Journal of Cancer Research

Volume 2014 (2014), Article ID 486460, 5 pages

http://dx.doi.org/10.1155/2014/486460

Clinical Study

Implications of Post-LLETZ “Treatment Failure” for Further Management of HIV-Infected Women

Louis-Jacques van Bogaert

National Health Laboratory Service, Polokwane/Mankweng Hospital Complex, and University of Limpopo, Polokwane 0700, South Africa

Received 20 August 2013; Revised 21 January 2014; Accepted 4 February 2014; Published 11 March 2014

Academic Editor: Andrea Vecchione

Copyright © 2014 Louis-Jacques van Bogaert. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. Since the preconisation presence of high-risk human papillomavirus (HR-HPV) is the main determinant of the risk of progression of preinvasive lesions; the state of the excision margins could be of less importance. Relatively little is known about the effect of human immunodeficiency virus (HIV) infection on the relation between the states of the excision margins. Methods. We compared 120 HIV-infected and 139 HIV-uninfected women who underwent a hysterectomy after large loop excision of the transformation zone (LLETZ) for abnormal Pap smear. Results. The excision margins had been reported negative in 21.7% of infected and 7.8% of uninfected cases (). Three (11.5%) of 26 negative margins in HIV-infected and 2 (18.2) out of HIV-uninfected cases were falsely negative as evidenced on hysterectomy specimens (). The persistence rate of the initial lesion was similar in both groups (). The persistence rate with highly active antiretroviral treatment (HAART) was similar to untreated patients (). The progression rate from low-grade to high-grade preinvasive lesions was higher in HIV-infected than HIV-uninfected women (). Conclusion. HIV-infected women with incomplete excision margins after LLETZ are at higher risk of progression of residual preneoplastic lesions.

1. Introduction

The prevention of cervical cancer is twin-pronged: primary (i.e., vaccination and life style) and secondary (i.e., screening and treatment). Many screening strategies are still under investigation and awaiting validation. They comprise cytology and/or human papillomavirus (HPV) testing, visualization of the cervix (naked eye, colposcopy, and cervicography), and excision or destruction of preinvasive lesions [1]. Destruction (by cryotherapy or laser) has the disadvantage of lacking “gold standard” biopsy confirmation but the advantage of on the spot treatment (see and treat) [2]. This is of special importance in low-resource settings (LRS). Excision methods are many: cold knife conisation (CKC) and thermal excision called either large loop excision of the transformation zone (LLETZ) or loop electrosurgical excision procedure (LEEP). Both allow for histopathological diagnosis although, as opposed to CKC, they have the possible disadvantage of burn artifacts of the excision margins. The state of the excision margins (healthy or involved by the preneoplastic process) is, arguably, a prognostic indicator and a guide to further follow-up [3].

LRS like sub-Saharan Africa carry the double burden of inexistent or inefficient screening programs and high cervical cancer and human immunodeficiency virus (HIV) endemicity [1]. Data about screening, prevalence of preneoplasia, and “see-and-treat” strategies are relatively limited. “See-and-treat” strategies are mostly implemented using destructive methods (i.e., cryosurgery) [2]. Therefore, potential information provided by the gold standard of colposcopy-directed biopsy/LLETZ/LEEP/CKC is lacking.

It has been suggested that the two main predictors of persistent cytological abnormalities among HIV-infected women are post-LLETZ excision margin involvement and the level of immunodepression as expressed by the CD4+ T-cell count [4–7]. There is also some evidence that post-LLETZ margin involvement might be more frequent in HIV-infected than HIV-uninfected women [8, 9]. However, local data have not confirmed this [5]. Because of these contradicting data we investigated the status of LLETZ specimen margins in HIV-infected and HIV-uninfected women in the Limpopo province of South Africa.

2. Methods

The study was carried out at the histopathology division of the National Health Laboratory Service, Polokwane, Limpopo province. All consecutive LLETZ cases received in 2013 were collected prospectively. All participants underwent HIV screening. The following information was collected from the histology request form and laboratory database: age, HIV status, CD4+ T-cell count (when available), and pre-LLETZ cytology findings. The LLETZ procedures were indicated for abnormal Pap smears (≥low-grade squamous intraepithelial lesion). Repeat LLETZ and hysterectomies were carried out for reported incomplete excision of preinvasive lesions on the initial LLETZ. In the HIV-uninfected group, 4 (2.9%) had a repeat LLETZ; 6 (5.0%) HIV-infected patients had a repeat LLETZ. All of the others had a post-LLETZ total hysterectomy. For repeat LLETZ cases the pathology of the first excision was compared with repeat procedure.

