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Papoutsis D, Underwood M, Parry-Smith W, Tzavara C. Endocervical crypt involvement by high-grade cervical intraepithelial neoplasia and its association with high-grade histopathological recurrence after cervical excision in women with negative excision margins: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:939-948. [PMID: 37821642 PMCID: PMC10867046 DOI: 10.1007/s00404-023-07242-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/20/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND There is a growing body of evidence suggesting that endocervical crypt involvement by high-grade cervical intraepithelial neoplasia (CIN) may represent a risk factor for disease recurrence after cervical treatment. OBJECTIVES To provide a systematic review and meta-analysis on whether endocervical crypt involvement by high-grade CIN on the excised cervical specimen is associated with high-grade histopathological recurrence during the follow-up of women after cervical excisional treatment. SEARCH STRATEGY We searched the Medline, Scopus, Central, and Clinical Trials.gov databases from inception till May 2023. SELECTION CRITERIA Studies that reported on women with a single cervical treatment with any method of excision for CIN2 or CIN3 lesion, negative excision margins, and whose recurrence was defined histopathologically were included. DATA COLLECTION AND ANALYSIS Two reviewers independently evaluated study eligibility. We used the fixed effects model for meta-analysis. MAIN RESULTS There were 4 eligible studies included in the present systematic review that evaluated 1088 women treated with either large loop excision of the transformation zone (LLETZ) or with cold knife conization (CKC). We found no significant association of endocervical crypt involvement by CIN2-3 with high-grade histopathological recurrence at follow-up after cervical excision (OR 1.93; 95% CI 0.51-3.35). The subgroup analysis of women with LLETZ cervical excision showed again no significant association with high-grade histopathological recurrence at follow-up (OR 2.00; 95% CI 0.26-3.74). CONCLUSION Endocervical crypt involvement by high-grade CIN does not seem to be a risk factor for high-grade histopathological recurrence after cervical excision with negative excision margins.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK.
- School of Health Sciences, University of Western Macedonia, 50100, Ptolemaida, Kozani, PC, Greece.
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
| | - Chara Tzavara
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Wang B, Su Y, Zhang C, Zhou M, Yuan S, Zhang M, Zhang L, Zhou Y, Cao L, Zhang M, Zhang T. The effect of local photodynamic therapy with 5-aminolevulinic acid in treating different grades of cervical intraepithelial neoplasia. Photodiagnosis Photodyn Ther 2022; 40:103196. [PMID: 36368451 DOI: 10.1016/j.pdpdt.2022.103196] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cervical intraepithelial neoplasia (CIN) is a precursor lesion of cervical cancer. Traditional treatments for CIN might have negative effects on cervical anatomical structure and physiological function. Topical 5-aminolevulinic acid photodynamic therapy (5-ALA PDT) is a novel, non-invasive targeted therapy for intraepithelial lesions. This study aims to evaluate and compare the efficacy and safety of 5-ALA PDT for different grades of CIN. METHODS A retrospective study of 183 patients aged 19-50 with histologically confirmed CIN and receiving ALA-PDT was conducted. ALA-PDT was performed with 20% ALA thermosensitive gel and irradiation at a wavelength of 635 nm and density of 80-100 J/cm2. ALA-PDT was conducted every 7-10 days for 4-6 times. Patients were followed up three, six, nine, and twelve months after treatment. The effect was evaluated through HPV genotyping, ThinPrep cytology test (TCT), and colposcopy-directed biopsy. RESULTS The HPV clearance rate was 71.0% (130/183) at the six-month follow-up and 84.5% (147/174) at the 12-month follow-up. The complete lesion remission (CR) rate was 90.2% (165/183). No statistically significant differences concerning the CR rate (P>0.05) or HPV clearance rates (P>0.05) were observed in CIN I, CIN II, and CIN III. In women with CIN III, gland involvement was revealed to be associated with a significantly lower HPV clearance rate (63.16% vs. 92.60%, P= 0.036) at the 12-month follow-up. Our study showed that the atypical vessels seemed to be a risk factor for HPV clearance rate in the CIN II group at six-month follow-up, although the difference was not statistically significant (P= 0.089). During the follow-up, 13 cases had persistent lesions (7.1%), four cases recurred (2.3%), and none of the patients progressed. The study also showed that the efficacy of PDT in the treatment of patients with CIN III involving glands was comparable to that of CKC (P>0.05). CONCLUSIONS ALA-PDT is an effective andsafe treatment for CIN, and responseis unaffected by the grade of lesions. However, for patients with atypical vessels and glandular involvement, the effect of PDT seems to be poorer.
