This study was approved by the ethics committee of Obstetrics and Gynecology Hospital of Fudan University. We reviewed the medical records of all 6443 patients who had undergone LEEP at the Obstetrics and Gynecology Hospital of Fudan University from October 2010 to September 2013. All of these 6443 patients underwent LEEP due to abnormal cervical biopsy revealed as LSIL or higher.
Of these patients, 4336 were diagnosed with HSIL, 895 were diagnosed with LSIL, 903 were diagnosed with chronic cervicitis, 308 were diagnosed with invasive cervical cancer, and 1 was diagnosed with neuroendocrine carcinoma. Among the 4336 patients with HSIL, 275 (6.34 %) had HSIL-involved surgical margins and the others were margin-free or LSIL-involved margins. In 275 patients, 37 were excluded due to loss of follow-up or rejection of follow-up. Finally, a total of 238 patients were enrolled in this study.
The data in the study were collected from hospital’s archived database and for the purpose of research. This study didn’t involve in the diagnosis and treatment of the patients. Informed consent was waived by the the ethics committee of Obstetrics and Gynecology Hospital of Fudan University.
Information that was collected included patient characteristics, details regarding the initial LEEP specimens (e.g., depth, thickness and maximum diameter), histology of the first LEEP specimen and ECC specimen, number and location of involved margin sections, cervical cytology results, high-risk HPV results, biopsy and ECC findings during follow-up, and histology from the second LEEP and hysterectomy after the initial LEEP.
The initial LEEP
The initial LEEP was performed in an outpatient setting by attending physicians in department of Cervical Disease of Obstetrics and Gynecology hospital through a standard procedure with a loop electrode attached to an electrosurgical unit. The unit was operated in a blended mode that consisted of 70 W for cutting and 30 W for coagulation. In all of the LEEPs performed, specimens were obtained from the transformation zone and the endocervical canal for histopathological evaluation.
The standardized procedure was as the follows: on the day of operation, every patient underwent a repeat colposcopy prior to LEEP to indentify cervical lesions and transformation zone. 5 % acetic acid and Lugol’s iodine solution were used in sequence to distinguish cervical lesions and active transformation zone. The excision started at 2 o’clock position of the cervix. A rotary cut was performed with an electrode moving clockwise to remove the entire active transformation zone. The presence of lesions were far from the edge of the specimen (≥3 mm). The depth of excision depended on the transformation zone: 1) approximate 1 cm if the squamo-columnar junction (SCJ) was observed; 2) if the SCJ could not be observed, the addition LEEP in the canal was performed (top hat LEEP) that the depth of the specimen was approximate 2.5 cm. Cauterization was applied on the cervical crater and bleeders for hemostasis. The duration of the operation was about 5 min.
The LEEP specimens were marked length-wise with ink and were radially sectioned after the endocervical portion had been marked for orientation. Before fixation, each LEEP specimen was measured to determine its depth, thickness and maximum diameter. The margins of the LEEP specimens were subdivided into the following categories: the upper margin, lower margin, bilateral margin, outer margin, inner margin and stromal margin.
Sequential treatment
According to ASCCP’s guidelines: “If CIN2, 3 is identified at the margins of an excisional procedure or post-procedure ECC, cytology and ECC at 4–6 month is preferred, but repeat excision is acceptable and hysterectomy is acceptable if re-excision is not feasible”. So we performed either a strict follow-up or a secondary LEEP or hysterectomy according to patients’ conditions and intentions.
-
1.
Forty-three patients underwent a ThinPrep® cytologic test (TCT) with an HPV test at the first follow-up, which was 3–4 months after the initial LEEP. The subsequent follow-ups occurred every 6–12 months. If the TCT showed abnormal cytology, including atypical squamous cells of undetermined significance (ASC-US), LSIL and HSIL, a biopsy was performed. If the TCT was normal and if two consecutive HPV tests were positive, a biopsy was also performed. If HSIL was confirmed by biopsy, a secondary LEEP or hysterectomy was performed. This group was named TCT group.
-
2.
One hundred and six patients underwent a TCT, an HPV test at the first follow-up, and a colposcopically directed biopsy simultenously. If the cytology was abnormal and the biopsy showed LSIL or a less pathological lesion, the TCT was repeated and a biopsy was performed 3–6 months later. If the biopsy showed HSIL, a second LEEP or hysterectomy was performed. If both the TCT and biopsy were normal, the patients were followed every 6–12 months thereafter. This group was named TCT and biopsy group.
-
3.
Twenty-two patients received a secondary LEEP at a median of 48 days (range 12–120 days) after the initial one (LEEP group). After the second LEEP, the patients were regularly followed-up with a TCT and an HPV test.
-
4.
Sixty-seven patients received hysterectomy at a median of 33 days (range 8–250 days) after the initial LEEP (Hysterectomy group) as they had the following reasons : 1) They feared disease persistence/recurrence unless the uterus was removed and they had no reproductive need; 2) Secondary LEEP was technically impossible; 3) They experienced difficulties with a regular follow-up. After the hysterectomy, the patients were followed-up with the TCT and HPV test to detect vaginal lesions.
During the follow-up period, the cervical cytology sample, which simultaneously contained both an ectocervical and an endocervical sample, was obtained with a disposable ThinPrep® brush (Hologic, Marlborough, MA, USA). The sample was then fixed in ThinPrep® PreservCyt® Solution (Hologic, Marlborough, MA, USA).
Cervical samples for the HPV test were collected with the Digene cervical sampler kit (Digene, Gaithersburg, MD, USA). The sample was then stored in a tube that contained Digene Specimen Transport Medium (Digene, Gaithersburg, MD, USA). An HPV test was performed with the HC2 system. The chemiluminescent reaction was analyzed by a luminometer and compared with the relative light units of clinical samples and the positive control containing 1.0 pg/mL. With regard to a relative light unit, a positive control ratio of 1 or more was considered a positive result. All samples were analyzed for the presence of the HR-HPV types (16, 18, 32, 34, 36, 39, 45, 51, 52, 56, 58, 59 and 68).
Colposcopy was performed with 5 % acetic acid and Lugol’s iodine solution to distinguish cervical lesions during colposcopically directed biopsies. If no obvious abnormality was found after staining,biopsies were taken from 3, 6, 9 and 12 o’clock positions of the cervix. Along with biopsy, the ECC specimens were obtained for histopathological evaluation using an endocervical curette.
A subsequent LEEP was performed with the same approach as the initial LEEP. Laparoscopic hysterectomy was performed by experienced chief physicians.
All specimens were evaluated at the Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University. A consensus was reached for all specimens after an independent review of the original diagnoses by two experienced gynecological pathologists.
Definition of persistence/recurrence
Persistence/recurrence was defined as histopathological HSIL, which was diagnosed from a biopsy or a subsequent surgical (including hysterectomy and LEEP) specimen at any time after the initial LEEP was performed. HSIL (CIN2/3) was diagnosed based on Pathology and Genetic of Tumours of the Breast and Female Genital Organs, World Organization Classification of Tumours (2003) [17].
Statistics
Analysis of the data was performed with IBM© SPSS® 20 software for Windows (SPSS Inc., Chicago, IL, USA). Fisher’s exact tests, the t-test, one-way analysis of variance (ANOVA), and Mann-Whitney tests were utilized to identify factors that were related to the presence of persistent/recurrent disease in the univariate analysis. Fisher’s exact test was used to determine the age group that was associated with a significantly increased risk of disease persistence/recurrence. Results were considered statistically significant if a P < 0.05 was obtained. A multivariate logistic regression was used to determine the independent value of the factors found to be significant in the univariate analysis.