Underwent Loop Electrosurgical Excision Procedure Research Articles

P16 expression in patient with Loop Electrosurgical Excision Procedure (LEEP)

HIGHLIGHTS Clinicopathologic characteristic of patient with LEEP procedures dominated by women above 35 years old, with total parity less than 3 and without history of contraceptive usage. The p16 expression analyzed by immunohistochemistry technique. The positive and negative reactivity of p16 ratio was 3:5 on LEEP specimen which microscopically appear as chronic cervicitis, low-grade and high-grade squamous intraepithelial lesion. ABSTRACT Objective: The study aim was to reveal p16 expression with the clinicopathological characteristics of patients who underwent cervical biopsy using the Loop electrosurgical procedure (LEEP) at Udayana University Hospital for the period 2020 – 2023. Materials and Methods: The research was conducted at Anatomic Pathology Laboratory of Udayana University Hospital, Denpasar, Bali, Indonesia. The samples were selected based on inclusion criteria such as the formalin fixed paraffin embedded (FFPE) sample from positive IVA patient and continue for LEEP procedure. Otherwise, the exclusion criteria were moldy FFPE sample and incomplete clinical data. Then, p16 immunostaining procedure was carried out manually. The interpretation of p16 results was analyzed using SPSS software, version 25 by International Business Machines (IBM) Corporation. Results: The positive p16 expression was revealed in 12 samples (38.7%), in contrast the negative staining appeared in 19 samples (61.3%). Unfortunately, p16 expression was not significant statistically based on age, parity, and contraceptive history, with p-values of 1.00, 0.45, and 0.65, respectively. Meanwhile, a statistically significant association was found between p16 expression and histopathologic diagnostic (p = 0.02, 95% CI 1.4 – 38.3). In addition, 22.2% of the variation of p16 expression based on multivariate analysis demonstrating a significant correlation (p = 0.01). Conclusion: p16 expression with histopathology diagnostic characteristic in patient who underwent Loop Electrosurgical Excision Procedure (LEEP) was found statistically significant. Moreover, clinical application of p16 in daily practice should be performed with consideration especially for pre-cancer lesion in LEEP biopsy specimen procedure and clinicopathological approach is essential.

HPV DNA Testing and Mobile Colposcopy for Cervical Precancer Screening in HIV Positive Women: A Comparison Between Two Settings in Ghana and Recommendation for Screening.

Women living with HIV (WLHIV) have higher prevalence and persistence rates of high-risk human papillomavirus (hr-HPV) infection with a six-fold increased risk of cervical cancer. Thus, more frequent screening is recommended for WLHIV. This retrospective descriptive cross-sectional study was conducted to investigate and compare the prevalence of hr-HPV infection and abnormal findings on mobile colposcopy in two cohorts of WLHIV following cervical screening in rural and urban settings in Ghana. Through the mPharma 10 000 Women Initiative, WLHIV were screened via concurrent hr-HPV DNA testing (MA-6000; Sansure Biotech Inc., Hunan, China) and visual inspection (Enhanced Visual Assessment [EVA] mobile colposcope; MobileODT, Tel Aviv, Israel) by trained nurses. The women were screened while undergoing routine outpatient reviews at HIV clinics held at the Catholic Hospital, Battor (rural setting) and Tema General Hospital (urban setting), both in Ghana. Two-hundred and fifty-eight WLHIV were included in the analysis (rural, n = 132; urban, n = 126). The two groups were comparable in terms of age, time since HIV diagnosis, and duration of treatment for HIV. The hr-HPV prevalence rates were 53.7% (95% CI, 45.3-62.3) and 48.4% (95% CI, 39.7-57.1) among WLHIV screened in the rural vs urban settings (p-value = .388). Abnormal colposcopy findings were found in 8.5% (95% CI, 5.1-11.9) of the WLHIV, with no significant difference in detection rates between the two settings (p-value = .221). Three (13.6%) of 22 women who showed abnormal colposcopic findings underwent loop electrosurgical excision procedure (LEEP), leaving 19/22 women from both rural and urban areas with pending treatment/follow-up results, which demonstrates the difficulty faced in reaching early diagnosis and treatment, regardless of their area of residence. Histopathology following LEEP revealed CIN III in 2 WLHIV (urban setting, both hr-HPV negative) and CIN I in 1 woman in the rural setting (hr-HPV positive). There is a high prevalence of hr-HPV among WLHIV in both rural and urban settings in this study in Ghana. Concurrent HPV DNA testing with a visual inspection method (colposcopy/VIA) reduces loss to follow-up compared to performing HPV DNA testing as a standalone test and recalling hr-HPV positive women for follow up with a visual inspection method. Concurrent HPV DNA testing and a visual inspection method may also pick up precancerous cervical lesions that are hr-HPV negative and may be missed if HPV DNA testing is performed alone.

