Positive Ectocervical Margins Research Articles

Risk factors predicting residual lesion in subsequent hysterectomy following cold knife conization (CKC) for high-grade squamous intraepithelial lesion (HSIL)

ObjectiveTo determine risk factors predicting residual lesion in a subsequent hysterectomy follow a cold knife conization (CKC) for high-grade squamous intraepithelial lesion (HSIL).MethodBetween January 2010 and December 2021, a total of 740 patients who underwent a hysterectomy within 3 months after CKC for HSIL were included in this study. We analyzed their demographic features and pathological parameters. A logistic regression model was used to analyze the relationship between parameters and residual lesion in subsequent hysterectomy specimens.Results104 (14.1%) had residual lesion in the hysterectomy specimen, 3 patients with microinvasive carcinoma. The rate of residual lesion in patients with positive endocervical margin was 31.3%, with positive ectocervical margin was 15.3%, with positive combine margin was 38.6%. In multivariate analysis, positive margin (OR 4.015; 95% CI 2.526–6.381; P < 0.001), glandular involvement (OR 3.484; 95% CI 1.457–8.330; P = 0.005), HPV16/18 infection (OR 2.804; 95% CI 1.705–4.611; P < 0.001) and multiple HR-HPV infection (OR 1.813; 95% CI 1.130–2.909; P < 0.014) were independent risk factors for residual lesion. The AUC calculated by logistic regression model was 0.78.ConclusionPositive margin, positive glandular involvement, HPV16/18 and multiple HR-HPV infection were independent high risk factors of residual lesion in a subsequent hysterectomy following CKC for HSIL.

Laparoscopic Upper Colpectomy for VAIN III after Previous Total Hysterectomy

To demonstrate the feasibility of laparoscopic upper colpectomy for the treatment of vaginal intraepithelial neoplasia (VAIN) after previous total hysterectomy. Stepwise demonstration of the technique with narrated video footage. In 2014, our patient aged 60 years underwent a routine smear that reported severe dyskaryosis. This was treated with large loop excision of the transformation zone. Histopathology confirmed cervical intraepithelial neoplasia II, with positive ectocervical margins. The patient was counseled for both repeat large loop excision of the transformation zone and hysterectomy, opting for definitive surgery. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed in January 2015, completely excising the residual cervical intraepithelial neoplasiaII. A vault smear was performed in October 2015, reporting further severe dyskaryosis. The patient subsequently underwent examination under anesthesia and multiple upper vaginal mapping biopsies-identifying extensive VAIN III. The case was successfully managed by a laparoscopic upper colpectomy. When determining the area of VAIN to be excised, it can be useful to place a vaginal marker stitch; however, we chose to perform a colposcopy and apply acetic acid to help delineate the extent of the VAIN, immediately before laparoscopy. The right-sided pelvic sidewall dissection proved more extensive owing to the disease burden on that side. No intra- or postoperative complications occurred. The final histopathology confirmed a 65 × 35 × 8-mm upper colpectomy specimen with VAIN III and clear surgical margins. The patient has since had a normal vault smear and no recurrence to date. We highlight the importance of gaining early retroperitoneal access and developing the lateral pelvic spaces to identify the ureters and gain vascular control of the pelvis. We demonstrate an approach to safely developing the posthysterectomy vesicovaginal plane, with the aid of bladder filling. We used a McCartney tube (Kebomed UK, Cullompton, Devon) to facilitate colpotomy and closed the vagina using a laparoscopic suturing technique. We believe laparoscopic upper colpectomy offers definitive management of VAIN-a condition that otherwise has a propensity for recurrence and is hence often associated with multiple vaginal excisional procedures.

What is the value of pre-surgical variables in addition to cone dimensions in predicting cone margin status?

ObjectivePrevious studies have shown associations between independent pre-conization variables (e.g. smoking, age, cytological grade, menopause) and positive or negative cone margins. However, it is not clear if these pre-surgical variables add predictive value to cone dimensions in the prediction of cone margin status. This study aimed to compare different models predicting positive ecto- or endocervical margins to assess whether pre-conization variables provide significant added value compared with cone dimensions alone. Study designOne hundred and sixty-one consecutive women with high-grade cervical intra-epithelial neoplasia on cone specimens were analysed retrospectively. The sample was divided into women with positive ecto- or endocervical cone margins and women with negative ecto- or endocervical cone margins. Pre-conization clinical features, cone volume and cone length were included among the study variables. Multivariate stepwise regression analysis was used to create different models predicting incomplete cervical excision. The added value of pre-conization predictors was measured with receiver operating characteristic (ROC) curve comparisons. ResultsFifty-seven (35.4 %) women had incomplete cervical excision. Multivariate analysis showed that a positive ectocervical margin was significantly associated with low-grade cervical cytology [odds ratio (OR) = 0.25, 95 % confidence interval (CI) 0.09–0.70] and cone length (OR = 0.69, 95 % CI 0.58–0.82, criterion <9 mm). The area under the curve (AUC) of the combined model for prediction of a positive ectocervical margin was 0.78 (95 % CI 0.70–0.84, p < 0.001). A positive endocervical margin was associated with cone length (OR=0.78, 95 % CI 0.65–0.93, criterion <9 mm) and age (OR=1.07, 95 % CI 1.02–1.11, criterion ≥45 years). The AUC of the combined model for prediction of positive endocervical margin was 0.75 (95 % CI 0.66–0.82, p < 0.001). Comparison of ROC curves showed that the addition of pre-conization variables to cone length did not yield significant predictive results for either ecto- or endocervical cone margins (p = 0.228 and 0.349, respectively). ConclusionsThe addition of pre-conization clinical variables to cone dimensions did not improve the prediction of cone margin status significantly in the study cohort. Among cone dimensions, cone length was the best predictor of come margin status.

