Factors affecting outcome after incomplete excision of cervical intraepithelial neoplasia

Purpose: Conservative treatment for cervical intraepithelial neoplasia (CIN) by ablative or excisional techniques is widely used. However, women with incomplete excision have a variable risk of CIN recurrence. The aim of this study was to identify possible risk factors for recurrence of CIN after large loop excision of the transformation zone (LLETZ) with involved margins of excision.

Methods: All cases of women treated with LLETZ for CIN between 1989-2000, in whom histological evaluation of the excised specimen revealed extension of CIN to the excision margins, were retrospectively studied. A woman was considered to have recurrence when she had histologically confirmed CIN following a second LLETZ or hysterectomy during the follow-up period. The characteristics that were examined as possible risk factors were age, parity, smoking habit, grade of initial lesion and extension to the endo- or ectocervical margin.

Results: Treatment failure was diagnosed in 18 out of 65 (27.7%) women with involved margins. The only characteristic that reached statistical significance was age. The mean age of women with recurrence was 35.8 years, whereas the mean age of women without recurrence was 32.8 years (p = 0.044). Also, a trend was evident in women with high-grade initial lesions (CIN II-III) (p = 0.168) and involvement of the endocervical margins (p = 0.149). No differences were observed between the two groups regarding parity and smoking habit.

Conclusions: Increased age is a risk factor for recurrence in women with incomplete excision of CIN after LLETZ. Larger studies are required for definite conclusions.

Cervical intraepithelial neoplasia; Large loop excision of the transformation zone; Involved margins; Recurrence; Risk factors

[1] Paraskevaidis E., Lolis E., Koliopoulos G., Alamanos Y., Fotiou S., Kitchener H.C.: "Cervical intraepithelial neoplasia outcomes following loop excision with clear margins". Obstet. Gynecol., 2000, 95, 828.

[2] White C.D., Cooper W.L., Williams R.R.: "Cervical intraepithelial neoplasia extending to the margins of resection in conization of the cervix". J. Reprod. Med., 1991, 36, 635.

[3] Vedel P., Jakobsen H., Kryger-Baggesen N., Rank F., Bostofte E.: "Five-year follow up of patients with cervical intra-epithelial neoplasia in the cone margins after conization". Eur. J. Obstet Gynecol. Rep rod. Biol., 1993, 50, 71.

[4] Lapaquette T.K., Dinh T.V., Hannigan E.V., Doherty M.G., Yandell R.B., Buchanan V.S.: "Management of patients with positive margins after cervical conization". Obstet. Gynecol., 1993, 82, 440.

[5] Paraskevaidis E., Koliopoulos G., Paschopoulos M., Stefanidis K., Navrozoglou I., Lolis D.: "Effects of ball cauterization following loop excision and follow-up colposcopy". Obstet. Gynecol., 2001, 97, 617

[6] Lopes A., Morgan P., Murdoch J., Piura B., Monaghan J.M.: "The case for conservative management of'incomplete excision'of CIN after laser conization". Gynecol. Oncol., 1993, 49, 247.

[7] Narducci F., Occelli B., Boman F., Vinatier D., Leroy J.L.: "Positive margins after conization and risk of persistent lesion". Gynecol. Oncol., 2000, 76, 311.

[8] Reich O., Lahousen M., Pickel H.. Tamussino K., Winter R.: "Cervical intraepithelial neoplasia III: long-term follow-up after coldknife conization with involved margins". Obstet. Gynecol., 2002, 99, 193.

[9] Jansen F.W., Trimbos J.B.. Hermans J., Fleuren G.J.: "Persistent cervical intraepithelial neoplasia after incomplete conization: predictive value of clinical and histological parameters". Gynecol Obstet. Invest., 1994, 37, 270.

[10] Murdoch J.B., Morgan P.R., Lopes A., Monaghan J.M.: "Histological incomplete excision of CIN after large loop excision of the transformation zone (LLETZ) merits careful follow up, not retreatment". Br. J. Obstet. Gynaecol., 1992, 99, 990.

[11] Paraskevaidis E., Kitchener H., Adonakis G., Parkin D., Lolis D.: "Incomplete excision of CIN in conization: further excision or conservative management?". Eur. J. Obstet. Gynecol. Reprod. Biol., 1994, 53, 45.

[12] Dobbs S.P., Asmussen T., Nunns D., Hollingworth J., Brown L.J., Ireland D.: "Does histological incomplete excision of cervical intraepithelial neoplasia following large loop excision of transformation zone increase recurrence rates? A six year cytological follow-up". Br. J. Obstet. Gynaecol., 2000, 107, 1298.