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Affiliation(s)
- Bingjie Wang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuehui Su
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chunyan Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengjiao Zhou
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuyu Yuan
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengzhuo Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Luoman Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yingying Zhou
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lili Cao
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengzhen Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Ting Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Papoutsis D, Underwood M, Williams J, Parry-Smith W, Panikkar J. Expansile Endocervical Crypt Involvement by CIN2 - 3 as a Risk Factor for High Grade Cytology Recurrence After Cold Coagulation Cervical Treatment. Geburtshilfe Frauenheilkd 2020; 80:941-948. [PMID: 32905285 PMCID: PMC7467802 DOI: 10.1055/a-1202-2157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 06/17/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction
To determine whether expansile endocervical crypt involvement (ECI) on pretreatment cervical punch biopsies is a risk factor for high grade cytology recurrence in women following cold coagulation for cervical intraepithelial neoplasia (CIN).
Materials and Methods
This was a secondary analysis on the results of an observational study of women who had a single cold coagulation cervical treatment between 2001 – 2011 and who were followed up for cytology recurrence. Women with a previous cervical treatment were excluded.
Results
559 women were identified with a mean age of 28.7 ± 6.2 years. Expansile and non-expansile ECI were identified in 5.4 and 4.3% of women, respectively. The proportion of women with high grade cytology recurrence was 10% for those with expansile ECI and 2.3% for those without. Multivariate analysis showed that women with expansile ECI when compared to those without, had a four-fold greater risk for high grade cytology recurrence (HR = 4.22; 95% CI: 1.10 – 16.29, p = 0.036). There was no significant association found between non-expansile ECI and overall or high grade cytology recurrence. The increased biopsy depth and the CIN3 grade of pretreatment cervical punch biopsies were significantly associated with greater odds for the detection of expansile ECI. We calculated that the optimal-cut off of pretreatment cervical punch biopsy depth for the detection of expansile ECI was 4 mm (sensitivity: 73.3%; specificity: 55.1%).
Conclusions
Expansile ECI is a risk factor that increases the likelihood of high grade cytology recurrence following cold coagulation. Deeper pretreatment cervical punch biopsies need to be taken so as not to miss expansile ECI prior to ablative treatment.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom.,Department of Health Sciences, University of Western Macedonia, Koila, Kozani, Greece
| | - Martyn Underwood
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Joanna Williams
- Department of Histopathology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Jane Panikkar
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
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Endocervical Crypt Involvement by CIN2-3 as a Predictor of Cytology Recurrence After Excisional Cervical Treatment. J Low Genit Tract Dis 2015; 19:311-8. [DOI: 10.1097/lgt.0000000000000128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Papoutsis D, Underwood M, Parry-Smith W, Panikkar J. Risk factors for treatment failure following cold coagulation cervical treatment for CIN pathology: a cohort-based study. Arch Gynecol Obstet 2015; 292:1329-37. [DOI: 10.1007/s00404-015-3761-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/13/2015] [Indexed: 01/08/2023]
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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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Kodampur M, Kopeika J, Mehra G, Pepera T, Menon P. Endocervical crypt involvement by high-grade cervical intraepithelial neoplasia after large loop excision of transformation zone: Do we need a different follow-up strategy? J Obstet Gynaecol Res 2012; 39:280-6. [DOI: 10.1111/j.1447-0756.2012.01943.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Heatley MK. Comparison of the overall dimensions of large loop excision specimens of the cervix with the dimensions on histology. Pathology 2009; 41:242-4. [DOI: 10.1080/00313020802579581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Jimenez-Flores R, Mendez-Cruz R, Ojeda-Ortiz J, Muñoz-Molina R, Balderas-Carrillo O, de la Luz Diaz-Soberanes M, Lebecque S, Saeland S, Daneri-Navarro A, Garcia-Carranca A, Ullrich SE, Flores-Romo L. High-risk human papilloma virus infection decreases the frequency of dendritic Langerhans' cells in the human female genital tract. Immunology 2006; 117:220-8. [PMID: 16423058 PMCID: PMC1782223 DOI: 10.1111/j.1365-2567.2005.02282.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Dendritic cells (DC) are often arranged in planar layers in tissues with high antigenic exposure, such as skin and mucosae. Providing an en face view, this arrangement optimizes in situ analysis regarding morphology (even of individual dendrites), topographic distribution (regular/clustered) and quantification. The few reports on human genital DC usually utilize single markers and conventional sections, restricting immunolabelling only to cell parts sectioned by the cut. To better assess DC in situ, we labelled epithelial sheets, prepared from fresh cervix biopsies, with antibodies to major histocompatibility complex (MHC)-CII, CD1a and Langerin, revealing (with each of these markers) a dense DC network in a planar-like, regular distribution. Using the hybrid capture system to detect the high-risk mucotropic human papilloma virus (HPV) group, 16 positive and five negative women were studied and the results were compared between these groups. DC frequency per area was substantially reduced (to approximately 50% for the three markers) in samples from all HPV-infected patients compared with samples from controls. Unlike HPV(-) samples, Langerin(+) DC in HPV(+) cervix exhibited a highly accentuated dendritic appearance. We believe this to be the first study using these three DC-restricted markers (Langerin, CD1a and MHC-CII) in cervical epithelial sheets from high-risk HPV(+) donors and also the first study to demonstrate the morphological and quantitative changes triggered by high-risk HPV infection. Cervical DC reduction in early, premalignant high-risk HPV infection might represent viral subversion strategies interfering with efficient antigen handling by the immune system's peripheral sentinels, the DC, perhaps hampering appropriate recruitment and subsequent development of effector (cytotoxic) T cells.
