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Akis S, Keles E, Ozyurek SE, Purut YE, Ozturk UK, Kabaca C, Api M, Cetiner H. Is Endocervical Glandular Involvement Related to The Depth of Cone Biopsy? Int J Surg Pathol 2023; 31:11-19. [PMID: 35651307 DOI: 10.1177/10668969221102616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction. This study aimed to determine whether endocervical glandular involvement by squamous intraepithelial lesion would differ with respect to the depth of the excised specimen and analyze the related factors that may define endocervical glandular involvement among cases treated with cone biopsy. Methods. Between April 2016 and December 2018, women who underwent colposcopy and excisional procedures in the department of gynecologic oncology were retrospectively investigated. Patients with multiple specimens, or whose specimen depths were not measured, and a negative/unknown HPV status were excluded from the study. Also, patients with no dysplasia or microinvasive/invasive cancer in the final pathology report and those who had not undergone endocervical curettage during colposcopy were excluded. HPV genotypes, degree of dysplasia, surgical margin status, and specimen depth were documented from medical records. Further, the association of these factors with endocervical glandular involvement was evaluated. Results: A total of 321 patients who fulfilled the criteria were included in the study, with a mean age of 41.9 years. In total, 101 patients (31.5%) had endocervical glandular involvement. The mean excised specimen depth was 17.04 mm; 17.9 and 16.7 mm for the positive and negative glandular involvement groups, respectively (p = .13). The mean ages were 42.7 and 41.6 years for these groups, respectively (p = .32). There was no association between the HPV genotypes and glandular involvement. Conclusions: Endocervical glandular involvement is not associated with the depth of the excised specimen. A deeper cone biopsy may not necessarily enable a more effective treatment of the disease.
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Affiliation(s)
- Serkan Akis
- Faculty of Medicine, Department of Gynecologic Oncology, 162296Adıyaman University, Adıyaman, Turkey
| | - Esra Keles
- University of Health Sciences, Department of Gynecologic Oncology, 147023Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Sefik Eser Ozyurek
- University of Health Sciences, Department of Gynecologic Oncology, 147023Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Yunus Emre Purut
- University of Health Sciences, Department of Gynecologic Oncology, Van Training and Research Hospital, Van, Turkey
| | - Ugur Kemal Ozturk
- University of Health Sciences, Department of Gynecologic Oncology, 147023Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Canan Kabaca
- University of Health Sciences, Department of Gynecologic Oncology, 147023Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Murat Api
- University of Health Sciences, Department of Gynecologic Oncology, 147023Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
| | - Handan Cetiner
- University of Health Sciences, Department of Pathology, 147023Zeynep Kamil Women's and Children's Disease Training and Research Hospital, Istanbul, Turkey
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Nakanuma Y, Sugino T, Kakuda Y, Uesaka K, Okamura Y, Nomura Y, Watanabe H, Terada T, Sato Y, Sinimzu S, Ohnishi Y, Fukumura Y. Intraepithelial involvement of non-neoplastic glands in papillary preinvasive neoplasms of the biliary tract: a potential diagnostic pitfall. Hum Pathol 2023; 131:98-107. [PMID: 36370824 DOI: 10.1016/j.humpath.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/02/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
Intracholecystic papillary neoplasms of the gallbladder (ICPN) and intraductal papillary neoplasms of the bile duct (IPNB) show intramural neoplastic growths in addition to intraluminal papillary or polypoid neoplastic growth. Such intramural growths include intraepithelial involvement of non-neoplastic glands by preinvasive neoplastic epithelia (glandular involvement) as well as stromal invasive carcinoma. A total of 29 ICPN cases and 84 IPNB cases were pathologically examined for their glandular involvement. Glandular involvement was characterized by intramural neoplastic glands (1) showing cytological and phenotypical similarities to intraluminal preinvasive papillary neoplasms and (2) showing reminiscent configurations of non-neoplastic glands, such as (i) a mixture of preinvasive neoplastic epithelia and non-neoplastic epithelia within the same glands, (ii) neoplastic glands close to or within clustered non-neoplastic glands, or (iii) continuous growth of intraluminal preinvasive neoplastic glands into the walls. Such glandular involvement was found in 16 of 29 ICPN and 48 of 84 IPNB, and 15 of the former and 28 of the latter were not associated with invasive carcinoma. Non-invasive ICPN and IPNB with glandular involvement showed a favorable postoperative overall survival (OS). Glandular involvement by preinvasive neoplastic epithelia was frequently found in ICPN and IPNB. Such lesions may be diagnostic pitfalls in ICPN and IPNB referring to invasion. Glandular involvement without invasive carcinoma was not associated with an unfavorable postoperative OS in ICPN and IPNB. Recognition of glandular involvement may thus prevent overestimation of invasive carcinoma in ICPN and IPNB.
