Evaluation of the intraoperative human papillomavirus test as a marker of early cure at 12 months after electrosurgical excision procedure in women with cervical high-grade squamous intraepithelial lesion: a prospective cohort study

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.

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.

Focused ultrasound versus the loop electrosurgical excision procedure to treat women with cervical high-grade squamous intraepithelial lesions under 40: a retrospective study

BACKGROUND

This study aimed to compare the efficacy of focused ultrasound (FUS) and the loop electrosurgical excision procedure (LEEP) for the treatment of cervical high-grade squamous intraepithelial lesions (HSILs) among women of reproductive age.

METHODS

Case records of patients aged < 40 years who were treated for cervical HSILs using either FUS or LEEP from September 1, 2020 to May 31, 2022 were retrospectively reviewed. Patients were followed up for cure, recurrence, human papillomavirus (HPV) clearance, and complications within 1 year of treatment. Odds ratios and 95% confidence intervals were determined using univariate and multivariate logistic regression models to analyze the association between disease evidence or HPV clearance and treatment modalities or other covariates.

RESULTS

Of the 1,054 women who underwent FUS or LEEP, 225 met our selection criteria. Among the selected women, 101 and 124 received FUS and LEEP, respectively. There was no significant difference between the FUS and LEEP groups in the cure rate during the 3-6 months of follow-up (89.11% vs. 94.35%, P = 0.085) and recurrence rate during the 6-12 months follow-up (2.22% vs. 1.71%, P = 0.790). Both groups exhibited enhanced cumulative HPV clearance rates; however, the rates were not significantly different between the FUS and LEEP groups (74.23% vs. 82.79%, P = 0.122 during the 3-6 months follow-up; 84.95% vs. 89.17%, P = 0.359 during the 6-12 months follow-up). Furthermore, the incidence of complications caused by the FUS and LEEP techniques was comparable (5.0% vs. 5.6%, P = 0.818).

CONCLUSIONS

We found that FUS and LEEP have similar efficacy, safety, and reliability in treating women (aged < 40 years) with HSILs.

The 5-year risk of recurrence of grade 2/3 cervical intraepithelial neoplasia after treatment in a population screening programme by human papillomavirus status: A cohort study in central Italy

OBJECTIVES

(a) To estimate the risk of recurrent cervical intraepithelial neoplasia, grade 2/3 or worse (CIN2+/CIN3+), lesions within 5 years of follow-up in human papillomavirus-negative/human papillomavirus-positive cohorts; (b) to assess whether certain risk factors can predict the recurrence of CIN2+/CIN3+ lesions; and (c) to provide recommendations for follow-up after treatment of cervical intraepithelial neoplasia, grade 2/3 to prevent cervical cancer.

SETTING

Organized cervical cancer screening programme in Central Italy.

METHODS

We included 1063 consecutive first excisional treatments performed between 2006 and 2014 for screening-detected cervical intraepithelial neoplasia, grade 2/3 lesions among women aged 25-65. The study population was divided into two groups according to the human papillomavirus test results performed 6 months after treatment: Human papillomavirus-negative and human papillomavirus-positive cohorts. The 5-year risk of developing cervical intraepithelial neoplasia, grade 2/3 or worse (CIN2+/CIN3+) was estimated using the Kaplan-Meier method and the Cox regression model.

RESULTS

Among 829 human papillomavirus-negative and 234 human papillomavirus-positive women, six (0.72%; three cervical intraepithelial neoplasia, grade 2, three cervical intraepithelial neoplasia, grade 3) and 45 (19.2%; 15 cervical intraepithelial neoplasia, grade 2, 30 cervical intraepithelial neoplasia, grade 3), respectively, developed CIN2+ recurrence within 5 years of follow-up. The cumulative risks for CIN2+ and CIN3+ were 0.9% (95% confidence interval: 0.4%-2.0%) and 0.5% (95% confidence interval: 0.1%-1.4%), respectively, for the human papillomavirus-negative cohort, and 24.8% (95% confidence interval: 18.5%-32.7%) and 16.9% (95% confidence interval: 11.4%-24.5%), respectively, for the human papillomavirus-positive cohort. Risk factors associated with increased risk of recurrence were both margins positive for the human papillomavirus-negative cohort, and positive margins, cervical intraepithelial neoplasia, grade 3 lesions, high-grade cytology and high viral load for the human papillomavirus-positive cohort.