HPV E6/E7 mRNA combined with thin-prep cytology test for the diagnosis of residual/recurrence after loop electrosurgical excision procedure in patients with cervical intraepithelial neoplasia

To evaluate the diagnostic value of combining HPV E6/E7 mRNA testing with Thin-Prep cytology (TCT) for residual/recurrence detection, a total of 289 patients who underwent loop electrosurgical excision procedure (LEEP) for high-grade cervical lesions were included. Patients were followed up at different time points, and residual/recurrent lesions were confirmed through vaginoscopy. TCT, HPV-DNA, and HPV E6/E7 mRNA tests were conducted. Diagnostic performance, including sensitivity, specificity, positive predictive value, negative predictive value, and accuracy, was assessed. Among the patients, 76 cases showed residual lesions/recurrence, while 213 cases showed no residual/recurrence. Positive margins in the cervical-vaginal and cervical canal areas were associated with a higher risk of residual/recurrence. The combined HPV E6/E7 mRNA and TCT test showed higher diagnostic efficacy than individual tests at 6-, 12-, and 24-months follow-up. The combined test consistently demonstrated higher specificity and sensitivity, with significantly larger area under the curve (AUC) values compared to the individual tests.

Certification as dysplasia unit and its impact on large loop electrosurgical excision (LEEP)

PurposeThis study evaluates the overall treatment indicators and outcomes of patients who underwent loop electrosurgical excision procedure (LEEP) at the Department of Women’s Health Tübingen and the impact of certification as a dysplasia unit on treatment quality.MethodsRetrospective data analysis of 1596 patients from 2013 to 2018 who underwent LEEP excision at the Department of Women’s Health Tübingen. Data of cytology, colposcopy, biopsy, LEEP histology, repeat LEEP histology and general characteristics were collected and analyzed descriptively.Results85.4% (1364) of patients had CIN 2 + and 14.6% (232) had CIN 1 or normal findings on LEEP histology. The proportion of CIN 2 + excisions increased significantly from 82.4% in 2013 to 89% in 2018. The concordance of HSIL biopsy and LEEP histology was 89.1% in 2013 and 92.6% in 2018. In 2018, more biopsies and colposcopies were performed before excision. Complete resection (R0) was achieved in 88.3% of all excisions. R0 rates in patients with CIN 3 increased in 2014–2017 compared to 2013, resulting in fewer Re-LEEP excisions and hysterectomies.ConclusionCertification as a dysplasia unit and the associated requirements have improved the diagnostic quality for patients with cervical dysplasia undergoing LEEP. This was demonstrated by several treatment indicators such as the number of colposcopies and biopsies and treatment outcomes such as an increased proportion of CIN 2 + excisions and R0 resections.

Identifying risk factors for post-operative bleeding in women undergoing loop electrosurgical excision procedure for cervical dysplasia.

