Management and Outcome of Cervical Intraepithelial Neoplasia Lesions: A Study of Matched Cases According to HIV Status

Abstract

A review of medical records at St. Pierre Hospital in Brussels identified 95 women with HIV infection who had undergone a cervical biopsy between January 1995 and March 2002. Sixty-eight of these patients had a diagnosis of cervical intraepithelial neoplasia (CIN), were not pregnant, and had sufficient data for analysis. They were matched according to stage of disease, age, and, when possible, parity to women who were negative for HIV infection. The management and outcomes of these 2 groups of patients were compared for this study. Treatment choices included follow up alone, vaporization or cryotherapy, or conization. Among women with CIN I (n = 24), 9 HIV-positive and 6 HIV-negative patients were followed with no treatment; 5 and 8, respectively, were treated with vaporization or cryotherapy, and 3 each underwent conization. In the patients with CIN II (n = 50), only 1, an HIV-negative woman, was followed with no other treatment, 2 HIV-positive and 8 HIV-negative patients had vaporization or cryotherapy, and 23 and 15, respectively, underwent conization. Only 1 of 52 patients with CIN III was not treated by conization; she was an HIV-positive patient who had cervical vaporization. One HIV-negative woman with CIN II underwent hysterectomy. Positive margins were seen in the cone specimen of 43% of patients with HIV compared with 20% of patients not infected with HIV (P <0.01). After treatment, HIV-positive women were nearly twice as likely as HIV-negative women to have a positive cervical smear (64% vs. 31%, P <0.001). The cytologic results for HIV-positive women were 16 low-grade and 13 high-grade squamous intraepithelial lesions (LSIL and HSIL, respectively) compared with 2 diagnoses of LSIL and 5 of HSIL for HIV-negative patients. Among patients who underwent conization, those positive for HIV were significantly more likely to have a positive cervical smear after treatment than nonHIV-infected women (P <0.01). Similar results were seen when the analysis was restricted to only those with positive margins in the cone specimen. With an overall follow-up period of 2 to 97 months (median, 22 months for HIV-positive and 21 months for HIV-negative women), HIV-positive women were more likely to have a recurrence of CIN compared with HIV-negative patients (78% vs. 36%, P <0.001). Treatment choice did not seem to affect the outcome. Among 9 HIV-positive women who received no further treatment, there were 2 normal and 5 abnormal smears. In the 8 patients with HIV who had vaporization or cryotherapy, 3 had normal follow-up smears and 5 had abnormal results. There were 17 normal and 27 abnormal cervical smears among HIV-positive women who underwent conization. Patients negative for HIV infection were more likely to have normal than abnormal follow-up cervical smears across all treatment groups. Thirteen of 28 HIV-positive women with negative margins in the cone specimen nevertheless had recurrent CIN. There were no recurrences in HIV-negative women with negative margins (P <0.01). Among women with HIV infection, 9 of 44 (20%) patients with recurrent dysplasia were considered to be positive responders to antiviral therapy (ie, they had at least 1 viral load lower than 50 copies/mL from the time of treatment to the time of biopsy) compared with 7 of 12 (60%) who did not develop recurrent dysplasia (P <0.01).