Evaluation of Pathology Results After Treatment With HSIL LEEP Conization, The Incident of What If Surgical Limit Is Positive :-(

Evaluation of Pathology Results After Treatment With HSIL LEEP Conization, The Incident of What If Surgical Limit Is Positive :-(

Removal or effacing of precancerous (Cancer precursor) cervical lesions wth conization prevent the risk of cervical cancer development in 95% in the first 8 years of period (Soutter WP, de Barros Lopes A, Fletcher A et al. Invasive cervical cancer after conservative therapy for cervical intraepithelial neoplasia. Lancet. 1997; 349: 978)

However, when all cases are evaluated, recurrence possibility of cervical cancer precursors, in other words cervical dysplasia (CIN 1-2-3) changes between 5 and 17% in 20 years of period after the treatment. (Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2013)

Fundamental factors specifying these rates and recurrence risks are listed below:

  1. Presence of lesions covering 2/3 or more of the cervix. In other words, observing precancerous lesion for example CIN III in a cervix area wider than 2/3.
  2. Affected glandular epithelium covering inside of cervix (endocervical gland uptake)
  3. Positive limits in conization. Therefore your doctor should provide you the pathology results after the operation and pathologist should specify the statuses of surgical limits clearly in this report. Is the limit positive or negative. (Ghaem-Maghami S, Sagi S, Majeed G, Soutter WP. Incomplete excision of cervical intraepithelial neoplasia and risk of treatment failure: a meta-analysis. Lancet Oncol. 2007;8(11):985.)
  4. Continuation of HPV infection in the controls. HPV Type 16 is detected especially in pathology representation obtained after the conization and if it is still detected as positive at the end of 1 year and a problem is detected in the cervix in the smear received especially after 6 months, recurrence possibility of the lesion increases and it increases to 17% rate specified above. (Gök M, CoupéV.M., Berkhof J. Et al. HPV16 and increased risk of recurrence after treatment for CIN. Gynecol Oncol. 2007;104(2):273.)

Evaluation of Results Achieved After Conization and Impacts On The Patient

  1. If Surgical Limit is Negative After Conization:

In case surgical limits are negative after conization, recurrence risks of precancerous cervical lesions are quite low. The largest study related to the subject is a research published in 2001 and involved 4417 patients. There are CIN III (HGSIL) lesions in all patients.

The patients with negative surgical limits after conization were monitored for 18 years and high cancer precursor lesions, in other words HGSIL (CIN 2 or CIN 3) were detected only in 15 of 4417 cases. Recurrence time is 8.9 years in average. No relapse occurred in remaining 99.7% group.

(Reich O, Pickel H, Lahousen M. et al. Cervical intraepithelial neoplasia III: long-term outcome after cold-knife conization with clear margins. Obstet Gynecol. 2001;97(3):428.) .)

  1. If Limits Are Positive After Conization:

If the limits are positive, risk limits increase 5-6 times compared of patients with negative limits. Here important problem is at which stage the positivity is. You will say “What is it now?” 🙂 Let me explain as far as I can and please do not panic. They are definitely circumstances that we can overcome also without detriment to your fertility 🙂

During conization, as the name implies, we remove a part of the uterus in come shape and in a way to include “transition zone”. There are certain sections of this part removed. For example, I have mentioned about glandular epithelium covering cervix canal while I have listed the risks above, if entire lesion keeping this part is not removed and the limits are positive and also the limits are positive in outer part of the cervix, risk increases very much.

An interesting research related to this issue was published by Reich et. al. in 2002. (Reich O, Lahousen M, Pickel H. et al. Cervical intraepithelial neoplasia III: long-term follow-up after cold-knife conization with involved margins. Obstet Gynecol. 2002;99(2):193.)

Reish et. al. demonstrated at the end of 6 and 30 years of observation that the recurrence risk of the lesion increased respectively 17 times, 21 times and 52 times if the patient was CIN III and the limits were positive in ecto-cervix (external part of the cervix), endocervix (internal part of the cervix) or in both of them.

Therefore, it is quite important that surgical limits are negative or if positive, to determine where they are positive.

So, if the limits are positive, when does the lesion recur?

Recurrence period of the disease in a patient, to whom LEEP Conization is applied and the limits are positive, is 4 years in average. (Manchanda R, Baldwin P, Crawford R. et al. Effect of margin status on cervical intraepithelial neoplasia recurrence following LLETZ in women over 50 years. BJOG. 2008;115(10):1238.)

  1. Patients, In Whom HGSIL Is Detected In Colposcopic Biopsy but Lesion Is Not Detected In Conization Material

This situation may be really confusing and it is difficult for the gynecologist to explain the issue to the patient. It is helpful to emphasize an issue for one more time. If we talk about HPV infection, it should be emphasized that the relationship between HPV and human immunity system is still not understood clearly. In this respect, we encounter so many problems that we cannot clarify.

No lesion, neither CIN 2 not CIN 3 may be detected in conization performed within the framework of the pathology result achieved after colposcopic biopsy. The reason for it is that all present lesion is removed when the colposcopic biopsy is received.

The patient asks the question of “Then why did you do?”, when we explain it. We perform conization, because while biopsy of the lesion is received, it is impossible for us to know that it completely disappears. And in fact not detecting a lesion or very small lesion does not demonstrate that you require a different follow-up.

Livasy et. al. reported in a research published in 2004 that no lesion was detected in 14 of 674 patients, to whom LEEP conization was made due to CIN 3 (HGSIL). However, when the patients were followed up, it was detected that recurrence frequencies of the precancerous lesions in cervix in these cases were not different than other patients.

Therefore, routine never disappears. Also HPV typing is quite important in these cases. It must be performed. HPV typing should be made in conization materials received or from smear in subsequent follow-ups, though there is no lesion. (Livasy CA, Moore DT, Van Le L. The clinical significance of a negative loop electrosurgical cone biopsy for high-grade dysplasia. Obstet Gynecol. 2004)

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