The lesions were classified as low-grade cervical intraepithelial neoplasia (CIN1), high-grade CIN2+ (including carcinoma in situ), and invasive cancer (IC). Regression was defined as the disappearance of a previous CIN or a downgrade of the initial lesion. Persistence was defined as a residual lesion of same grade as initially found. Progression was defined as worsening of the severity compared to the initial diagnosis.

The specimens were measured; step sections were embedded. The average length and thickness were 2.5 cm ± 0.9 (median 2.0) and (median 1.0), respectively. An average of (median 9.0) sections was cut per LLETZ specimen. Four-micron sections were stained with hematoxylin and eosin.

The state of the excision margins was assessed and compared with the histopathological findings on the ensuing procedure: total hysterectomy or repeat LLETZ for previous incomplete LLETZ. Positive margins were reported regardless of their number (i.e., exocervical, endocervical, and/or deep).

The time elapsed between the first and second procedure was recorded. In case of repeat LLETZ the time was measured between the first and second procedure. All cases were handled anonymously.

Statistical analysis was carried out using column statistics, Student’s -test for continuous variables, and rank sum test for nonparametric variables. The level of statistical significance was set at .

3. Results

One hundred twenty patients were HIV-infected and 139 HIV-uninfected. Fifty (41.7%) were on highly active antiretroviral treatment (HAART). The CD4+ T-cell count was known in 50 cases: median 279.0 (range: 6.0−964.0). Seventeen (37.0%) had a count below 200/mm³ and 7 (15.2%) above 500. The median CD4+ T-cell count of 15 women on HAART was 280.0 (range: 16.0−964.0) and 299.0 (range: 6.0−842.0) in untreated patients ().

Table 1 shows that the HIV-infected patients were significantly younger than the HIV-uninfected patients (). The time elapsed between the first and second procedure was longer in the HIV-infected patients than their uninfected counterparts (). The prevalence of histopathological reported positive margins was higher in the HIV-uninfected group than HIV-infected group (). There was no difference in distribution of biopsy-diagnosed pathology between the two groups. The regression rate was higher in HIV-uninfected patients (). The progression rate was higher in HIV-infected group (). The persistence rate was similar in both groups (). The persistence rate was 30 (57.7%) out of 52 on HAART and 47 (69.3%) out of 60 untreated ().

Table 1: Comparative clinico-pathologic data: HIV-infected versus uninfected.

Variables
HIV-infected 

HIV-uninfected 

Age (years)
39.5 ± 6.5 39.0 

(22.0–58.0)*
  45.0 

(25.0–77.0)
6.0
<0.0001

Weeks between LLETZ and hysterectomy
28.0 (2–96)**
18.0 (3–64)

0.0016

reported positive margins
94 (78.3)***
128 (92.1)

0.03

CIN1 on hysterectomy or repeat LLETZ
5 (4.2)
8 (5.7)

0.18

CIN2+
106 (88.3)
121 (87.1)

0.28

Microinvasive cancer
9 (7.5)
10 (7.2)

0.06

Regression to ≤CIN1
20 (16.7)
39 (28.1)

0.035

Progression to ≥CIN2+
24 (20.0)
3 (2.1)

0.027

Persistence
76 (63.3)
97 (69.8)

0.10

Values are mean ± SD Median; Values are median (range); Values are numbers (%).

4. Discussion

The reported rates of positive margins after conisation vary widely from 5.0% or less to up to more than 50.0% with an average around one-third [5, 10–18]. The variations are attributed to instrumentation and operator variability [10, 16, 19–26]. The advantage of LEEP/LLETZ is that it is a less invasive in-office procedure than CKC that promotes patient’s compliance [27]. This is especially relevant in LRS where compliance and loss to follow-up rates are high [5, 27]. The procedure has been shown to be safe in HIV-infected women [7–9, 23].

Traditionally, cervical preinvasive lesions were managed by CKC. The clinician was eager to know the characteristics of the excision margins (clear or involved) to guide further management and follow-up. Knowledge of the role played by low-risk (LR) and high-risk (HR) HPV has brought about a paradigm shift in our understanding and management of cervical preinvasive lesions. For instance, the concept of conisation “with therapeutic intent” is under debate because the natural history of these lesions depends on the clearance or persistence of HR-HPV [3]. In this perspective, it appears that it does not seem to matter that much whether the margins are clear or not [28]. One study, for instance, showed that HPV persistence following LLETZ was associated with smoking and age above 35 years irrespective of margin status [29].