Loop electrosurgical excision is a procedure utilised in the treatment of high-grade squamous intraepithelial lesion (HSIL) of the cervix. Post-operatively women may experience immediate and/or delayed per vaginal bleeding. The objective of this prospective pilot study was to assess the feasibility of identifying and quantifying patients' subjective experiences of post-operative bleeding following a loop electrosurgical excision procedure (LEEP) for HSIL. In addition, an analysis of demographical, lifestyle and surgical factors was undertaken to assess for any statistically significant correlation with post-operative bleeding. This study included 110 patients who underwent a LEEP for biopsy-proven or suspected HSIL between 2017 and 2020. Subjective data were collected from weekly post-operative surveys and correlated with procedural data. Primary outcome assessed was the subjective rate of bleeding experienced. Baseline demographics were age, body mass index (BMI), specimen size, human papilloma virus variant and histopathology. Other variables of interest collected were exercise intensity, and alcohol intake. No association of statistical significance was discovered between age, BMI, or day of menstrual cycle. There was a statistically significant association between exercise intensity or specimen size (greater than the median) and increased bleeding, primarily in the first 2 weeks. Women who undergo intense or prolonged exercise in the post-operative period may experience heavier bleeding particularly in the first 2 weeks post-LEEP. Heavy bleeding was also associated with a larger specimen size. There was no correlation between BMI, age or any other demographical factor.

Factors Associated with Cyto-Histological Misinterpretation of Cervical Smear according to Menopausal Status.

ObjectivesThis study aimed to compare histological outcomes between pre-menopausal and post-menopausal women with cervical cytological abnormalities and to investigate the clinical factors affecting the misinterpretation of cytology and histology.MethodsWe conducted a retrospective analysis of 599 patients with abnormal cervical cytology who underwent loop electrosurgical excision procedure (LEEP) between January 2010 and May 2019. Baseline characteristics were collected, including age, height, weight, body mass index, gravity, parity, and menopausal status. In total, 477 pre-menopausal women and 122 post-menopausal women were recruited.ResultsAtypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions were cytologically observed in 73.4% (135/184) of the pre-menopausal women, which were high-grade lesions confirmed by LEEP. In post-menopausal patients with cytology results that cannot exclude high-grade squamous intraepithelial lesions (ASC-H) or high-grade squamous intraepithelial lesions (HSIL), 27.0% (24/89) were confirmed to have histologically low-grade lesions. High-risk HPV (hrHPV) prevalence in abnormal cervical smears was 92.2%. Moreover, other hrHPVs had a higher risk of unexpected histological outcomes unrelated to cytologic results.ConclusionsMenopausal status and HPV infection are associated with misinterpretation of cervical cytology and histology. Therefore, the menopausal status of patients should be considered for the management of cervical cytology, and primary co-testing is recommended to identify women at risk of cervical abnormalities.

The role of endocervical curettage in detection and treatment of cervical canal lesions.

To screen out high-risk groups of endocervical lesions, explore the effect of length of excision on margin status in women with abnormal endocervical curettage (ECC) and explore the role of ECC in the additional detection of high-grade squamous intraepithelial lesion or worse (HSIL+) under colposcopy and lesion-targeted biopsies. The study included 936 patients who underwent loop electrosurgical excision procedure (LEEP) for cervical lesions which were diagnosed by cervical biopsy and ECC at the cervical clinic of the First Affiliated Hospital of Chongqing Medical University from January 2014 and December 2018. The correlations among abnormal ECC, human papillomavirus (HPV) type, cytology, margin of excision, and age were analyzed by Pearson's χ² test and multivariate logistic regression analysis. Abnormal ECC was associated with HPV-16 infection (P<0.001), or HSIL cervical cytology or worse (P<0.001), or aged 50 years old or older (P<0.001). Abnormal ECC was associated with positive margin of excision (P<0.001). For patients with abnormal ECC, the length of excision was independent of margin status (P=0.762). Among all the 491 patients with HSIL+ diagnosed by either cervical biopsy or ECC, the additional detection rate of HSIL+ by ECC was only 8.76% (43/491). In our study, ECC was recommended in women with HPV16 infection, HSIL cervical cytology or worse, aged 50 or older, or invisible transformation zone in colposcopy. At the same time, our results suggested that ECC abnormalities were associated with positive margin of excision. The data did not support performing a longer length of excision in patients with abnormal ECC, especially in women with fertility needs. In summary, patients with abnormal ECC should be given more attention and follow-up to avoid missing residual lesions.orse prognostic factor in breast cancer patients.