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Affiliation(s)
- Yasuni Nakanuma
- Department of Diagnostic Pathology, Shizuoka Cancer Center, Shizuoka, Japan; Department of Diagnostic Pathology, Fukui Prefecture Saiseikai Hospital, Japan.
| | - Takashi Sugino
- Department of Diagnostic Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuko Kakuda
- Department of Diagnostic Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Department of Hepatobiliary Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yasuyuki Okamura
- Department of Surgery, Nihon University School of Medicine, Tokyo, Japan
| | | | | | - Takuro Terada
- Department of Hepatobiliary-Pancreatic Surgery, Fukui Prefecture Saiseikai Hospital, Fukui, Japan
| | - Yasunori Sato
- Department of Human Pathology, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Shinichiro Sinimzu
- Department of Diagnostic Pathlogy, Funahashi Municipal Medical Center, Funahashi, Japan
| | - Yoshifumi Ohnishi
- Department of Internal Medicine, Shizuoka Medical Center, Shizuoka, Japan
| | - Yuki Fukumura
- Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
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Kim NR, Baek ZH, Lee AJ, Yang EJ, Ouh YT, Kim MK, Shim SH, Lee SJ, Kim TJ, So KA. Clinical Outcomes Associated with Endocervical Glandular Involvement in Patients with Cervical Intraepithelial Neoplasia III. J Clin Med 2022; 11:jcm11112996. [PMID: 35683385 PMCID: PMC9181062 DOI: 10.3390/jcm11112996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022] Open
Abstract
This study aimed to determine whether endocervical glandular involvement (GI) affects the clinical prognosis of patients with cervical intraepithelial neoplasia (CIN) III who underwent the loop electrosurgical excision procedure (LEEP). This retrospective study included 250 patients who underwent LEEP for the treatment of CIN III between August 2005 and May 2020. The medical records of 234 patients were analyzed; 137 (58.5%) patients were GI negative, and 97 (41.5%) were GI positive. Margin involvement of the LEEP specimen was found in 59 (45.4%) patients in the GI-negative group and 54 (58.7%) patients in the GI-positive group (p = 0.051). The additional surgical procedures (repeat conization or hysterectomy) were significantly more performed in GI-positive patients than in GI-negative patients (40.9% vs. 23.1%, p = 0.004). When comparing the LEEP specimens of GI-1 (GI-positive confirmed via cervical biopsy before conization) and GI-2 (GI-positive confirmed via conization), we found that the mean depth was significantly greater in the GI-1 group (10.9 mm) than in the GI-2 group (7.6 mm) (p = 0.024). Surgical margin involvement was more frequently observed in the GI-2 group than in the GI-1 group (p = 0.030). There was no significant difference in the recurrence rates of CIN between the GI-negative and GI-positive groups (p = 0.641). In conclusion, despite no significant differences in residual disease and CIN recurrence between the GI-negative and GI-positive groups, additional surgical treatments were more frequently performed in GI-positive patients. Repeat surgery based on GI positivity should be carefully considered to avoid overtreatment and surgical complications.
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Affiliation(s)
- Nae Ry Kim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
| | - Zee Hae Baek
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
| | - A Jin Lee
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
| | - Eun Jung Yang
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
| | - Yung-Taek Ouh
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Kangwon National University, Kangwon 24341, Korea;
| | - Mi Kyung Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea;
| | - Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
| | - Sun Joo Lee
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
| | - Tae Jin Kim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
| | - Kyeong A So
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul 05030, Korea; (N.R.K.); (Z.H.B.); (A.J.L.); (E.J.Y.); (S.-H.S.); (S.J.L.); (T.J.K.)
- Correspondence: ; Tel.: +82-2-2030-7524
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Oncologic and obstetric outcomes after conization for adenocarcinoma in situ or stage IA1 cervical cancer. Sci Rep 2020; 10:19920. [PMID: 33199765 PMCID: PMC7669853 DOI: 10.1038/s41598-020-75512-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/16/2020] [Indexed: 01/23/2023] Open
Abstract
This study aims to reveal the risk factors associated with recurrence or new-onset high-grade squamous intraepithelial lesions (HSILs) or more severe lesions (HSILs +) and analyze obstetrical outcomes in patients with adenocarcinoma in situ (AIS) or stage IA1 cervical cancer patients after conization. A retrospective cohort study was developed from January 1, 2002, and July 1, 2018, in a single center, where all patients with AIS or stage IA1 cervical cancer who accepted conization for primary surgery were reviewed and followed up until July 1, 2019, for the pathological findings of HSILs + and obstetric outcomes. Two hundred and seventeen patients were identified, including 114 cases of AIS, 76 cases of stage IA1 squamous cell carcinoma (SCC) and 27 cases of stage IA1 adenocarcinoma (ADC). A total of 88 (40.6%) patients had an intact uterus without radiotherapy. Five patients experienced HSIL+ recurrence. The cumulative 3-, 5- and 10-year incidence rates of HSILs + were 1.0%, 1.5% and 2.0%, respectively. No significant risk factors, including primary disease, margin status and hysterectomy, were associated with recurrence. Twenty (66.7%) of 30 patients who attempted pregnancy had 23 successful pregnancies, which result in 7 miscarriages, 16 live births and 5 preterm births. Age at conization was the only independent risk factor associated with pregnancy, live births and preterm births. In conclusion, conization is safe for young women with AIS, stage IA1 SCC and ADC who desire future fertility, and the associated HSIL recurrence rate is low. Increased age significantly lowered the conception or live birth rate.
