Study of conizations of the cervix after five years of cervical cancer screening with co-testing

Rosa Oncins Torres Mª Ángeles Aragón Sanz Eduardo Clemente Roldán Mª Dolores Comes García Gorka Muñiz Unamunzaga Lorena Guardia Dodorico Víctor Vallés Gallego About the authors

ABSTRACT

Background:

Uterine Cervical Cancer (UCC) screening has changed with the introduction of the High Risk Human Papilloma Virus test (HRHPV) and its evaluation is necessary. The objective of this study is to analyze the effectiveness of UCC screening with activities aimed at early detection and treatment to modify the natural history of the process and improve its prognosis.

Methods:

Cytology and HR-HPV (co-testing) were performed according to the SEGO protocol of 2010 between 2011 and 2015 with follow-up until 2017. The HR-HPV DNA test was HC2 Hybrid Capture (Digene®) at the beginning (16.1% of the cases) and Cobas 4800 (Roche®) afterwards. Target population: Barbastro´s health area. The initial treatment was conization with loop (LLETZ). Sensitivity and Positive Predictive Value of tests were studied, as well as the association between demographic and pathological variables.

Results:

238 high-grade dysplasias (HSIL) or more (CIN2+) were detected with a mean age of 37.9±10.3 years and 60.0% were genotype 16 and/or 18 positive. 220 patients (92.4%) underwent conization completed thereafter with reconization or hysterectomy in 25 cases (11.4%). HSIL was diagnosed in 220 cases (92.4%) and invasive carcinoma in 18 (7.6%), 7 microinvasive (2.9%). 14.4% of cones had no HSIL (negative cone) and 83.2% got free margins. 52.0% had involvement in a single quadrant and the mean horizontal extension was 3.5±3.1mm. Only in 14 (6.7%) patients the disease (HR-HPV positive) persisted after treatment. A statistically significant association was found in our cases between affected borders and age over 45 years (p=0.005).

Conclusions:

The co-test has detected small preinvasive lesions, localized in a single quadrant and microinvasive cancers . Loop conization was effective, achieving the cure of 93.3% of the patients.

Key words:
Conization; Screening; Cervical intraepithelial neoplasia; Human papillomavirus; Co-testing; Margin

INTRODUCTION

The necessary presence of Human Papillomavirus (HPV) for the development of uterine cervical cancer (UCC)11. Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55:244-265. has led scientific societies to include the screening of high-risk papillomavirus (hrHPV) test, combined or not with gynecological cytology. The name given to the joint performance of the cytology and hrHPV test22. Cortés J, Martinón-Torres F, Ramón y Cajal JM, Gil A, Velasco J, Abizanda M, et al. Prevención primaria y secundaria de los cánceres de cuello de útero y vulva: recomendaciones para la práctica clínica. Prog Obstet Ginecol 2010;53 (supl 1):1-19. is co-testing (double test).

