Defining the short-term disease recurrence after Loop Electrosurgical Excision Procedure (LEEP)

Abstract

Purpose: The goal of cervical cancer screening is to identify dysplastic lesions for subsequent excision in order to prevent invasive disease. There is clinical equipoise, on how to best follow women for disease surveillance after treatment with some Canadian provinces exclusively performing colposcopy and some utilizing HPV testing in addition to cervical cytology. Loop Electrosurgical Excision Procedure (LEEP) is used to treat pre-invasive HPV-mediated disease and patients are typically followed for 12 months after disease excision. This study aims to quantify the prevalence of high-grade disease at the time of the second follow-up colposcopy visit, in a practice setting that utilizes laser ablation in addition to LEEP. Methods: In a retrospective cohort study, consecutive patient charts were accessed through the electronic medical record system, ARIA, at the Tom Baker Cancer Centre, in Calgary, Alberta, from January 2010 to December 2015. Data was extracted and a REDCap database was used to compile pertinent information from charts meeting inclusion criteria. Descriptive and analytic statistics were performed. Results: Of the 303 patients identified, 221 patients met inclusion criteria. 86% of these patients met discharge criteria from colposcopy after the second follow up visit. Of the 31 (14%) who were seen in a subsequent visit, 7 (3.2%) underwent further treatment for high-grade disease (CIN 2/3). The remaining 23 (10.6%) had a third – negative – visit, resulting in discharge from colposcopy. Conclusion: In summary, our data demonstrates a prevalence of 3.2% of high-grade disease at the time of a second colposcopic follow up visit after treatment, in a setting which frequently utilizes laser ablation in combination with LEEP, for large lesions. This recurrence rate is consistent with most published literature on recurrence rates of CIN2/3.

Loop Electrosurgical Excision Procedure in Managing Persistent Low-Grade Abnormality or Human Papillomavirus Positivity

“…In our cohort, approximately half of patients have abnormal results among those who underwent a LEEP for persistent low-grade or HPV positivity over a follow-up period of approximately 2 years, which is not significantly altered by whether occult high grade was identified on the LEEP specimen. This rate of abnormal cytology and/or hrHPV positivity is slightly higher than reported in literature [9][10][11] but nevertheless suggests that intense surveillance is needed for these patients, likely akin to those who underwent LEEP for high-grade dysplasia. Possible reasons for higher rate of abnormal cytology and/or hrHPV positivity on follow-up are the consistent use of HPV-based testing for surveillance at our center, the intentional use of small LEEPS in this population to prevent future adverse reproductive outcomes, and selection bias by patients who opt to follow up with their local gynecologist and would have only returned to our center if abnormal testing was identified.…”

“…In terms of counseling patients with persistent low-grade abnormalities, it is important to note that our risk of positive margins in this study is higher than generally reported in the literature for LEEPs performed for women undergoing LEEPs for biopsy-proven HSIL (5%-20%). [9][10][11] This is intentional, as we counsel patients in the group undergoing LEEP for persistent low-grade abnormalities that we will intentionally do a small "diagnostic" LEEP so as to remove as little cervix as possible while "ruling out" an occult high-grade diagnosis, when the diagnosis is uncertain, as it is known that smaller excisions are less likely to result in adverse pregnancy outcomes, and we want to limit the amount of tissue removed. We explain that if a high-grade lesion is found and the margins are positive, we can place them into surveillance under the ASCCP guidelines.…”