Risk Factor Analysis of Persistent High-Grade Squamous Intraepithelial Lesion After Loop Electrosurgical Excision Procedure Conization.

The aim of the study was to analyze the clinical outcomes of high-grade squamous intraepithelial lesion (HSIL) 6 months after loop electrosurgical excision procedure (LEEP). We explored the risk factors of persistent cervical HSIL after LEEP and evaluated the methods of follow-up. This retrospective study included women who underwent a LEEP and had a diagnosis of HSIL in their LEEP specimen during 2011 to 2015. The purpose was to determine the risk factors among these women for having persistent HSIL disease at their 6-month follow-up visit. At their follow-up visit, each woman underwent cervical cytology and high-risk human papilloma virus (hrHPV) testing, colposcopy-directed punch biopsy, and/or endocervical curettage. A total of 3582 women were enrolled. There were 9 cases invasive cervical cancer found and 101 women had persistent HSIL. The persistence rate was higher in women 50 years or older. The circumference, length, and width of LEEP specimens did not differ statistically between the persistent and nonpersistent group. The persistence rate among women with positive LEEP specimen margins was higher than among women with negative margins. Positive endocervical margins were associated with a higher rate of persistence than positive ectocervical margins. Multivariate logistic analysis showed that age, positive margins, abnormal cytology, and positive hrHPV during follow-up were all independent risk factors for persistent HSIL lesions. Being 50 years or older, positive margins, particularly endocervical margins, and having abnormal cytology and positive hrHPV testing during follow-up were risk factors for persistent HSIL lesions after LEEP conization. Colposcopy plays an indispensable role in the diagnosis of persistent HSIL and progression.

Clinical outcome and high risk factor for residual lesion analysis of HSIL half a year after loop electrosurgical excision procedure: a clinical study of 1 502 cases

Objective: To analyze clinical outcome of high-grade squamous intraepithelial lesion (HSIL) half a year after loop electrosurgical excision procedure (LEEP) and explore the high risk factor of residual cervical HSIL. Methods: The retrospective study was carried out on 1 502 patients who underwent LEEP, with HSIL in the LEEP histopathology from January 2011 to December 2013 at Obstetrics and Gynecology Hospital of Fudan University to confer the difference between residual group and non-residual group after 6 months of the leep conization. Patients were followed with ThinPrep cytologic test (TCT), high risk HPV (HR-HPV) test, colposcopy guided biopsy (CBD) and endocervical curettage (ECC). The high risks of residual cervical HSIL was analyzed. Results: Among 1 502 cases, 48 (3.20%, 48/1 502) cases suffered HSIL residual disease. Forty cases were diagnosed by CBD, 4 cases were diagnosed by ECC. The other 4 cases were both positive in CBD and ECC. Residul rate were different among different age groups. The residual rate was higher in the age ≥50 years old compared to the age below 50 [9.70% (16/165), 2.39% (32/1 337); χ(2)=25.33, P<0.01]. For post-LEEP specimens, both circumference (2.5, 2.8 cm; Z=-3.17, P<0.01) and width [0.6, 0.6 cm; Z=-2.88, P<0.01) were less in HSIL lesion residual group than those in non-residual group, though length showed no obvious difference [1.5, 1.5 cm; Z=-1.55, P>0.05) . The residual rate of leep positive margin was obviously higher than that in the negative margin group [6.77% (18/266) vs 2.43% (30/1 236) ; χ(2)=13.30, P<0.01]. Different positive margin had diverse residual rate, as positive endocervical margin was 16.07% (9/56), positive margin undetermined was 7.29%(7/96) and positive ectocervical margin was 3.33%(4/120). Both positive endocervical margin and positive margin undetermined had a higher residual rate than residual rate (χ(2)=26.99, P<0.01; χ(2)=4.24, P<0.05). Abnormal cytology showed higher residual rate than the non-residual with significant difference [6.00% (6/100) vs 1.29% (14/1 083) , χ(2)=9.50, P<0.01]. In terms of the post-LEEP HR-HPV test follow-up, HR-HPV positive's residual rate was higher than that in the negative group [2.91% (6/206) vs 0.96% (7/727)], while there was no statistical significance (χ(2)=3.10, P>0.05). Multivariate logistic analysis showed that abnormal cytology in 6 month's follow-up post-LEEP conization was an independent risk factor on residual lesion (OR=3.75, P<0.05). Conclusions: Patient with age ≥50 years old and positive endocervical margin are high risk factors for the residual HSIL lesion after LEEP conization,especially for abnormal cytology during follow up is independent risk factor for residual lesion. Colposcopy directed biopsy and (or) ECC still play an indispendsable role in finding the HSIL residual lesion.