Due to its generalization, the screening of UCC in previous decades has led to a decrease in the incidence and mortality of this tumor, although it has been opportunistic. Among the hrHPV screening tests, those able to detect the DNA of the virus (hrHPV DNA) are the ones recommended by the ASCO (American Society of Clinical Oncology) guide33. Jeronimo J, Castle PE, Temin S, Shastri SS. Secondary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline Summary. Published online ahead of print October 12, 2016. J Glob Oncol. doi: 10.1200/JGO.2016.006577.
https://doi.org/10.1200/JGO.2016.006577...
. The preinvasive disease is called High-Grade Lesion (HSIL)44. Darragh TM, Colgan TJ, Thomas Cox J, Heller DS, Henry MR, Luff RD, et al; Members of the LAST Project Work Groups. The Lower Anogenital Squamous Terminology Standardization project for HPV-associated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Int J Gynecol Pathol. 2013;32:76-115. equivalent to Cervical Intraepithelial Neoplasia (CIN) grade 2 or 3. The treatment for HSIL is conization, usually with a loop of diathermy or LEEP (“Loop Electrosurgical Procedure”) that manages to control the disease in most cases55. Puig-Tintoré LM, Cortés J, Castellsague X, Torné A, Ordi J, de Sanjosé S et al. Prevención del cáncer de cuello uterino ante la vacunación frente al virus del papiloma humano. Prog Obstet Ginecol. 2006;49 (Extraordinario 2).. Therefore, screening will identify and treat early stages to decrease the risk of invasive cancer. Colposcopy, cytology and the hrHPV test22. Cortés J, Martinón-Torres F, Ramón y Cajal JM, Gil A, Velasco J, Abizanda M, et al. Prevención primaria y secundaria de los cánceres de cuello de útero y vulva: recomendaciones para la práctica clínica. Prog Obstet Ginecol 2010;53 (supl 1):1-19.,55. Puig-Tintoré LM, Cortés J, Castellsague X, Torné A, Ordi J, de Sanjosé S et al. Prevención del cáncer de cuello uterino ante la vacunación frente al virus del papiloma humano. Prog Obstet Ginecol. 2006;49 (Extraordinario 2). are useful for monitoring the cure. The goal of this study was to describe the efficacy of UCC cancer screening with co-testing, early diagnosis and conization treatment of all patients with pre-invasive or invasive lesions treated during five years, in the area attended by the Hospital of Barbastro to improve its prognosis.

SUBJECTS AND METHODS

A retrospective descriptive study of HSIL and invasive cancers; diagnosed from January 1st, 2011 to December 31st, 2015 and their follow-up until June 30th, 2017.

The Health sector population of Barbastro, located in the eastern area of the province of Huesca, which consists of 107,428 inhabitants (52,535 women), mostly rural, aging and dispersed, attended by 15 Primary Care teams. The Health area covered by the Hospital of Barbastro has an organized opportunistic screening. The target population for UCC screening was 27,401 women between 25 and 64 years of age. The immigrant population is 14%. The 2010 Protocol of the Spanish Society of Gynecology (SEGO) was followed22. Cortés J, Martinón-Torres F, Ramón y Cajal JM, Gil A, Velasco J, Abizanda M, et al. Prevención primaria y secundaria de los cánceres de cuello de útero y vulva: recomendaciones para la práctica clínica. Prog Obstet Ginecol 2010;53 (supl 1):1-19.. Women under 30 years of age were screened with cytology every 3 years and the hrHPV DNA test and gynecological cytology were performed every 5 years for patients between 30 and 64 years of age. See figure 1a for the indication of cytology, HPV test or co-test. The primary care midwives carried out conventional cytology and HPV test and sent them to the Hospital’s Pathology Service. This service has been accredited with the ISO 15185 standards for conventional cytology since 2011 and subsequently for the hrHPV DNA test and for liquid cytology. The result of the cytology was reported according to the Bethesda System66. Solomon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;287:2114-2119.,77. Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Acta Cytologica. 2015;59:121-132.. The hrHPV DNA test was performed with HC2 (Quiagen®) that reported positive or negative results during the first 10 months of the study (16.1% of cases); and cobas 4800 (Roche®) which provided information about the results for genotype 16 and 18 and the group of other 12 genotypes (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68) the rest of the time. The sampling and application of the protocol have already been described in other articles88. Oncíns Torres R, Aragón Sanz MA, Comes García MD, Vallés Gallego V, Cortés Ramas A. Evaluación de un nuevo protocolo de cribado de cáncer cervical con citología convencional y test del virus del papiloma humano. Prog Obstet Ginecol. 2014;57:14-19.,99. Comes MD, Oncins R, Clemente E, Aragón MA, Cortés A, Vallés V, et al. Prevalence of human papillomavirus and genotype distribution in women undergoing cervical cancer screening in the area of Barbastro, Spain. Rev Esp Patol. 2016;49:208-13.. The patients in whom lesions were detected in their first screening test were identified as “diagnosis by the first test” and they differed from the group of patients who attended the program on a regular basis, identified as “diagnosis by screening” The group of “diagnosis by follow-up” corresponded to the screened patients who were followed by an abnormal cytology or/and positive HPV (figure 1b).