Treatment Outcomes of Patients With Cervical Intraepithelial Neoplasia or Invasive Carcinoma Who Underwent Loop Electrosurgical Excision Procedure.

BackgroundThis study aimed to evaluate the treatment outcomes of cervical intraepithelial neoplasia (CIN) or cancer patients who underwent loop electrosurgical excision procedure (LEEP) in terms of primary outcome and factors associated with persistence/recurrence.MethodsPatients with CIN or cancer who underwent LEEP from January 2007 to December 2015 were reviewed. Data collected were age, parity, menopausal status, human immunodeficiency virus (HIV) infection, smoking, cervical cytology, histopathology from cervical biopsy and LEEP including margin status, final histopathology, and follow-up data.ResultsThe mean age of 385 patients was 41.9 ± 10.8 years (range 18 - 79 years). Majority were multiparous (81.6%) and premenopausal (78.2%). There were 15.3% of patients with HIV infection. The most common cervical cytology was high-grade squamous cell intraepithelial lesion (HSIL, 44.1%), followed by atypical squamous cells of undetermined significance (ACS-US, 21%). Minor complications of bleeding or infection from LEEP were encountered in 7.3%. Among 153 patients (39.7%) who had positive margin(s), 43 underwent second LEEP, whereas 76 had hysterectomy. From all patients, 47 had failure after treatment (12.2%), being either persistence (30 patients; 7.8%) or recurrence (17 patients; 4.4%). Factors associated with persistence or recurrence by multivariate analysis were age ≥ 55 years old, HIV infection, final diagnosis of invasive cancer, and positive endocervical margin or both ecto- and endo- cervical margins.ConclusionsLEEP had low rate of persistence/recurrence. Age ≥ 55 years old, HIV infection, final diagnosis of cancer, and positive endocervical or both endo- and ecto- surgical margin(s) were significantly associated with persistent or recurrent diseases.

Predictors of recurrence in patients with high-grade cervical intraepithelial neoplasia after cervical conization.

This study was to identify the predictors of recurrence in patients with high-grade cervical intraepithelial neoplasia (CIN) after cervical conization.Totally 415 patients with CIN ≥ II who underwent loop electrosurgical excision procedure (LEEP) or cold knife conization (CKC) were included in this retrospective study. Cox proportional hazards model was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) regarding the association between postoperative recurrence and clinicopathological data.After the mean follow-up of (21.48 ± 5.82) months, 90 (21.69%) out of 415 cases were subjected to recurrence after cervical conization. The influencing factors for postoperative recurrence included times of full-term birth, history of preterm birth, history of abortion, positive margin, cone length, width, depth, smoking, and history of complicating diseases (P < .05). Multivariate Cox model indicated the positive margin (HR = 2.144, 95% CI: 1.317–3.492, P < .05), history of preterm birth (HR = 4.515, 95% CI: 1.598–12.754, P < .05), history of complicating diseases (HR = 3.552, 95% CI: 1.952–6.462, P < .05) were independent risk factors for recurrence after cervical conization. The restricted cubic diagram showed that the cone depth >0.5 cm was a protective factor for postoperative recurrence.For the patients with high-grade CIN after cervical conization, positive margins, histories of preterm birth, and complicating diseases were associated with increased risk of recurrence, but cone depth (>0.5 cm) with lower risk of recurrence.

Follow-up After Loop Electrosurgical Excision of Cervical Intraepithelial Neoplasia: The Use of Combined Cytology and Human Papillomavirus Testing.