Value of endocervical margin and high-risk human papillomavirus status after conization for high-grade cervical intraepithelial neoplasia, adenocarcinoma in situ, and microinvasive carcinoma of the uterine cervix

ObjectiveThe aim of this study was to analyze clinico-pathologic factors and the optimal cut-off value of high-risk human papillomavirus (HR-HPV) viral load for predicting high-grade residual/recurrent disease after the conization in cervical intraepithelial neoplasia (CIN 2–3), adenocarcinoma in situ (AIS), and microinvasive carcinoma of the uterine cervix (MICA). MethodsWe retrospectively reviewed data from 701 patients with CIN 2–3, AIS, and MICA who underwent conization between September 2003 and June 2012. Receiver-operating characteristic curve analysis was used to find out the cut-off value of HR-HPV viral load for predicting residual/recurrent disease. Clinico-pathologic variables, including resection margin and HR-HPV status, were evaluated as possible predictors of residual/recurrent disease. ResultsAt a cut-off value of 1.16 RLU/CO for post-cone HR-HPV viral load, the sensitivity was 88.2% and the specificity was 98.3%. Multivariate analysis demonstrated that post-cone cytology (p=0.001, OR=83.808, 95% CI=6.688–1050.232), endocervical margin status (p<0.001, OR=80.478, 95% CI=7.421–872.732), and post-cone HR-HPV status (p<0.001, OR=79.660, 95% CI=8.539–743.129) were significantly associated with residual/recurrent disease. The post-cone HR-HPV positivity was observed more in the patients who showed positive endocervical margin than in the patients with positive ectocervical margin (32.6% vs. 5.3%, p=0.002). ConclusionsFollow-up using liquid based cytology in combination with HR-HPV test at 12months after the conization, and not the early HR-HPV test, might be acceptable. Post-cone endocervical margin status combined with post-cone HR-HPV test is critical for predicting residual/recurrent disease and clinical management.

Repeat LEEP conization in patients with cervical intraepithelial neoplasia grade 3 and positive ectocervical margins

Objective To evaluate the effectiveness of repeat loop electrosurgical excision procedure (LEEP) conization in patients with cervical intraepithelial neoplasia (CIN) grade 3 and positive ectocervical margins. Method A retrospective study of 56 women who underwent repeat LEEP conization for CIN 3 and positive ectocervical margins. Results Final diagnosis after repeat LEEP conization revealed 6 women (10.7%) with microinvasive squamous cell carcinoma (Stage IA1); 1 (1.8%) with CIN 1; 1 (1.8%) with CIN 2; 21 (37.5%) with CIN 3; and 27 (48.2%) with chronic cervicitis. Ectocervical or endocervical margins were negative after repeat LEEP conization in the majority of women, except for 2 patients (3.6%) with CIN 3 and positive ectocervical margins. Recurrence rate for the median follow-up time of 2 years was 6.1% (3 patients). Conclusion Repeat LEEP conization can reveal undiagnosed microinvasive cervical carcinoma in women with positive ectocervical margins.

Conservative management of positive resection margins after loop electrosurgical excision procedure.

We sought to determine the pres-ence of residual neoplasia in women reported previously as having positive surgical margins after loop electrosurgical excision procedure of the cervix. Of 460 loop electrosurgical excision procedures of the cervix, 127 (27.6%) had margins positive for cervical intraepithelial neoplasia. We re-viewed the charts of 74 patients (58%). We found positive en-docervical margins in 68 of 74 (92%) and positive ectocervical margins in 4 of 74 (5%). In 2 of 74 (3%), the location of the positive margin was unknown. Patients were followed either with three consecutive Papanicolaou smears (n = 43) during the year after the procedure or with conization or hysterec-tomy (n = 31). The overall rate of spontaneous regression of cervical intraepithelial neoplasia was 64%. The small study sample does not permit us to conclude whether either positive ectocervical or endocervical margins were more amenable to recurrence. No invasive cancer was diagnosed in the study. With a reliable patient population, patients with cervical margins positive for cervical intraepithelial neoplasia after loop electrosurgical excision procedure can be followed safely with cytology.