Our rate of positive margins was high but significantly lower in HIV-infected cases. The importance of margin negativity, however, is uncertain and no guarantee of safety [14, 26, 28]. Nonetheless, it appears potentially beneficial to reduce the proportion of diseased margins and the ensuing risk of persistence/progression [18, 30]. The mere fact that conisation eradicates HPV infection in two-thirds of patients indicates that further follow-up is always mandatory [31]. There is growing evidence that preconisation HPV testing strongly predicts the behavior of preinvasive lesions. The risk of progression is low in the absence of HR-HPV and high in their presence especially with positive excision margins [7, 17, 32, 33].

Both local and our data show that the HIV status does not significantly affect the characteristics of the excision margins [5]. The fact remains that regardless of the excision margins follow-up is necessary. This should be done with Pap smear and/or HPV DNA testing [30, 33–36]. Current data show that HR-HPV testing has higher sensitivity than cytology with a similar specificity; therefore, some recommend HR-HPV DNA testing (with Hybrid Capture II, or low-cost/low-tech tests) as the preferred follow-up test [28, 36]. In LRS, low-cost/low-tech tests have been successfully validated [36]. An alternative could be immunohistochemistry, a surrogate biomarker of HR-HPV [37, 38].

Finally, one may wonder whether HIV-infected women require a specific management and follow-up of preinvasive lesions. The evidence is still limited [8]. Lehtovirta et al. found no difference in recurrence rate after positive margins [39]. Nappi et al., on the contrary, found that immunodepression, as evidenced by CD4+ T-cell counts below 200 mm³, increased the risk of preinvasive lesions [4]. This concurs with South African findings that the presence of disease at both margins and CD4+ T-cell count were the most important predictors [5].

5. Conclusion

The progression rate from low-grade to high-grade preinvasive lesions was higher in HIV-infected than HIV-uninfected women. HIV-infected women with incomplete excision margins after LLETZ are at higher risk of progression of residual preneoplastic lesions especially if the CD4+ T-cell count is below 200/mm³.

Conflict of Interests

The author declares no conflict of interests.

References

L. J. van Bogaert, “Cervical cancer prevention in resource-limited settings with special emphasis on areas of high cervical cancer and human immunodeficiency virus endemicity,” in Human Papillomavirus: Prevalence, Detection, and Management, H. B. Smith, Ed., pp. 405–419, Nova Publishers, New York, NY, USA, 2013.

K. S. Pfaendler, M. H. Mwanahamuntu, V. V. Sahasrabuddhe, V. Mudenda, J. S. A. Stringer, and G. P. Parham, “Management of cryotherapy-ineligible women in a “screen-and-treat” cervical cancer prevention program targeting HIV-infected women in Zambia: lessons from the field,” Gynecologic Oncology, vol. 110, no. 3, pp. 402–407, 2008.

L. J. van Bogaert, “Large loop excision of the transformation zone (LLETZ): a pathology evaluation in the Limpopo Province, South Africa,” Southern African Journal of Gynaecologic Oncology, vol. 3, pp. 66–69, 2011.

L. Nappi, C. Carriero, S. Bettocchi, J. Herrero, A. Vimercati, and G. Putignano, “Cervical squamous intraepithelial lesions of low-grade in HIV-infected women: recurrence, persistence, and progression, in treated and untreated women,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 121, no. 2, pp. 226–232, 2005.

Y. Adam, C. J. van Gelderen, G. de Bruyn, J. A. McIntyre, D. A. Turton, and N. A. Martinson, “Predictors of persistent cytologic abnormalities after treatment of cervical intraepithelial neoplasia in Soweto, South Africa: a cohort study in a HIV high prevalence population,” BMC Cancer, vol. 8, article 211, 2008.

M. I. Lima, A. Tafuri, A. C. Araújo, L. de Miranda Lima, and V. H. Melo, “Cervical intraepithelial neoplasia recurrence after conization in HIV-positive and HIV-negative women,” International Journal of Gynecology and Obstetrics, vol. 104, no. 2, pp. 100–104, 2009.

C. T. Lodi, M. A. Michelin, M. I. Lima et al., “Factors associated with recurrence of cervical intraepithelial neoplasia after conization in HIV-infected and noninfected women,” Archives of Gynecology and Obstetrics, vol. 284, no. 1, pp. 191–197, 2011.

P. M. Tebeu, A. L. Major, P. Mhawech, and E. Rapiti, “The recurrence of cervical intraepithelial neoplasia in HIV-positive women: a review of the literature,” International Journal of STD and AIDS, vol. 17, no. 8, pp. 507–511, 2006.