The aims of the study were to investigate how many women after 1 or 2 follow-up examinations, based on combined cervical cytology and human papillomavirus (HPV) testing, could finish posttreatment follow-up and continue with the general screening program and to determine the 5-year risk of recurrence in this group. This is a prospective observational study that includes women, who underwent loop electrosurgical excision procedure (LEEP) in the North Denmark Region, from January 1, 2012, to May 31, 2014. All included women had histologically verified diagnosis of high-grade cervical intraepithelial neoplasia (CIN 2+) or adenocarcinoma in situ (AIS) before LEEP and posttreatment follow-up with cervical cytology and HPV combination testing. Study period was until October 2019. Totally, 563 women were included in the study. After finishing the posttreatment follow-up, 439 (78%) could continue to the general screening program and 362 of them had a screening during the study period. Six women (1.7%) had either cervical dysplasia and/or HPV infection in the cervical screening, and of these, 3 (0.8%) had high-grade dysplasia corresponding to CIN 2. None was diagnosed with CIN 3, AIS, or invasive carcinoma. One hundred twenty-one women (36%) chose to be screened sooner than recommended in the national guidelines. Human papillomavirus and cytology combination test after LEEP allows women, irrespective of margin status, safely to continue with the general screening program after a short posttreatment follow-up period. Improved information is mandatory to reduce "opportunistic" screening after finishing posttreatment follow-up.

Near-Histologic Resolution Images of Cervical Dysplasia Obtained With Gabor Domain Optical Coherence Microscopy.

ObjectiveHistopathology is the criterion standard for evaluating cervical squamous intraepithelial neoplasia (dysplasia). In this pilot feasibility study, we examined whether a novel 3-dimensional imaging device using Gabor-domain optical coherence microscopy (GDOCM) could distinguish features of cervical dysplasia comparable with histopathology.MethodsA prospective observational pilot study enrolled a small sample of women undergoing loop electrosurgical excision procedure for cervical squamous intraepithelial neoplasia. Fresh ex vivo specimens were imaged with the GDOCM device. Digital images were reviewed by a pathologist who was blinded to the histopathology results. Histopathologic features were then compared with the digital observations.ResultsStandard histologic features of cervical squamous epithelium and of squamous intraepithelial neoplasia could be observed in GDOCM images. Cervical epithelium, stroma, basement membrane, and squamous papilla could all be identified. Human papillomavirus effects, such as vacuolization and cellular density, were also observed.ConclusionsA GDOCM imaging system has the potential to obtain histologic resolution images of the cervix in the evaluation of squamous intraepithelial neoplasia. This pilot study allowed for optimizing the imaging system and paved the way for a future diagnostic accuracy study. The development of this technology could streamline the evaluation of patients at risk for cervical neoplasia.

Effects of Mefenamic Acid in Pain Control during Loop Electrical Excision Procedure:A Prospective Double-Blind Randomized Control Trial.

Objective: To investigate the effectiveness of pre-procedural oral mefenamic acid compared with placebo in women undergoing Loop Electrosurgical Excision Procedure (LEEP) with intracervical lidocaine injection. Study designs:A prospective double-blinded randomized control trial. Materials, Setting, Methods:Women undergoing LEEP for any indications were asked to participate in the study. The participants were randomly allocated into two groups. In group 1 (oral mefenamic acid), the participants were offered oral mefenamic acid (500 mg) for 30 minutes before procedures. In group 2 (placebo), the patients were given oral placebo (identical tablet) for 30 minutes before operation. All participants received immediate 10 mL of 2% lidocaine with 1:100,000 of epinephrine intracervical injection before undergoing the LEEP. All participants were excised in one piece of LEEP. No top-hat excision in this study. The patients graded their pain on a 10-cm visual analog scale (VAS) at different points during the procedure, including speculum insertion, at starting excision, and 30 minutes post excision. Primary outcomes revealed the difference of VAS during all steps of LEEP by generalized estimating equations procedure. Results:Sixty participants (30 in mefenamic group and 30 in placebo group) participated in this study. The study did not find differences of VAS during all steps of LEEP and analgesic drug requirement at 30 minutes after LEEP procedure. All patients reported no immediate complications and no intervention-related adverse events were observed. Conclusion:Using pre-procedural oral mefenamic acid before LEEP procedure was not associated with pain reduction during all steps of excision.

