HPV Determination in the Control After LEEP Due to CIN II-III: Prospective Study and Predictive Model:

Intraoperative Human Papillomavirus Test Predicts 24-Month High-Grade Squamous Intraepithelial Lesion Recurrence Saving Costs: A Prospective Cohort Study

OBJECTIVES

The human papilloma virus (HPV) test is recommended in the posttreatment follow-up of cervical intraepithelial neoplasia. The aim of the study was to assess whether the intraoperative HPV (IOP-HPV) test had a similar diagnostic accuracy that HPV test performed at 6 months to predict high-grade squamous intraepithelial lesion (HSIL) recurrence.

MATERIALS AND METHODS

In a prospective cohort study, 304 women diagnosed with HSIL by biopsy and/or endocervical curettage before treatment and/or confirmation in the histological specimen were included. Immediately after surgery, HPV testing was performed. This test was compared with the test at 6 months and other predictors of recurrence. Patients were followed for 24 months. An economic analysis was performed to compare the costs of IOP-HPV and HPV test at 6 months.

RESULTS

Recurrence rate of HSIL was 6.2% (19 patients). The diagnostic accuracy of the IOP-HPV test to predict HSIL recurrence at 24 months was similar to the HPV test at 6 months, with comparative sensitivities of 100% versus 86.7%, specificities of 82.0% versus 77.9%, positive predictive values of 27.1% versus 18.1%, and negative predictive values of 100% versus 99.0%. Direct economic saving per high-grade intraepithelial lesion patient was 172.8 &OV0556;.

CONCLUSIONS

The HPV test performed after loop electrosurgical resection procedure predicted recurrence of HSIL at 24 months with a similar diagnostic accuracy than the HPV test at 6 months. The use of the IOP-HPV test in the management of HSIL will allow early detection of the risk of recurrent disease and to save costs because of potential suppression of the need of HPV and follow-up controls at 6 months.

Incomplete excision of cervical precancer as a predictor of treatment failure: a systematic review and meta-analysis

BACKGROUND

Incomplete excision of cervical precancer is associated with therapeutic failure and is therefore considered as a quality indicator of clinical practice. Conversely, the risk of preterm birth is reported to correlate with size of cervical excision and therefore balancing the risk of adequate treatment with iatrogenic harm is challenging. We reviewed the literature with an aim to reveal whether incomplete excision, reflected by presence of precancerous tissue at the section margins, or post-treatment HPV testing are accurate predictors of treatment failure.

METHODS

We did a systematic review and meta-analysis to assess the risk of therapeutic failure associated with the histological status of the margins of the tissue excised to treat cervical precancer. We estimated the accuracy of the margin status to predict occurrence of residual or recurrent high-grade cervical intraepithelial neoplasia of grade two or worse (CIN2+) and compared it with post-treatment high-risk human papillomavirus (HPV) testing. We searched for published systematic reviews and new references from PubMed-MEDLINE, Embase, and CENTRAL and did also a new search spanning the period Jan 1, 1975, until Feb 1, 2016. Studies were eligible if women underwent treatment by excision of a histologically confirmed CIN2+ lesion, with verification of presence or absence of CIN at the resection margins; were tested by cytology or HPV assay between 3 months and 9 months after treatment; and had subsequent follow-up of at least 18 months post-treatment including histological confirmation of the occurrence of CIN2+. Primary endpoints were the proportion of positive section margins and the occurrence of treatment failure associated with the marginal status, in which treatment failure was defined as occurrence of residual or recurrent CIN2+. Information about positive resection margins and subsequent treatment failure was pooled using procedures for meta-analysis of binomial data and analysed using random-effects models.

FINDINGS

97 studies were eligible for inclusion in the meta-analysis and included 44 446 women treated for cervical precancer. The proportion of positive margins was 23·1% (95% CI 20·4-25·9) overall and varied by treatment procedure (ranging from 17·8% [12·9-23·2] for laser conisation to 25·9% [22·3-29·6] for large loop excision of the transformation zone) and increased by the severity of the treated lesion. The overall risk of residual or recurrent CIN2+ was 6·6% (95% CI 4·9-8·4) and was increased with positive compared with negative resection margins (relative risk 4·8, 95% CI 3·2-7·2). The pooled sensitivity and specificity to predict residual or recurrent CIN2+ was 55·8% (95% CI 45·8-65·5) and 84·4% (79·5-88·4), respectively, for the margin status, and 91·0% (82·3-95·5) and 83·8% (77·7-88·7), respectively, for high-risk HPV testing. A negative high-risk HPV test post treatment was associated with a risk of CIN2+ of 0·8%, whereas this risk was 3·7% when margins were free.

INTERPRETATION

The risk of residual or recurrent CIN2+ is significantly greater with involved margins on excisional treatment; however, high-risk HPV post-treatment predicts treatment failure more accurately than margin status.

FUNDING

European Federation for Colposcopy and Institut national du Cancer (INCA).