Figure 1a
Screening and monitoring algorithm (citology, HPV testing or co-testing). Based on Protocol SEGO 201022. Cortés J, Martinón-Torres F, Ramón y Cajal JM, Gil A, Velasco J, Abizanda M, et al. Prevención primaria y secundaria de los cánceres de cuello de útero y vulva: recomendaciones para la práctica clínica. Prog Obstet Ginecol 2010;53 (supl 1):1-19.

Figure 1b
Distribution of patients by regular screening, after follow-up or in their first testing

HSIL treatment was conization with LLEP that was completed with reconization and hysterectomy with or without double anexectomy, according to the diagnosis of conization and other benign diagnoses of the patient.

Conization specimens were submitted in a fresh state to Pathology, oriented with a silk suture at the 12 o´clock position. The margin was painted with India ink and sections were taken according to clock hours. The endocervical curettage performed after the conization was also received. p16INK4a was used as a complementary technique for diagnosis or for margin evaluation in cases with artifact or doubtful diagnosis.

Invasive cases were referred for treatment to their reference hospital either for radical surgery or radiotherapy. Chemotherapy was administered in our own hospital.

The following variables were recorded: Age (grouped into the categories of ≤45 years and higher than 45 years); nationality (classified into Spanish and foreigners); result of cytology (grouped into low-grade intraepithelial lesion-LSIL- or less and high-grade intraepithelial lesion -HSIL- or higher, according to the Bethesda System); result of the HPV test for genotype 16 and/or 18 (alone or associated with multiinfection with other viruses) were grouped as risk virus; and the histological result of the biopsy that was diagnosed as intraepithelial neoplasia (CIN), was classified in three grades (CIN 1, 2 and 3) and reclassified according to the LATS44. Darragh TM, Colgan TJ, Thomas Cox J, Heller DS, Henry MR, Luff RD, et al; Members of the LAST Project Work Groups. The Lower Anogenital Squamous Terminology Standardization project for HPV-associated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Int J Gynecol Pathol. 2013;32:76-115. terminology in LSIL (CIN1) and HSIL (CIN2/3). CIN3 included adenocarcinoma in situ (AIS). Subsequently, HSIL or higher cases (invasive cancer) were grouped as CIN2+. The conization result being benign, LSIL, HSIL or invasive; In addition, the affected quadrants were recorded (grouped into one quadrant versus more than one quadrant); the size (maximum horizontal extension expressed in mm), grouped into less than 1mm versus 1mm or more; and the state of the margins. When the lesion did not reach the ink, negative margin was considered. If the endocervical curettage was valuable and not involved after a positive cone margin, the case was considered negative margin. The margin was indeterminate when dysplasia was followed by an ulceration that reached the margin without appreciating healthy mucosa between the lesion and the margin, these cases were considered positive in the follow-up. The margin was finally grouped into negative and positive. The date of diagnosis, conization, first post-treatment control and last control were recorded. In invasive tumors, the stage was also recorded, and also the date of last control or death.

The follow-up until 2015, according to 2006 SEGO Protocol55. Puig-Tintoré LM, Cortés J, Castellsague X, Torné A, Ordi J, de Sanjosé S et al. Prevención del cáncer de cuello uterino ante la vacunación frente al virus del papiloma humano. Prog Obstet Ginecol. 2006;49 (Extraordinario 2). was controlled with co-test at 3 months if positive margin and at 6 if negative. If both tests were negative, the follow-up continued with annual cytology for 2 years. Since January 2015, follow-up was updated according to the new Oncoguía Protocol1010. Oncoguía SEGO: Prevención del cáncer de cuello de útero. Guías de práctica clínica en cáncer ginecológico y mamario. Publicaciones SEGO, Octubre 2014. with co-test at 6 months, second control at 24 months and third at three years if negative margin. When margin was positive, the first control was performed at four months, the second control at one year and the third at two years. In the study, the criteria were unified and the variable was recorded as first control, second and third; It was also specified if there had been an HPV study and the date of the last test.

