Is large loop excision of the transformation zone depth a risk factor for affected endocervical margins?

Abstract

Objective: The aim of the study was to determine if the depth of large loop excision of the transformation zone (LLETZ) is a risk factor for presenting affected endocervical margins. Methods: A cross-sectional retrospective study was performed on 353 patients that underwent LLETZ after presenting cervical biopsies with CIN grade 2 and grade 3 or persistent CIN grade 1 at Hospital Universitario Santa Lucía, Cartagena, Spain, from November 2011 to December 2016. Automatized measurement of the LLETZ depth was performed in microns and added to cervical canal extensions when these were performed. Other variables studied in positive endocervical margins were age (under or over 35 years), premenopause/postmenopause, number of affected quadrants, CIN grading, the presence of HPV 16 before LLETZ, parity (nulliparous vs multiparous) and the location where the LLETZ was performed (operating room vs consultation room). Results: Our multivariant analysis showed that LLETZ depth ≤ 10 mm did not increase the risk in affected endocervical margins (P = 0.366) and no statistically significant difference between the two groups (affected and nonaffected margins) was found. CIN grading and parity did prove a statistically significant association (P = 0.039 and P = 0.011, respectively). Age, menopause, number of affected quadrants, HPV 16 and the location did not show statistical association with positive endocervix margins. Conclusions: LLETZ depth equal to or lower than 10 mm was not proven to be a risk factor to have affected endocervical margins after the treatment. Therefore, higher LLETZ depth would not be justified to ensure oncological results.

The clinical relevance of excisional margins after large loop excision of the transformation zone for the persistence of cervical dysplasia

“…Different data have been published about excisional margin status and treatment outcomes. 5,11,16 The largest study, a meta-analysis by Arbyn et al 11 in which 97 studies, and almost 45 000 women in total, were included, showed that the overall risk of treatment failure(definedasCIN≥2)was6.6%after2 yearsofprimarytreatment. This meta-analysis showed that the risk of residual/recurrent disease was increased in case of positive excisional margins, e.g.15.6%(95%CI12.7-22.1).…”

“…Different data have been published about excisional margin status and treatment outcomes 5,11,16 . The largest study, a meta‐analysis by Arbyn et al 11 in which 97 studies, and almost 45 000 women in total, were included, showed that the overall risk of treatment failure (defined as CIN ≥2) was 6.6% after 2 years of primary treatment.…”

Rate of Involved Endocervical Margins According to High-Risk Human Papillomavirus Subtype and Transformation Zone Type in Specimens with Cone Length ≤ 10 mm versus > 10 mm—A Retrospective Analysis

“…Nevertheless, the advised length of cervical excision in relation to the TZ remains a recommendation and cannot be generalized for every patient, since the length of the cervix itself can vary considerably, as well as the location and extent of the neoplastic lesion. Thus, the appropriate application of excisional treatment in order to remove as little cervical tissue as possible but as much as necessary in patients of childbearing age wishing to conceive is essential, given that an excision length > 10 mm has been described as an independent risk factor for prematurity and premature rupture of membranes, and should be determined individually [ 13 , 14 , 15 ]. In addition, adverse pregnancy events due to cervical incompetence after LLETZ have been reported in several studies and meta-analyses with a directly correlated risk of preterm birth to the dimensions of the cone, which particularly increases with an augmenting cone length [ 13 , 16 , 17 , 18 ].…”

“…Thus, the appropriate application of excisional treatment in order to remove as little cervical tissue as possible but as much as necessary in patients of childbearing age wishing to conceive is essential, given that an excision length > 10 mm has been described as an independent risk factor for prematurity and premature rupture of membranes, and should be determined individually [ 13 , 14 , 15 ]. In addition, adverse pregnancy events due to cervical incompetence after LLETZ have been reported in several studies and meta-analyses with a directly correlated risk of preterm birth to the dimensions of the cone, which particularly increases with an augmenting cone length [ 13 , 16 , 17 , 18 ]. On the other hand, endocervical margin positivity is a predictor for therapeutic failure, i.e., persistent or recurrent HSIL, occurring in up to 25% of cases, which is associated with a higher rate of hr-HPV persistence post-LLETZ [ 19 , 20 , 21 , 22 ].…”

Operator Sex and Experience Do Not Influence Conization Outcomes in Terms of Cone Volume, Depth or Resection Margins

“…Incomplete resection usually warrants repeat surgery. Some researchers have postulated that cone volume and cone length are predictors of margin positivity (11)(12)(13). By extension, a more radical approach to CIN excision might lead to a lower incidence of cervical cancer during follow-up.…”