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Affiliation(s)
- Rafael Jimenez-Flores
- Department of Experimental Pathology, CINVESTAV-IPNMexico
- Faculty of High Studies, Iztacala, UNAMMexico
| | - Rene Mendez-Cruz
- Department of Experimental Pathology, CINVESTAV-IPNMexico
- Faculty of High Studies, Iztacala, UNAMMexico
| | - Jorge Ojeda-Ortiz
- Cervical Pathology and Colposcopy Unit, Pachuca Regional HospitalMexico
| | | | | | | | | | - Sem Saeland
- Laboratory for Immunological ResearchLyon, France
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Tjalma W, Weyler J, Pollefliet C, Bogers J, Van Marck E, van Dam P, Buytaert P. The evaluation of proliferative activity in CIN III and microinvasive cervical cancer and its role in recurrence. Eur J Obstet Gynecol Reprod Biol 2001; 94:270-5. [PMID: 11165738 DOI: 10.1016/s0301-2115(00)00333-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the proliferation activity in CIN III lesions and Ia1 carcinoma according to the risk of recurrence. STUDY DESIGN The proliferation markers PCNA (proliferating cell nuclear antigen) and mitotic index were studied in 75 patients with CIN III and in 20 patients with an Ia1 squamous carcinoma of the cervix by staining representative tissue sections for the PCNA and assessing the mitotic index. Associations between the studied proliferation markers and various histopathologic characteristics as well as recurrence were assessed. RESULTS Three groups of PCNA were constituted: <20, 20--40, > OR =40% positive tumour nuclei, which contained, respectively, 45 (47%), 29 (31%), and 21 (22%) patients. Microinvasive carcinomas have a higher proliferation activity than CIN III (PCNA P=0.005; mitotic index P=0.094). For CIN III, there was a significantly lower risk for recurrence in the group with lower mitotic activity, compared to the group with higher mitotic activity (Kaplan-Meier: log-rank testing P=0.044). Significance was, however, not reached for the different PCNA categories (Kaplan-Meier, log-rank test P=0.068). Multiple regression analysis showed that in our population of CIN III lesions, only age of diagnosis and treatment modality were relevant (independent) prognostic indicators for recurrence. CONCLUSIONS In CIN III lesions there is evidence for an association between proliferation activity and the risk of recurrence. The observed crude association weakens when adjusting for age at diagnosis and treatment modality. Apparently this feature is associated with more aggressive biological behaviour and could be used to identify women who are at higher risk of recurrence.
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Affiliation(s)
- W Tjalma
- Laboratory of Cancer Research and Clinical Oncology, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium.