CONCLUSIONS

Human papillomavirus testing can identify women at increased risk of recurrence and this supports a recommendation for its use in the post-treatment follow-up of cervical intraepithelial neoplasia, grade 2/3 lesions.

Overexpression of E6/E7 mRNA HPV Is a Prognostic Biomarker for Residual Disease Progression in Women Undergoing LEEP for Cervical Intraepithelial Neoplasia 3

The risk of overtreatment or not treating an occult carcinoma exists in women at risk of residual disease after a LEEP excision for CIN3. Our goal was to discover an efficient method to select patients requiring a second LEEP from those requiring a FU only through an mRNA-detection test. In a population of 686 women undergoing a LEEP excision for CIN 3, we selected 285 women at risk of residual disease and subjected them to a search for E6/E7 mRNA HPV. The women with negative mRNA were subjected to a follow up, while the women with positive mRNA were subjected to a second LEEP. The histological examination of the second cone revealed 120 (85.7%) cases of residual disease in the mRNA-positive women: 40 cases of CIN2, 51 cases of CIN3, 11 cases of squamous microinvasive carcinoma, 7 cases of squamous carcinoma, 9 cases of AIS (adenocarcinoma in situ) and 2 cases of adenocarcinoma. Among the mRNA-negative women undergoing a follow up, there were only five cases of residual disease. During the follow-up period of about 6 years, we witnessed the regression of the residual disease and the elimination of the virus, just as predicted by the negative result of the mRNA test. Testing patients for E6/E7 mRNA allowed us to identify women with residual disease (CIN2+) and treat them appropriately.

Construction and Evaluation of a Clinical Prediction Scoring System for Positive Cervical Margins Under Colposcopy

Introduction

Currently, the commonly used surgical methods for cervical lesions include loop electrosurgical excision procedure (LEEP) and cold knife conization (CKC). However, the positive rate of surgical margins after LEEP is relatively high, which leads to disease recurrence and places further demand on clinical treatment. This study investigated factors related to positive margins after LEEP and established a scoring system to enhance preoperative risk assessment and surgical selection.

Materials and Methods

A retrospective analysis of the clinical data of 411 patients undergoing LEEP surgery for cervical lesions in the First Affiliated Hospital of University of Science and Technology of China (USTC), from January 2016 to March 2021, was performed. Cases were divided into a negative margin group (349 cases) and a positive margin group according to postoperative pathology. In the positive group (62 cases), single-factor and multi-factor analyses screened influencing factors; a logistic and additive scoring system was established; furthermore, a ROC curve was used to evaluate scoring effectiveness.

Results

The positive rate of resection margins after LEEP was 15.1%. Univariate analysis indicated a relationship to patient age, menopause, preoperative ThinPrep Cytology Test (TCT) results, lesion quadrant number under colposcopy, cervical biopsy, and the result of endocervical curettage (ECC). Multivariate analysis showed that age >35 y, menopause, preoperative TCT being high-grade squamous intraepithelial lesion (HSIL), four quadrants being involved under colposcopy, and ECC being HSIL were all independent influencing factors of positive margins after LEEP (P < 0.05). These were included with the above factors to establish a logistic and additive scoring system. When the logistic score was 17, the sensitivity and specificity of predicting positive margins after LEEP were 80.6 and 61.6%, respectively. When the additive score was 6, the sensitivity and specificity were 74.2 and 66.2%, respectively. Both scoring systems had good predictability (area under the curve AUC >0.75).