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Jones R, Dale F, Fite JJ, Cowan ML, Williamson B, DeLuca J, VandenBussche CJ. Endocervical glandular involvement is associated with an increased detection rate of high-grade squamous intraepithelial lesions on the Papanicolaou test. J Am Soc Cytopathol 2020; 9:137-145. [PMID: 32147423 DOI: 10.1016/j.jasc.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Although The Bethesda System for Reporting Cervical Cytopathology does not mandate reporting of endocervical glandular involvement (EGI) in Papanicolaou test specimens with high-grade squamous intraepithelial lesions (HSIL), several studies have suggested that EGI diagnosed on surgical specimens is associated with higher rates of residual or recurrent dysplasia. When suspected, EGI is reported for Papanicolaou test specimens at our institution, but the performance of this diagnosis has not been assessed. MATERIALS AND METHODS The archives were queried for Papanicolaou test specimens with a diagnosis of HSIL-EGI (2006-2017). All follow-up surgical pathology specimens within a year of the Papanicolaou test diagnosis were evaluated for cytologic-histologic correlation. This same query was repeated for all surgical pathology specimens with a diagnosis of HSIL-EGI. All preceding Papanicolaou test diagnoses within a year were assessed for cytologic-histologic correlation. Twenty Papanicolaou test specimen glass slides were reviewed by 6 observers to assess for interobserver variability. RESULTS Patients with HSIL-EGI on surgical specimens were more likely to have a preceding Papanicolaou diagnosis of HSIL and atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) (32.3% versus 25.5%, P = 0.03, and 16.7% versus 11.8%, P = 0.04, respectively). Patients with an HSIL-EGI diagnosis on a Papanicolaou test were significantly more likely to have HSIL-EGI detected on a follow-up histology (41.6% versus 24.0%, P < 0.001). Interobserver concordance was poor for the assignment of EGI in Papanicolaou test specimens. CONCLUSIONS Overall, the diagnosis of HSIL-EGI on Papanicolaou test specimens is complicated by poor sensitivity and interobserver concordance.
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Affiliation(s)
- Robert Jones
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - J Judd Fite
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Morgan L Cowan
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bonnie Williamson
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Juliana DeLuca
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher J VandenBussche
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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The effects of different instruments and suture methods of conization for cervical lesions. Sci Rep 2019; 9:19114. [PMID: 31836814 PMCID: PMC6910914 DOI: 10.1038/s41598-019-55786-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/03/2019] [Indexed: 11/22/2022] Open
Abstract
This study is to compare the surgical outcomes of patients undergoing cold knife conization (CKC) versus electrosurgical conization (ESC). Among 10,086 patients in a single center admitted between January 2000 and January 2019, CKS or ESC was used for grade 3 cervical intraepithelial neoplasia (CIN3) or more severe lesions. Modified Sturmdorf or Figure-of-eight sutures were applied after conization. A regression model was used to determine the risk factors for margin involvement and short-term post-operative complications. In total, 7275 (72.1%) and 2811 (27.9%) patients underwent CKC and ESC, respectively. Women who underwent ESC were older and had a higher risk of margin involvement and endocervical glandular involvement than those who underwent CKC in univariate analysis. However, in the multivariate analysis, age (odds ratio [OR] 1.032, 95% confidence interval [95% CI] 1.025–1.038) and glandular involvement (OR 2.196, 95% CI 1.915–2.517) were the independent risk factors associated with margin involvement, but the incision methods used caused no significant difference. Modified Sturmdorf sutures and Figure-of-eight sutures were applied in 3520 (34.9%) and 6566 (65.1%) patients, respectively. The modified Sturmdorf sutures was the only risk factor associated with wound hemorrhage (OR 1.852, 95% CI 1.111–3.085) after adjusted with other epidemiological and surgical factors. Various incision or suture methods had similar risk of cervical stenosis. Therefore, ESC is an acceptable alternative to CKC for the diagnosis and treatment of cervical lesions regarding the pathologic accuracy and integrity, and short-term safety. Modified Sturmdorf sutures increased the risk of wound hemorrhage compared with Figure-of-eight sutures.
