More isn’t always better: Risk of recurrent high-grade squamous intraepithelial lesions after single-pass loop electrosurgical excision procedure (LEEP) versus LEEP with top hat (398)

Abstract

<b>Objectives:</b> The preferred treatment for high-grade intraepithelial neoplasia (HSIL) is the excisional procedure. Single-pass LEEP (LEEP- SP) and LEEP with a top hat (LEEP-TH) are commonly used excisional procedures. There is limited evidence to show the superiority of one surgical technique to another in terms of treatment failure. The objective of this study was to determine the risk of recurrent HSIL at two years after LEEP-SP versus LEEP-TH. <b>Methods:</b> Following IRB approval, this single-institution retrospective cohort study included all patients undergoing LEEP-SP or LEEP-TH for HSIL between 2005 and 2019. Patient demographics and risk factors for cervical neoplasia were collected along with preoperative cytology and colposcopy results. Follow-up cytology, colposcopy, and repeat surgical excision data were collected over a two-year follow-up period. Qualitative and quantitative analyses of the two patient cohorts were performed using descriptive statistics, Chi-squared or Fischer's exact for categorical variables, and Mann- Whitney U test for continuous variables using IBM SPSS Statistics (version 28.0.0.0). <b>Results:</b> A total of 340 patients met the inclusion criteria; 178 patients underwent a LEEP-SP, and 162 patients underwent a LEEP- TH. Patients undergoing LEEP-TH were more likely to be older (mean age: 40.40 +/- 10.13 years vs 36.49 +/- 10.45 years; p < 0.001), and have had a positive pre-procedure endocervical sampling ECS (68.5% vs 11.8%; p < 0.001). HSIL histology was found in 126 patients undergoing LEEP-SP (70.7%) and in 125 patients who underwent LEEP-TH (74.4%; p=0.182). Positive margins were found in 23 patients who underwent LEEP-SP (12.9%) and 25 who underwent LEEP-TH (15.4%; p=0.507). There was no significant difference in depth of excision between LEEP-SP and LEEP-TH (13.21+/- 23.19 mm vs 17.37 +/- 28.26 mm; p=0.138). In eight (4.9%) patients undergoing LEEP-TH, the initial pathology of the first pass specimen was benign, and only the top hat had HSIL. Only two (25%) of those patients also had a positive ECS. At two years follow-up, there was no difference in the rates of HSIL cytology (7 patients [5.2%] vs 8 [6.3%]), any positive HPV test or HSIL cytology (27 patients [25%] vs 19 [15%]), or repeat excision (11 patients [8.9%] vs 16 [12.4%]) between LEEP-SP and LEEP-TH. Repeat excision was performed in 27 patients, who were more likely to be older (mean age: 42.26 +/- 10.75 years vs 36.77 +/- 10.36 years; p=0.016) and have initial cytology HSIL (63.0% vs 33.3%; p=0.003), compared to patients who did not undergo repeat excision. <b>Conclusions:</b> In this single-institution study, there is no difference in the rate of recurrent HSIL or repeat excision in patients who undergo LEEP-SP compared with LEEP-TH. Additionally, there appears to be no difference in the rate of positive margins or positive ECS at the time of excision between the two groups. This suggests that a LEEP-TH may have limited additional benefit over a single pass LEEP in the treatment of cervical HSIL.