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Zaitoun AM, McKee G, Coppen MJ, Thomas SM, Wilson PO. Completeness of excision and follow up cytology in patients treated with loop excision biopsy. J Clin Pathol 2000; 53:191-6. [PMID: 10823137 PMCID: PMC1731153 DOI: 10.1136/jcp.53.3.191] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To assess the relation between the grade and the status of follow up cytology, the completeness of loop excision biopsies with cervical intraepithelial neoplasia (CIN), and the findings at follow up cytology, as well as the differences between complete and incomplete exclusion, using the odds ratio. Treatment failure was assessed. METHODS 1600 women with CIN (290 CIN1, 304 CIN2, 1006 CIN3) were followed for a minimum of six months and a maximum of 10 years. A database was created and comparisons performed. The mean age of the patients was 37 years. RESULTS Excision was complete in over 84% of loops. Residual disease and recurrence of high grade dyskaryosis was more common in women with CIN 3 than CIN 2 or 1. No high grade dyskaryosis was seen in the fifth follow up smear in patients with CIN 1 and CIN 2. Residual, recurrent, and persistent disease was most common in patients with incompletely excised CIN at ectocervical and endocervical margins and deep margins of resection than in patients with completely excised CIN. The odds ratios were significantly higher in the women who had incomplete excision of CIN at ectocervical, endocervical, both ecto- and endocervical, and deep margins of resection compared with those with apparent complete excision of CIN lesions. One patient developed invasive squamous cell carcinoma 44 months after loop excision which showed CIN 3 invading endocervical crypts and extending to both ectocervical and endocervical margins of resection. CONCLUSIONS At long term follow up, patients with CIN who have residual disease are at increased risk of persistent disease and should therefore be followed up regularly with cytology and colposcopy. The findings support national policy of returning women with treated CIN of any grade to normal recall after five years except for cases of CIN3 where excision was incomplete or equivocal. In these cases follow up with annual smear for 10 years is recommended.
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Affiliation(s)
- A M Zaitoun
- Department of Pathology, Mayday University Hospital, Surrey, UK.
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12
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Abstract
Clinical, subclinical, and latent human papillomavirus (HPV) infections are distinguished from HPV-associated neoplasia. Besides HPV additional cofactors are necessary to transform HPV infected tissue to intraepithelial or invasive neoplasia. Risk factors for the presence of HPV are high number of sexual partners, early cohabitarche, young age at first delivery, suppression and alteration of immune status, young age and hormonal influences. While the fact of a high number of sexual partners exclusively increases the risk of HPV infection, it is not known whether the other factors lead to either an increased risk for HPV infection and/or to HPV-associated neoplasia. Subclinical and latent genital HPV infections are highly prevalent. The prevalence rate depends on the sensitivity of the HPV detection system used, on age and sexual activity of the population screened, and on the number of subsequent examinations performed for each subject. Sexual transmission is the main pathway for genital HPV's, however, vertical, peripartal, and oral transmission are also possible. Seroreactivity against genital HPV may be due to an active infection or the result of contact with HPV earlier in life. Antibodies against the HPV 16 E7 protein indicate an increased risk for cervical cancer. Compared with humoral response cellular immune response is probably more important for regression of genital HPV infection: impaired cellular response is characterized by depletion of T helper/inducer cells and/or Langerhans cells and impaired function of natural killer cells and/or the infected keratinocyte. In condylomata replication and transcription of viral nucleic acids and antigen production coincide with cellular differentiation. However, the interaction between HPV and the keratinocyte on a molecular level in subclinical and latent disease is not well understood. Regression or persistence of subclinical and latent genital HPV infections as observed in longitudinal investigations show a constant come-and-go of HPV presence. Subclinical or latent cervical infections with high-risk HPV types (such as HPV 16 and 18) have an increased risk for the development of HPV-associated neoplasia.
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Koonings PP, d'Ablaing G, Schlaerth JB, Curtin JP. A clinical-pathology review of cervical intraepithelial neoplasia following cryotherapy failure. Gynecol Oncol 1992; 44:213-6. [PMID: 1541431 DOI: 10.1016/0090-8258(92)90044-j] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cervical intraepithelial neoplasia (CIN) after cryotherapy can pose both diagnostic and therapeutic problems. To clarify these issues, 27 consecutive patients who underwent cone biopsy for CIN after cryotherapy over a 10-year period at Women's Hospital LAC + USC Medical Center were reviewed. Although the initial features of the cervical intraepithelial neoplasia allowed for outpatient cryotherapy, the features of these failures did not (unsatisfactory colposcopy or CIN in the endocervical curettings). Eleven percent of these patients had stromal invasion on cone biopsy that was not suspected clinically. Patients presenting with cervical intraepithelial neoplasia following cryotherapy may, in fact, have progressive disease (i.e., stromal invasion) that is inapparent clinically. Hence, surgical excision should be considered in these circumstances.
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Affiliation(s)
- P P Koonings
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Women's Hospital, Los Angeles
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