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Leng F, Jiang L, Nong L, Ren X, Xie T, Dong Y, Tao X. Value of top-hat procedure in management of squamous intraepithelial lesion. J Obstet Gynaecol Res 2018; 45:182-188. [PMID: 30191638 DOI: 10.1111/jog.13781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 06/30/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Lin Nong
- Department of Pathology; Peking University First Hospital; Beijing China
| | - Xiying Ren
- Department of Obstetrics and Gynecology; Peking University First Hospital; Beijing China
| | - Tong Xie
- Department of Obstetrics and Gynecology; Peking University First Hospital; Beijing China
| | - Ying Dong
- Department of Pathology; Peking University First Hospital; Beijing China
| | - Xia Tao
- Department of Obstetrics and Gynecology; Peking University First Hospital; Beijing China
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Sangkarat S, Ruengkhachorn I, Benjapibal M, Laiwejpithaya S, Wongthiraporn W, Rattanachaiyanont M. Long-term outcomes of a loop electrosurgical excision procedure for cervical intraepithelial neoplasia in a high incidence country. Asian Pac J Cancer Prev 2014; 15:1035-9. [PMID: 24568447 DOI: 10.7314/apjcp.2014.15.2.1035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AIM To evaluate the operative, oncologic and obstetric outcomes of the loop electrosurgical excision procedure (LEEP) in cases with cervical neoplasia. MATERIALS AND METHODS A retrospective cohort study was conducted on patients who were suspected of cervical neoplasia and therefore undergoing LEEP at Siriraj Hospital, Mahidol University, Thailand, during 1995-2000. Outcome measures included operative complications in 407 LEEP patients and long-term outcomes in the 248 patients with cervical intraepithelial neoplasia (CIN) who were treated with only LEEP. RESULTS There were 407 patients undergoing LEEP; their mean age was 39.7±10.5 years. The histopathology of LEEP specimens revealed that 89 patients (21.9%) had lesions ≤CIN I, 295 patients (72.5%) had CIN II or III, and 23 patients (5.6%) had invasive lesions. Operative complications were found in 15 patients and included bleeding (n=9), and infection (n=7). After diagnostic LEEP, 133 patients underwent hysterectomy as the definite treatment for cervical neoplasia. Of 248 CIN patients who had LEEP only, seven (2.8%) had suffered recurrence after a median of 16 (range 6-93) months; one had CIN I, one had CIN II, and five had CIN III. All of these recurrent patients achieved remission on surgical treatment with re-LEEP (n=6) or simple hysterectomy (n=1). A significant factor affecting recurrent disease was the LEEP margin involved with the lesion (p=0.05). Kaplan-Meier analysis showed 5-year and 10-year disease-free survival (DFS) estimates of 99.9%. Twelve patients became pregnant a total of 14 times, resulting in 12 term deliveries and two miscarriages - one of which was due to an incompetent cervix. CONCLUSIONS LEEP for patients with cervical neoplasia delivers favorable surgical, oncologic and obstetric outcomes.
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Affiliation(s)
- Suthi Sangkarat
- Gynecologic Oncology Division, 2Gynecologic Cytology Unit, 3Gynecologic Endocrinology Unit, 4Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand E-mail :
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Güdücü N, Sidar G, Başsüllü N, Türkmen I, Dünder I. Endocervical glandular involvement, multicentricity, and extent of the disease are features of high-grade cervical intraepithelial neoplasia. Ann Diagn Pathol 2013; 17:345-6. [PMID: 23665088 DOI: 10.1016/j.anndiagpath.2013.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 04/07/2013] [Indexed: 10/26/2022]
Abstract
This study aimed to evaluate the rate of endocervical glandular involvement, positive surgical margins, multicentricity, and disease extent between low-grade and high-grade cervical intraepithelial lesions after loop electrosurgical excision procedure (LEEP). Pathology medical records of patients who underwent LEEP were reviewed retrospectively. Patients with negative LEEP results were excluded. Loop electrosurgical excision procedure reports of patients with cervical intraepithelial neoplasia (CIN) 1, 2, and 3 were compared. There was no statistically significant difference between patients with CIN 1 (n=24), CIN 2 (n=27), and CIN 3 (n=64) when age and surgical margin positivity were considered. Endocervical glandular involvement, multicentricity, and disease extent were higher in patients with CIN 3 (P=.001, P=.002, and P=.001, respectively). In conclusion, we recommend that patients with endocervical glandular involvement, lesions involving more than two-thirds of the LEEP specimen, and multicentricity be followed up more closely.
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Affiliation(s)
- Nilgün Güdücü
- Department of Obstetrics and Gynecology, İstanbul Bilim University, Istanbul, Turkey.
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