PARTICIPANTS

A group of 146 experts including representatives from 29 professional organizations, federal agencies, and national and international health organizations met on September 18-19, 2006, in Bethesda, MD, to develop the guidelines. MAJOR CHANGES IN THE GUIDELINES: The management of women with CIN grade 1 (CIN 1) has been modified significantly. In the earlier guidelines, management depended on whether the colposcopic examination was satisfactory and treatment using ablative or excisional methods was acceptable for women with CIN 1. In the new guidelines, cytological follow-up is the only recommended management option, regardless of whether the colposcopic examination is satisfactory, for women with CIN 1 who have a low-grade referral cervical cytology. Treatment of CIN 1 is particularly discouraged in adolescents. The basic management of women in the general population with CIN 2,3 underwent only minor modifications, but options for the conservative management of adolescents with CIN 2,3 have been expanded. Moreover, management recommendations for women with biopsy-confirmed AIS are now included.

CONCLUSION

Updated evidenced-based guidelines have been developed for the management of women with CIN or AIS. These guidelines reflect recent changes in our understanding of human papillomavirus-associated diseases of the cervix and the potential impact of treatment on future pregnancies.

2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ

A group of 146 experts representing 29 organizations and professional societies met Sept. 18-19, 2006, in Bethesda, MD, to develop revised evidence-based, consensus guidelines for managing women with abnormal cervical cancer screening tests. The management of low-grade cervical intraepithelial neoplasia (CIN) grade 1 has been modified significantly. Previously, management depended on whether colposcopy was satisfactory and treatment using ablative or excisional was acceptable for all women with CIN 1. In the new guidelines, cytological follow-up is the only recommended management option for women with CIN 1 who have low-grade referral cervical cytology, regardless of whether the colposcopic examination is satisfactory. Treatment is particularly discouraged in adolescents. The basic management of women in the general population with CIN 2,3 underwent only minor modifications, but options for the conservative management of adolescents with CIN 2,3 have been expanded. Moreover, management recommendations for women with biopsy-confirmed adenocarcinoma in situ are now included.