Recurrence of high-grade cervical dysplasia

The Italian retrospective multi-institutional study in the journal Gynecologic Oncology found that the 5-year recurrence rate was 8.1% for LEEP and 4% for laser conization (P = 0.023).¹

Patients undergoing LEEP are more likely to be diagnosed with positive margin, which is defined as a histological finding of the cervical intraepithelial neoplasia (CIN) along the specimen margin, in comparison with patients undergoing laser conization.

However, the risk of having persistent human papillomavirus (HPV) was similar between the two groups: 15.0% for LEEP vs. 11.6% for laser conization (P = 0.256).

“Many studies have been conducted to investigate the predictors of persistent/recurrent cervical dysplasia,” said principal investigator Giorgio, MD, PhD, a professor of ob/gyn at Fondazione IRCCS Istituto Nazionale dei Tumori in Milano, Italy. “A positive margin after conization and HPV persistence are well-defined predictors of persistent/recurrent disease.”

Dr. Bogani told Contemporary OB/GYN that treatment of recurrent disease might significantly impact a patient’s health. “In addition, the second conization might have a detrimental impact on fertility and might be associated with an increased risk of preterm delivery and premature rupture of membranes,” he said. “Therefore, studies aiming to reduce cervical dysplasia recurrence are of paramount importance.”

The current study evaluated the medical records of 2,966 consecutive patients with high-grade cervical dysplasia who underwent primary conization at Dr. Bogani’s institute and in 21 other centers in Italy between 2010 and 2014. The median patient age was 40 years (range 18 to 89)

During the study period, 20% of patients had laser conization and 80% had LEEP.

The reason for conization was CIN2 in 32.7% of patients and CIN3 in 66.9% of patients.

Overall, 175 women received a second conization within the first 5 years after primary treatment, for a recurrence rate of 6%. The median time to recurrence was 18 months, ranging from 5 to 52 months, with most patients developing recurrence within the first 2 years.

Women with a diagnosis of CIN3 were nearly four times as likelyto have recurrence, whereas women with HPV persistence were almost twice as likely.

“To overcome the biases related to the retrospective nature of the study, we applied a propensity-matched algorithm, from which we selected 500 patients undergoing laser conization and 1,000 undergoing LEEP for analysis,” Dr. Bogani said. After applying a propensity-matched algorithm, LEEP was associated with an increased risk of recurrence in comparison to laser conization.

One reason why laser conization is associated with a lower rate of recurrence than LEEP is that “similar to cold knife with conization, laser allows us to perform a step-by-step conization, following the geometry of the lesions, thus tailoring the radicality of the procedure,” Dr. Bogani said.

The extensive vaporization of the surgical margins caused by laser CO2 might also provide a higher rate of local control than diathermocoagulation.

HPV persistence was the only factor associated with 5-year recurrence after either laser conization (P = 0.003) or LEEP (P = 0.001). “This finding highlights the importance of HPV persistence as one of the main prognostic factors for recurrence,” Dr. Bogani said.

The author and his colleagues are now studying the long-term effect of vaccination against HPV in women who under conization. “We anticipate that vaccination against HPV in adolescent and young adults will reduce the burden of HPV-related diseases,” Dr. Bogani said.

Dr. Bogani reports no relevant financial disclosures.

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Reference

1. Bogani G, Di Donato V, Sopracordevole F. Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser conization: a 5-year follow-up study. Gynecol Oncol. Published online on September 3, 2020. doi:10.1016/j.ygyno.2020.08.025