H. Foulot, I. Heard, V. Potard, D. Costagliola, and C. Chapron, “Surgical management of cervical intraepithelial neoplasia in HIV-infected women,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 141, no. 2, pp. 153–157, 2008.

O. Sanu, A. Pal, and S. George, “A pilot study comparing efficacy of a cervical intraepithelial neoplasia excisor with loop electrosurgical excision procedure,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 151, no. 1, pp. 91–95, 2010.

E. Mulhem, E. L. Kennedy, and D. Lick, “Treatment of cervical dysplasia with the Fischer cone biopsy excisor in a Family Medicine Office: a case series,” Journal of the American Board of Family Medicine, vol. 23, no. 2, pp. 154–158, 2010.

A. Treacy, D. Devaney, N. J. Mulligan, W. Boyd, and J. C. Keane, “Can a more detailed evaluation of excision margins refine cytologic follow-up of women post-LLETZ for high-grade dysplasia?” International Journal of Gynecological Pathology, vol. 29, no. 5, pp. 479–482, 2010.

A. Baloglu, D. Uysal, I. Bezircioglu, M. Bicer, and A. Inci, “Residual and recurrent disease rates following LEEP treatment in high-grade cervical intraepithelial lesions,” Archives of Gynecology and Obstetrics, vol. 282, no. 1, pp. 69–73, 2010.

C. D. I. Gonzalez, L. C. C. M. Zahn, M. M. G. Retzloff, M. W. F. Moore, L. C. E. R. Kost, and C. R. R. Snyder, “Recurrence of dysplasia after loop electrosurgical excision procedures with long-term follow-up,” American Journal of Obstetrics and Gynecology, vol. 184, no. 3, pp. 315–321, 2001.

C. Kietpeerakool, J. Srisomboon, P. Suprasert et al., “Outcomes of loop electrosurgical excision procedure for cervical neoplasia in human immunodeficiency virus-infected women,” International Journal of Gynecological Cancer, vol. 16, no. 3, pp. 1082–1088, 2006.

M. Matsumura, T. Ota, N. Takeshima, and K. Takizawa, “Shimodaira-Taniguchi conization method: its utility and reliability,” International Journal of Gynecological Cancer, vol. 20, no. 6, pp. 1025–1030, 2010.

D. Wu, Y. Zheng, W. Chen et al., “Prediction of residual/recurrent disease by HPV Genotype after loop excision procedure for high-grade cervical intraepithelial neoplasia with negative margins,” Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 51, no. 2, pp. 114–118, 2011.

A. Lubrano, N. Medina, V. Benito et al., “Follow-up after LLETZ: a study of 682 cases of CIN 2-CIN 3 in a single institution,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 161, no. 1, pp. 71–74, 2012.

D. Ulrich, K. Tamussino, E. Petru, J. Haas, and O. Reich, “Conization of the uterine cervix: does the level of gynaecologist’s training predict margin status?” International Journal of Gynecologic Pathology, vol. 31, pp. 382–386, 2012.

B. D. Duggan, J. C. Felix, L. I. Muderspach et al., “Cold-knife conization versus conization by the loop electrosurgical excision procedure: a randomized, prospective study,” American Journal of Obstetrics and Gynecology, vol. 180, no. 2 I, pp. 276–282, 1999.

J. W. Shin, H. S. Rho, and C. Y. Park, “Factors influencing the choice between cold knife conization and loop electrosurgical excisional procedure for the treatment of cervical intraepithelial neoplasia,” Journal of Obstetrics and Gynaecology Research, vol. 35, no. 1, pp. 126–130, 2009.

L. L. Reimers, S. Sotardi, D. Daniel et al., “Outcomes after an excisional procedure for cervical intraepithelial neoplasia in HIV-infected women,” Gynecologic Oncology, vol. 119, no. 1, pp. 92–97, 2010.

G. G. Miroshnichenko, M. Parva, D. O. Holtz, J. A. Klemens, and C. J. Dunton, “Interpretability of excisional biopsies of the cervix: cone biopsy and loop excision,” Journal of Lower Genital Tract Disease, vol. 13, no. 1, pp. 10–12, 2009.

L. A. Boardman, M. M. Steinhoff, R. Shackelton, S. Weitzen, and L. Crowthers, “A randomized trial of the Fischer cone biopsy excisor and loop electrosurgical excision procedure,” Obstetrics and Gynecology, vol. 104, no. 4, pp. 745–750, 2004.