Four categories of LEEP for CIN of various areas: a retrospective cohort study

PURPOSE

To compare the effectiveness and safety of loop electrosurgical excision procedures (LEEP) with four different excisions in treating cervical intraepithelial neoplasia (CIN) of different areas.

METHODS

Four hundred and sixty-six cases of CIN were treated with different types of LEEP. Following visual inspection with acetic acid and Lugol's iodine, LEEP were performed to excise the transformation zone to a 20-25 mm depth with a 2-3 mm margin. Four categories of procedures are described below: (i) LEEP-A for lesion ≥2/3 of cervical area: conization of ≥2/3 of cervical tissue. (ii) LEEP-B for ≥1/3 but <2/3: conization of 1/3 to <2/3. (iii) LEEP-C for <1/3: conization of <1/3. (iv) LEEP-D: endocervical canal resection.

RESULTS

The cases included 108 of CIN I, 232 of CIN II, and 106 of CIN III (not including carcinoma in situ) patients. No positive margin was found in any specimens. The cure rates for LEEP-A, B, C, and D were 99.1%, 98.5%, 100.0%, and 93.2%, respectively (p > .05). The pregnancy rate at two years after LEEP was significantly higher in groups C and D compared to group A (p < .05).

CONCLUSIONS

Four categories of LEEP are highly effective in the treatment of CIN when appropriately applied. However, large loop excision may lead to adverse obstetric outcomes in pregnancy.

Association between human papillomavirus type 16 E6 and E7 variants with subsequent persistent infection and recurrence of cervical high-grade squamous intraepithelial lesion after conization

The study aimed to detect the variants of human papillomavirus (HPV) type 16 E6 and E7 in patients with cervical high-grade squamous intraepithelial lesion (HSIL), and to determine the existence and recurrence of persistent infection after treatment with loop electrosurgical excision procedure (LEEP). Preoperatively collected cervical exfoliated cells from 100 HPV 16 positive HSIL patients enrolled in the study were used to test for E6 and E7 variants. Follow-ups which included TCT, HPV test, and colposcopy were performed every 3 months after the operation, and colposcopic biopsy and endocervical curettage were performed for patients with abnormalities. Patients were followed for 2 years, and recurrence was defined as detecting low-grade squamous intraepithelial lesion (LSIL) or relapse of HSIL in 1 year. In 81% of patients, the E6 variant was the Asian prototype (As.P), 14% of patients had the European variant, 2% had the European prototype (EP), and 3% had the African 1 variant (Af1). The HPV16 could be easily cleared by LEEP in patients with As.P. Persistent infection or recurrence was very rare in this group. The patients with European variants T350G or A442C had a significantly higher incidence of persistent and recurring HPV16 infection. In conclusion, (i) in most cases, As.P caused HSIL. (ii) The European variant E6 T350G/A442C may be associated with higher rates of recurring and persistent HPV16 infection after the LEEP. (iii) The E7 gene mutation may not be a risk factor for recurring HSIL caused by HPV16 or persistent infection. J. Med. Virol. 88:1982-1988, 2016. © 2016 Wiley Periodicals, Inc.

Factors associated with the persistence/recurrence of CIN2/3 in women submitted to loop electrosurgical excision procedure in a teaching hospital in northeastern Brazil: a case-control study

OBJECTIVE

This study aimed to identify risk factors associated with the persistence/recurrence of cervical intraepithelial neoplasia (CIN) 2/3 in women submitted to loop electrosurgical excision procedure (LEEP) in a hospital in northeastern Brazil.

MATERIALS AND METHODS

A case-control study included 50 women with and 50 women without persistence/recurrence of CIN2/3 after LEEP at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between 2004 and 2011. Data were collected from June to December 2011. Inclusion criteria were diagnosis of CIN2/3 during follow-up (cases) and women free of CIN2/3 after a follow-up of 2 years or longer (controls). Exclusion criteria (cases/controls) were LEEP performed at another hospital, LEEP performed for persistent CIN1, invasive carcinoma in the cone specimen or at cytology, and/or histopathology within a 2-year follow-up period. Persistence was defined as residual disease detected in the first year after LEEP, and recurrence was defined as the reappearance of a lesion more than 1 year after surgery. Bivariate analysis was performed for biological, sociodemographic, sexual, reproductive, lifestyle, and clinical variables. Odds ratios (ORs) and their 95% confidence intervals (95% CIs) were calculated, and a multiple logistic regression analysis was performed to control for potential confounding factors. The study was approved by IMIP's internal review board.

RESULTS

Multiple logistic regression analysis showed a significant association between persistence/recurrence of CIN2/3 and living outside the capital city (OR=3.11, 95% CI=1.14-8.41), smoking (OR=4.22, 95% CI=1.18-15.05), and positive endocervical margins (OR=6.58, 95% CI=2.37-18.28).

CONCLUSIONS

Women with persistence/recurrence of CIN2/3 are more likely to live outside the state capital, be smokers, and have positive endocervical margins, so these women should be followed up more closely.