Factors Associated with Development of High-Grade Squamous Intraepithelial Lesions of the Uterine Cervix in Women Younger than 30 Years

Objective:To determine the factors associated with the increased risk of developing high-grade squamous intraepithelial lesions (HSIL) of the uterine cervix in women younger than 30 years compared with those aged ≥ 30 years who also had HSIL. Methods:Patients with HSIL who underwent loop electrosurgical excision procedure (LEEP) between January 2006 and July 2017 at Chiang Mai University Hospital were retrospectively reviewed. We analyzed the factors associated with the development of HSIL by comparing two age groups between women aged < 30 years and those aged ≥ 30 years. The factors analyzed included the well-recognized risk factors for cervical cancer, i.e. age at sexual debut, number of sexual partners, use of oral contraceptive (OC) pills, smoking history, sexually transmitted diseases and HIV status. Univariate and multivariate logistic regressions were used to assess factors associated with the increased risk of developing HSIL in women younger than 30 years compared with those aged ≥ 30 years. Results:During the study period, there were 345 patients with HSIL, 30 were < 30 years (case group) and 315 aged ≥ 30 years (control group). By multivariate analyses , early sexual debut(OR, 2.86; 95% CI, 1.01-8.13; P=0.047), multiple sexual partners (OR, 2.94; 95% CI, 1.23-7.02; P=0.015), history of genital warts (OR, 20.46; 95% CI, 2.27-183.72; P=0.007) and history of smoking (OR, 2.95; 95% CI, 1.10-7.93; P=0.032) were significantly associated with the development of HSIL in women younger than 30 years when compared with those aged ≥ 30 years. The OC use, HIV status and underlying diseases were not significantly different in both groups. Conclusion:Early age at sexual debut, multiple sexual partners, history of genital warts and smoking are significant risk factors for developing HSIL in women younger than 30 years. Cervical cancer screening should be considered in young women with such factors.

Effect of endocervical glandular involvement on residual and recurrent disease in patients with high grade cervical dysplasia

Purpose: The aim of this study was to evaluate the effect of endocervical glandular involvement on residual and recurrent disease in high-grade cervical dysplasia.Material and Methods: Patients underwent Loop Electrosurgical Excision Procedure (LEEP) or Cold Knife Conization (CKC) between January 2015 and June 2016 were identified. Patients that had low grade lesions in conization specimens were excluded. The data were collected for age, menopausal status, cytology, colposcopic findings, conization procedure, HPV positivity and subtype, diameters of specimen, number of pieces, pathologic data including status of margins, endocervical glandular involvement (EGI) and recurrence. Prognostic effect of EGI on residual and recurrent disease were evaluatedResults: Of 282 patients, 204 were eligible. Median age was 41 years in both groups. Age, menopausal status, cytology, diameters of specimen, number of pieces, colposcopy findings and conization procedure did not differ between groups.. Surgical margin positivity was higher in EGI positive group. HPV type 16 positivity was significantly higher in EGI positive patients. EGI was found to be the only prognostic factor for residual disease and was not a prognostic factor for recurrent disease.Conclusion: Our findings showed that EGI appears as a poor prognostic factor for residual disease but not for recurrence in patients with high-grade cervical dysplasia.

Value of top-hat procedure in management of squamous intraepithelial lesion.

To investigate the features of skip lesions and evaluate value of top-hat procedure in management of squamous intraepithelial lesion. We reviewed the records of patients who underwent loop electrosurgical excision procedure (LEEP) in Peking University First Hospital between 2011 and 2016. Patients were confirmed to have CIN1-3. The term 'skip lesion' refers to lesion lying deep in cervical canal discontiguous with other lesions in transformation zone and was confirmed by top-hat. We compared their lesion grade in patients with or without skip lesion using logistic regression. We further reviewed patients who underwent subsequent hysterectomy within 6 months following LEEP and evaluated if top-hat procedure led to less residual lesions or was able to predict residual lesions. A total of 2260 patients were included and 595 underwent top-hat procedure. Thirty-nine out of 595 patients had skip lesions (6.5%), among whom two patients had CIN1 (5.1%), eight had CIN2 (20.5%) and 29 had CIN3 (74.4%). Logistical regression showed CIN3 was associated with higher risk of skip lesions compared to CIN1 (OR = 4.433, 95%CI: 1.036-18.964), while CIN2 was not (OR = 1.762, 95%CI: 0.366-8.471). Sixty-two patients underwent hysterectomy within 6 months following LEEP (CIN1-3), 24 underwent top-hat. Analysis revealed top-hat procedure did not result in less residual lesions. Colposcopy impression or prior HPV test was unable to predict skip lesions. About 9.4% patients with CIN3 had skip lesions in the study, which is associated with elevated risk for residual lesion. Top-hat procedure is able to detect skip lesions, but should not be performed on routinely because its prognostic value is not proved.

