Positive Endocervical Margins at Conization: Repeat Conization or Colposcopic Follow-Up? A Retrospective Study

Abstract

BackgroundThe presence of residual cervical lesions was evaluated in patients submitted to repeat conization due to a finding of positive endocervical margins in a previous loop electrosurgical excision procedure (LEEP) specimen. In addition, the correlation between the presence of a residual lesion and risk factors for cervical cancer, and the use of repeat conization as first-choice treatment were analyzed.MethodsThis retrospective study included 44 patients submitted to repeat cervical conization or total hysterectomy following a finding of affected endocervical margins in LEEP specimens. The risk factors analyzed in relation to the presence of residual lesions were age, smoking, cone depth, glandular involvement and the histopathology findings of cervical intraepithelial neoplasia (CIN) 1, CIN 2 or CIN 3/carcinoma in situ. The Chi-square test and the Mann-Whitney t-test were used, with significance defined at P < 0.05.ResultsResidual lesions were found in 23/44 patients (52.3%), with 3/23 cases (13.0%) being compatible with invasive squamous cell carcinoma. Of the 23 patients, six (26.1%) were submitted to total hysterectomy, with one case being compatible with a moderately differentiated invasive squamous cell carcinoma. Two patients with a histopathology finding of CIN 3/carcinoma in situ in the previous LEEP specimen were diagnosed with invasive squamous cell carcinoma in the repeat conization specimen. Residual lesions were not significantly associated with the risk factors evaluated.ConclusionsIn view of the high frequency of residual disease found when positive endocervical margins were found in LEEP specimens, the indication for repeat cervical conization rather than colposcopic follow-up is viable and justified. Indeed, since the presence of a residual lesion and its progression in the cervical canal are more difficult to screen and control, patients unable to comply with regular colposcopic follow-up could benefit from repeat conization when trying to avoid a potentially negative outcome.

Menopausal status is associated with a high risk for residual disease after cervical conization with positive margins

“…This finding demonstrates a high prevalence of residual disease if endocervical margin involvement was noted after conization. This result is similar to findings of other studies that reported persistence rates of approximately 45–55% in this situation [1, 4, 8]. In this study, menopausal status was strongly associated with a high risk of persistent disease: 81.2% in menopausal women versus 46.9% in nonmenopausal women.…”

“…It is estimated that the rate of recurrence two years after treatment in patients without compromised margins is approximately 4 to 18% with an average of 8% [3]. However, in patients with positive margins, this risk of recurrence is typically higher, and some studies report rates of approximately 52% [1–4].…”

Management of high-grade squamous intraepithelial lesion patients with positive margin after LEEP conization

“…In our study, neither age nor glandular involvement were identified as risk factors for residual disease in patients with positive margins, which is similar to results in previously reported studies. [ 15 , 16 , 18 ]…”

“…Some assume that follow-up protocol is the ideal way for management of positive margin, [14] while others prefer a second surgical intervention such as repeat conization or hysterectomy. [3,11,[15][16][17] As for the management of positive margins, both over-treatment and insufficient treatment should be avoided. [18] Accordingly, many studies have focused on identifying the risk factors for residual and recurrent disease in patients with positive margin, such as age, menopausal status, TCT results, HPV infection, and the pathological characteristics of the conization specimens.…”

“…In our study, neither age nor glandular involvement were identified as risk factors for residual disease in patients with positive margins, which is similar to results in previously reported studies. [15,16,18] Through this research, we provided guidance for clinicians to manage patients with positive margins after cervical conization. However, it still has limitations such as insufficient sample size, relatively short follow-up time, and insufficient detailed patient's characteristics.…”