Conclusions

This study quantified factors influencing positive margins after LEEP and established a scoring system for evaluating patients before surgery to provide a basis for individualized treatment and selection of surgical methods.

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.

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.

Prevalence of human papillomavirus among females older than recommended age for vaccination by birth cohort, United States 2003‒2016

BACKGROUND

Apparent associations between HPV prevalence and age observed in cross-sectional studies could be misleading if cohort effects influence HPV detection.

METHODS

Using data from 2003-2016 National Health and Nutrition Examination Surveys (NHANES), we evaluated overall and 10-year birth cohort-specific cervicovaginal HPV prevalence estimates (any, high-risk [HR], and non-HR) by 3-year age group among 27-59 year-old females born in 1950-1979. Average percent changes (APC) in HPV prevalence by 3-year age were calculated using prevalence ratios from log-binomial models.

RESULTS

Overall, prevalence of any HPV declined from 49.9% in 27-29 year-olds to 33.8% in 57-59 year-olds [APC: -2.82% per 3-year age group, 95% confidence interval (CI): -4.02%, -1.60%] as did prevalence of HR-HPV [APC: -6.19% (95% CI: -8.09%, -4.26%)] and non-HR-HPV [APC: -2.00% (95% CI: -3.48%, -0.51%)]. By birth cohort, declines by age group were seen in prevalences of any HPV, HR-HPV, and non-HR-HPV for those born in the 1950s and 1970s and in any HPV and HR-HPV for those born in the 1960s (APC range: -14.08% - 0.06%).

CONCLUSIONS

Declines in HPV prevalence with age in these cross-sectional surveys cannot be explained by birth cohort differences alone, as associations were observed across all birth cohorts. These findings are consistent with biological and behavioral explanations.

Association Between Positive Human Papillomavirus Status After Conization and Disease Recurrence in Patients with Cervical Intraepithelial Neoplasia Grade 3

Objective

This study aimed to examine the associations of cone margin and human papillomavirus (HPV) status after conization with cytological abnormalities and disease recurrence in patients with cervical intraepithelial neoplasia grade 3 (CIN3).

Methods

This is a retrospective study of 366 women with CIN3 who underwent conization at Kagoshima University Hospital between 2004 and 2017. Conization was performed using an ultrasonic scalpel. The polymerase chain reaction for detecting HPV genotypes was performed using fresh cervical cell samples. We examined the associations of margin status and HPV status after conization with cytological abnormalities and recurrence.

Results

Among 224 women with CIN3, 193 (86.2%) underwent HPV genotype testing before conization. The HPV-positive rate was 84.9%. The most common HPV genotypes before conization were HPV 16, 31, 58, 52, 18, 35, and 33. In 191 patients, the uterus was preserved after conization. Sixteen patients had pathologically positive margins, 165 had negative margins, and 10 had unclear margins. There was no significant difference in abnormal cytology and recurrence rate after conization between the three groups. Five patients with positive margins and abnormal cytology during follow-ups were HPV16- or HPV58-positive in the preoperative HPV testing. Of the 191 women, 91 (47.6%) underwent pre- and postoperative HPV genotype testing, among whom 14 (15.4%) were HPV-positive after conization. No significant difference in abnormal cytology based on HPV status after conization was found. The recurrence rate tended to be higher in HPV-positive patients than in HPV-negative patients after conization (21.4% vs. 1.3%, p < 0.05). Three patients with HPV positivity after conization and recurrence during follow-up were HPV16- or HPV58-positive.

Conclusions

HPV positivity after conization for CIN3 was associated with a high recurrence rate, especially in HPV16- and HPV58-positive patients. HPV58 has not received much attention thus far, but abnormalities in cytology and recurrence may be as likely as those associated with HPV16. Thus, a careful follow-up in such patients is recommended.