Loop electrosurgical excision procedure with or without intraoperative colposcopy: a randomized trial

Loop electrosurgical excision procedure is the standard surgical treatment for cervical dysplasia. Loop electrosurgical excision procedure is advised to be performed under colposcopic guidance to minimize adverse pregnancy outcomes. To date, there is no evidence from randomized trials for this recommendation. We sought to assess the benefits of performing loop electrosurgical excision procedure under colposcopic guidance in women with cervical dysplasia. In a prospective, randomized trial, we compared loop electrosurgical excision procedure with loop electrosurgical excision procedure performed under direct colposcopic vision in a 1:1 ratio. The primary endpoint was resected cone mass; the secondary endpoints were margin status, fragmentation of the surgical specimen, procedure time, time to complete hemostasis, blood loss, and intraoperative and postoperative complications. A sample size of 87 per group (n= 174) was planned (with an assumed type I error of 0.05 and drop-out rate of 5%) to achieve 90% power to detect a 25% reduction in cone mass (with an assumed cone mass of 2.5 ± 1.6 g in the control group) using a nonparametric test (Mann-Whitney U). From October 2016 through December 2017, we randomized 182 women: 93 in the loop electrosurgical excision procedure group and 89 in the loop electrosurgical excision procedure-direct colposcopic vision group. Women undergoing loop electrosurgical excision procedure-direct colposcopic vision had significantly smaller cone specimens than those undergoing loop electrosurgical excision procedure (weight: median 1.86 [interquartile range 1.20-2.72] vs median 2.37 [interquartile range 1.63-3.31] g, respectively, P= .006). Secondary outcome measures did not differ significantly between groups: resection margin status involved vs free margin: 12 (13%) vs 75 (82%) and 11 (12.4%) vs 75 (84.3%); fragmentation no vs yes: 85 (92.4%) vs 7 (7.6%) and 84 (94.4%) vs 5 (5.6%); procedure time: 190 (interquartile range 138-294) and 171 (interquartile range 133-290) seconds; time to complete hemostasis: 61 (interquartile range 31-108) and 51 (interquartile range 30-81) seconds; intraoperative blood loss (Δhemoglobin): 0.4 (interquartile range 0.2-1.0) and 0.5 (interquartile range 0.1-0.9); complication rate: 6 (6.5%) and 2 (2.2%). In a multivariate analysis, study group allocation (P= .021) and parity (P= .028), but not age, body mass index, type of transformation zone, and dysplasia degree independently influenced the amount of resected cone mass. Loop electrosurgical excision procedure with intraoperative colposcopy leads to significantly smaller cone specimens without compromising margin status.

Diagnosis and treatment of cervical papillary squamous cell carcinoma with unknown depth of stromal invasion.

To evaluate the diagnosis and treatment of papillary squamous cell carcinoma (PSCC) of the uterine cervix with unknown depth of stromal invasion. In a retrospective study, the diagnostic and treatment strategies after colposcopy-guided biopsy sampling were assessed among patients seen at a university hospital in Shanghai, China, in 2008-2015. Among 55 patients, 29 with clinically visible lesions underwent radical hysterectomy; the final pathologic diagnosis was invasive squamous cell carcinoma in all patients. Of these patients, eight had undergone loop electrosurgical excision procedure (LEEP) and two had undergone a second biopsy sampling before radical hysterectomy was performed. Of the 26 patients with no clinically visible lesions, 17 had cervical lesions as confirmed by medical imaging and 12 of these patients underwent LEEP. The pathologic examination showed lesions of varying severity but no cancer in situ. The remaining five patients underwent radical hysterectomy; one of these patients was found to have micro-invasive cancer. Patients with PSCC with unknown depth of stromal invasion and clinically visible lesions receive radical hysterectomy rather than undergoing a second biopsy sampling or LEEP. Less invasive surgery is recommended for patients with no clinically visible lesions.