Y. Miyoshi, T. Miyatake, Y. Ueda et al., “Prediction, based on resection margins, of long-term outcome of cervical intraepithelial neoplasia 3 treated by Shimodaira-Taniguchi conization,” Archives of Gynecology and Obstetrics, vol. 285, no. 5, pp. 1427–1432, 2012.

D. L. Greenspan, M. Faubion, D. V. Coonrod, K. W. Hart, and K. Mathieson, “Compliance after loop electrosurgical excision procedure or cold knife cone biopsy,” Obstetrics and Gynecology, vol. 110, no. 3, pp. 675–680, 2007.

M. J. Huchko, E. A. Bukusi, and C. R. Cohen, “Building capacity for cervical cancer screening in outpatient HIV clinics in the Nyanza province of western Kenya,” International Journal of Gynecology and Obstetrics, vol. 114, no. 2, pp. 106–110, 2011.

L. O. Z. Sarian, S. F. M. Derchain, D. D. R. Pitta, S. S. Morais, and S. H. Rabelo-Santos, “Factors associated with HPV persistence after treatment for high-grade cervical intra-epithelial neoplasia with large loop excision of the transformation zone (LLETZ),” Journal of Clinical Virology, vol. 31, no. 4, pp. 270–274, 2004.

P. Suprasert, W. Panyaroj, and C. Kietpeerakool, “Recurrent rates with cervical intraepithelial neoplasia having a negative surgical margin after the loop electrosurgical excision procedure in Thailand,” Asian Pacific Journal of Cancer Prevention, vol. 10, no. 4, pp. 587–590, 2009.

K. Bodner, B. Bodner-Adler, F. Wierrani, O. Kimberger, C. Denk, and W. Grünberger, “Is therapeutic conization sufficient to eliminate a high-risk HPV infection of the uterine cervix? A clinicopathological analysis,” Anticancer Research, vol. 22, no. 6 B, pp. 3733–3736, 2002.

I. Alonso, A. Torné, L. M. Puig-Tintoré et al., “Pre- and post-conization high-risk HPV testing predicts residual/recurrent disease in patients treated for CIN 2-3,” Gynecologic Oncology, vol. 103, no. 2, pp. 631–636, 2006.

N. U. Dogan, M. C. Salman, and K. Yuce, “The role of HPV DNA testing in the follow-up of cervical intraepithelial neoplasia after loop electrosurgical excision procedure,” Archives of Gynecology and Obstetrics, vol. 283, no. 4, pp. 871–877, 2011.

N. H. Jeong, N. W. Lee, H. J. Kim, T. Kim, and K. W. Lee, “High-risk human papillomavirus testing for monitoring patients treated for high-grade cervical intraepithelial neoplasia,” Journal of Obstetrics and Gynaecology Research, vol. 35, no. 4, pp. 706–711, 2009.

A. G. Bais, M. J. C. Eijkemans, M. Rebolj et al., “Post-treatment CIN: randomised clinical trial using hrHPV testing for prediction of residual/recurrent disease,” International Journal of Cancer, vol. 124, no. 4, pp. 889–895, 2009.

M. Kocken, M. H. Uijterwaal, A. L. M. de Vries et al., “High-risk human papillomavirus testing versus cytology in predicting post-treatment disease in women treated for high-grade cervical disease: a systematic review and meta-analysis,” Gynecologic Oncology, vol. 125, no. 2, pp. 500–507, 2012.

Y. Qiao, J. W. Sellors, P. S. Eder et al., “A new HPV-DNA test for cervical-cancer screening in developing regions: a cross-sectional study of clinical accuracy in rural China,” The Lancet Oncology, vol. 9, no. 10, pp. 929–936, 2008.

L. van Bogaert, “ immunocytochemistry/immunohistochemistry: need for scoring uniformization to be clinically useful in gynecological pathology,” Annals of Diagnostic Pathology, vol. 16, no. 5, pp. 422–428, 2012.

L. J. van Bogaert, “High-risk human papillomavirus screening and testing with immunohistochemical surrogate biomarkers: an alternative to polymerase chain reaction,” Southern African Journal of Gynecologic Oncology, vol. 4, no. 1, pp. 30–33, 2012.

P. Lehtovirta, P. Finne, P. Nieminen et al., “Prevalence and risk factors of squamous intraepithelial lesions of the cervix among HIV-infected women—a long-term follow-up study in a low-prevalence population,” International Journal of STD and AIDS, vol. 17, no. 12, pp. 831–834, 2006.