Clinical Performance of Hybrid Capture 2 Human Papillomavirus Testing for Recurrent High-Grade Cervical/Vaginal Intraepithelial Neoplasm in Patients With an ASC-US Papanicolaou Test Result During Long-Term Posttherapy Follow-up Monitoring

Context

Women who have been treated for high-grade cervical or vaginal intraepithelial neoplasia (CIN or VAIN) or invasive carcinoma are at risk for recurrent/persistent disease and require long-term monitoring. The role of human papillomavirus (HPV) testing in this setting is unclear.

Objective

To evaluate the clinical performance of the Hybrid Capture 2 (HC2) HPV test for recurrent/residual high-grade CIN or VAIN in patients with a posttherapy abnormal squamous cells of undetermined significance (ASC-US) Papanicolaou test result.

Design

We reviewed the follow-up data on 100 patients who had an ASC-US Papanicolaou test and HC2 HPV results after treatment for high-grade CIN/VAIN or carcinoma. Human papillomavirus genotyping was performed for women with a negative HC2 result whose follow-up biopsy revealed CIN/VAIN 2+.

Results

The patients' mean age was 47 years. The HC2 test result was positive in 33% of the patients. Follow-up biopsy was available for 17 of these patients (52%) and for 25 of the 67 patients (37%) with a negative HC2 result. A total of 5 of the patients (29%) with a positive HC2 result and 2 of the patients (8%) with a negative HC2 result had CIN/VAIN 3 on follow-up biopsy, a statistically insignificant difference (P = .10). Human papillomavirus 16/18 genotypes were detected in the CIN/VAIN 2+ lesions of 5 patients with a negative HC2 result.

Conclusion

HC2 yielded a false-negative rate of 8% for CIN 3. HC2 testing therefore may not be sufficient for triage of patients with an ASC-US Papanicolaou test result. Patients with ASC-US during long-term posttherapy follow-up need close monitoring, with colposcopic evaluation if clinically indicated.

Human papillomavirus testing and cytologic/histopathologic "test of cure" follow-up results after excisional treatment for high-grade cervical intraepithelial neoplasia

INTRODUCTION

Recently published guidelines now specifically recommend cytology and HPV cotesting as follow-up after high-grade cervical intraepithelial neoplasia (CIN 2/3) excision.

MATERIALS AND METHODS

A total of 988 patients with CIN 2/3 treated by excision between July 2005 and December 2009 were identified with available "test of cure" follow-up results over an average of 36 months. Average age was 32 years.

RESULTS

CIN 2/3 was reported during follow-up in 67 of 988 (6.8%) patients; 45 of 67 (67.2%) follow-up CIN 2/3 diagnoses were within 2 years of excision. Post-treatment CIN 2/3 was significantly more likely after initial CIN 3 grade, positive excision margins, and human papillomavirus (HPV)-positive follow-up results, but not significantly associated in this cohort with age. A total of 514 women had follow-up HPV tests, and 32.3% had at least 1 HPV-positive result. Post-treatment CIN 2/3 was diagnosed in 24 of 165 (14.5%) patients with at least 1 follow-up HPV-positive result and in 6 of 349 (1.7%) with only follow-up HPV-negative results. No HPV-negative/cytology-negative follow-up results were documented among 30 post-treatment patients later developing recurrent CIN 2/3.

CONCLUSIONS

Cytology and HPV cotesting facilitates early intervention during follow-up after CIN 2/3 excision.

Topical treatment of CIN 2+ by cidofovir: results of a phase II, double-blind, prospective, placebo-controlled study

OBJECTIVE

Randomized controlled trial evaluating a topical treatment for cervical intraepithelial neoplasia 2 and 3 (CIN 2+) using cidofovir.

METHODS

Fifty-three women with a biopsy-proven CIN 2+ were randomly assigned, 6 weeks before their planned conisation, either 3 applications of 3 ml 2% cidofovir in Intrasite gel in a cervical cap or a placebo (the same volume of Intrasite alone). A cervical sample for high-risk types of human papillomaviruses (HPV) (Hybrid Capture 2 or HC2) was taken before treatment and before conisation. The cone was submitted for pathological examination, and subsequently, along with the initial biopsy, to in situ hybridization (ISH) for high-risk HPV.

RESULTS

Forty-eight patients were treated and followed according to the protocol, (23 cidofovir, and 25 placebo). Fourteen of the 23 cones were free of any CIN (60.8%) in the cidofovir group. Only 5 of 25 cones were free of any CIN (20%) in the placebo group (p<0.01). The difference remained significant in the ITT group (p<0.05). In the per-protocol and ITT populations, we observed more frequent viral clearance in the cidofovir group, but the difference was significant only when evaluated by ISH and not by HC2. No systemic toxicity was observed. Cervico-vaginal side effects of cidofovir were limited, and not statistically different from placebo.

CONCLUSION

The medical topical treatment with cidofovir, at this point, cannot replace conisation, but it is a promising candidate for topical chemotherapy of CIN 2+ lesions; a larger prospective randomized study is needed to confirm our results.