Patients were considered cured when the last cytology and/or HPV test were negative and sick when the last cytology was ASC-US or higher and/or the HPV test positive. In the event that the biopsy was negative after cytology with lesion, they were considered cured if the HPV was also negative. When the second or third HPV control was positive after the first negative, it was considered reinfection.

The data were extracted from the Pathological Anatomy database and from the Minimum Data Set (MBDS) of the hospital. Subsequently, the patients were anonymized with numerical codes. The statistical study was performed with SPSS. The continuous variables were studied with means, standard deviation, minimum, maximum and 95% confidence interval (95% CI). The categorical variables with frequencies and percentages.

Both the sensitivity and positive predictive value of the cytology and the HPV test were studied, and were expressed in percentages with confidence intervals. The sensitivity of the cytology was calculated: TP/TP+FN, where TP (True Positive) were the abnormal cytologies (LSIL, HSIL, carcinoma -ASC and AGC were excluded-) with CIN2+ biopsy and FN (False Negative) corresponded to CIN2+ biopsies with negative cytology in the last 3 years. The HPV sensitivity was calculated in the same way, the positive results of the test were true positive when correlated with CIN2+ and FN biopsies were the negative tests with CIN2+ biopsy. The Positive Predictive Value (PPV) was calculated using the formula PPV=TP/TP+FP, where TP (True Positive) were the abnormal cytologies (LSIL, HSIL, carcinoma -ASC and AGC were excluded-) with a CIN2+ biopsy. FP (False Positives) were abnormal cytologies with negative biopsy.

Positive cases with HC2 were included in the study of the sensitivity and PPV of the HPV test. They were excluded only when the genotype was required. Student’s T test and Chi-square Test (χ2) were used to study the association between quantitative and qualitative variables, respectively. It was determined that there were statistically significant differences if p was less than 0.05. All the variables were analyzed using the Kolmogorov-Smirnov test to determine their normality

RESULTS

22,743 cytologies and 17,111 hrHPV tests are performed along the 5 year study. A total of 238 CIN2+ cases are diagnosed, 220 of which are intraepithelial and 18 invasive.

Table 1 shows the epidemiological, clinical and histological characteristics of all cases. Romania is the most frequent foreign country of origin with 31 patients (13.7%) followed by Colombia with 5 (2.21%). Among foreign patients 45 (19.91%) are European and 17 (7.52%) Latin American. Out of 37 (15.5%) cases followed by positive HPV with normal cytology, only one patient is younger than 30 (there are a total of 53 cases under 30, 22.3%, in the CIN2+ group). Sensitivity of cytology is 79.4 (95% CI: 71.9-82.9) and HPV test 98.7 (95% CI: 95.5-99.3). The PPV: 78.8 (95% CI: 73.9-83.1). 112 cases (50.9%) were studied with p16INK4a.

Table 1
Epidemiological characteristics of all diagnosed cases in the cervical cancer screening programme, and separately intraepithelial (HSIL) and invasive

Figure 2 shows progressive improving of screening coverage. Table 2 shows treatment and follow-up data from HSIL lesions and microinvasive carcinomas. Conization is the initial treatment in 213 out of 220 patients who were diagnosed with intraepithelial lesions (96.8%) and in all patients with microinvasive carcinoma. Untreated patients were due to their own personal choice because of their age and/or pregnancy wishes. No conization is performed in any case with minor HSIL biopsy diagnosis and there is no hysterectomy as first-choice treatment for HSIL. Residual HSIL is found in 4 patients submitted for repeated conizations and in 5 for hysterectomies. 14 (6.7%) patients treated for HSIL have persistent disease. Microinvasive carcinoma is diagnosed after repeated conization or hysterectomy because it is underrepresented in biopsy and in cone specimen. None of the patients with microinvasive carcinoma are sick during the follow-up, in part because the majority of them (6 out of 7 patients) undergo a hysterectomy.