Factors Associated With Recurrence of Cervical Intraepithelial Neoplasia 2+ After Treatment Among HIV-Infected Women in Western Kenya

HIV-infected women are at increased risk for recurrence of cervical dysplasia after treatment. Short-term recurrence rates may reflect treatment efficacy and therefore impact screening protocols and follow-up planning. We conducted a prospective study of 297 HIV-infected women undergoing loop electrosurgical excision procedure for cervical intraepithelial neoplasia 2+ (CIN2+) in an HIV clinic in Kisumu, Kenya. By 6 months after the procedure, 20 (7.1%) of women had recurrent CIN2+. Recurrence was significantly associated with CD4 nadir but not with highly active antiretroviral therapy use. Longer-term follow-up of this cohort will illustrate the potential impact of highly active antiretroviral therapy and immune status on CIN2/3 disease recurrence.

Is the Correlation between Papanicolaou Smear and Histopathology Results Affected by Time to Colposcopy?

Time to colposcopy (TC) after abnormal Pap smears was evaluated for influence on cytohistologic correlation (CHC). This retrospective study assessed the correlation between TC and CHC of women who had abnormal Pap smears. Colposcopic chart review included participants from 2010- 2013 who attended a colposcopic clinic, Thammasat University Hospital, Thailand. Four hundred and sixty cases who had abnormal Pap smears were recruited. Pap reports were atypical smears with low grade squamous intraepithelial lesion (SIL), high grade SIL and cancer at 339, 114 and 7 cases, respectively. One hundred and twenty four patients underwent loop electrosurgical excision procedure (LEEP). A half of the cases were colposcopically examined within 1-2 months after abnormal Pap collection. CHC was 88 percent and not affected at all by TC. Subjects who attended cervical cancer screening from affiliated health providers had shorter TC than those screened in our tertiary hospital. Time to colposcopy with abnormal Pap smears conducted at Thammasat University Hospital had a highest frequency of 42 days, in line with the literature. Length of TC does not affect the correlation between Pap and histopathologic reports. A longer waiting period for colposcopy did not alter progression or regression of the disease.

Positive Margin Status in Uterine Cervix Cone Specimens is Associated With Persistent/Recurrent High-grade Dysplasia

The frequency of positive cone margins and its significance in cervical intraepithelial neoplasia are under controversy. The purpose of the current study was to identify factors associated with positive cone margin status and to evaluate its clinical significance in high-grade cervical intraepithelial neoplasia. Medical records of women who underwent loop electrosurgical excision procedure at the Soroka Medical Center (January 2001-July 2011) were reviewed retrospectively. Patient age, extent of dysplasia, endocervical glands involvement, positive margin status, type of margin involved, degree of margin involvement, and postcone endocervical curettage results were evaluated as possible factors associated with persistent/recurrent disease. A total of 376 women were included in the study. Cone margin involvement was observed in 33% (endocervical-22%, ectocervical-8%, both margins-3%). Factors significantly associated with cone margin involvement were older age (older than 35 y), widespread dysplasia in the cone specimen (≥4 sections) (P<0.001 for each), and endocervical glands involvement (P=0.003). Fifty patients (13%) had persistent/recurrent disease. Involvement of the cone margins (focal: hazard ratio=17, P<0.001; extensive: hazard ratio=28, P<0.001) and older age (hazard ratio=1.18 for every 5 additional years, P=0.03) were associated with persistent/recurrent disease. We conclude that women older than 35 yr with widespread high-grade dysplasia in the cone specimen and involvement of endocervical glands are more likely to have positive cone margins. Positive cone margins, particularly when extensively involved, and increased patient age are associated with persistent/recurrent disease. These factors should be considered while planning for further management.