Figure 2
Evolution of program coverage and CIN2+ cases detected during the 5 year study (women aged 25 to 64)

Table 2
Conization and follow-up results, by HSIL and microinvasive

Invasive cases from stage IB are described in table 3. Figure 3 shows HPV genotypes in HSIL (figure 3a) where 58% are positive for oncogenic viruses 16/18 which add up to 87% when being invasive (figure 3b) and 49% in follow-up. Thirty-three cases in figure 3a and two cases in figure 3b are not shown due to unknown genotype. There are also 4 cases of negative HPV: 2 pre-invasive, negative with cobas 4800® and HC2, but positive with p16INK4a in biopsy; and two invasive, one squamous carcinoma and one adenocarcinoma. The last one is a true negative being p16INK4a negative and also PCR (PGMY09 / PGMY11 and GP5+/GP6+). Figure 3c shows the distribution of genotypes in the follow-up. The fact that risk genotypes (16 and/or 18) are less frequent in follow-up than in HSIL and invasive cases (48.8%) can be seen.

Table 3
Invasive cases description, IB stage or more

Figure 3
Distribution of hrHPV genotypes in HSIL (3a), invasive (3b) and in the first follow-up control after conization (3c)

The bivariate analysis is shown in table 4. Patients over 45 years old, foreign or with a single involved quadrant are at greater risk of positive margins; all of them with statistical significance. No association is found among the horizontal extension of the lesion or genotype 16 and/or 18. However, genotype 16 and/or 18 do show a significant association when a single quadrant is involved in contrast to more than one. The average follow-up time since conization was 29.5 months (95% CI: 27.3-31.6).

Table 4
Bivariate study margin status, HPV genotype and post-treatment status, according to demographic and pathological features, for all the cases

DISCUSSION

Co-testing screening has detected small preinvasive lesions, in a single quadrant and microinvasive carcinomas. Conization is effective, achieving the cure of most of the patients.

Our series highlights the large number of HSIL with small lesions and microinvasive carcinomas. HSIL cases have increased considerably compared to the years prior to co-testing screening1313. Aragón Sanz MÁ, Vallés Gállego V, Clemente Roldán E, Oncíns Torres R, Comes García MD, González Ballano I, et al. Estrategias para la implantación del cribado poblacional de cáncer de cuello uterino con test del virus del papiloma humano. Prog Obstet Ginecol. 2016;59(6):377-382. and it is attributed especially to the greater sensitivity of the HPV testing compared to cytology1414. Cuzick J, Clavel C, Petry K-U, Meijer C, Hoyer H, Ratnam S, et al. Overview of the European and North American studies on HPV testing in primary cervical cancer screening. Int J Cancer. 2006;119:1095-1101.; also favored by the progressive coverage increase, given that increased diagnoses go side by side with coverage. About invasive carcinomas, a large percentage of them are detected in non-screened women, as found by other authors1515. Ibáñez R, Alejo M, Combalia N, Tarroch X, Autonell J, Codina L, et al. Underscreened Women Remain Overrepresented in the Pool of Cervical Cancer Cases in Spain: A Need to Rethink the Screening Interventions. Biomed Res Int. 2015;2015:605375. doi: 10.1155/2015/605375. pmid:26180804.
https://doi.org/10.1155/2015/605375...
and in a higher age range than in HSIL (4 patients were found outside the screening age range). The false negatives of cytology have been easily detected by the HPV testing, result similar to those obtained by Park1616. Park IU, Wojtal N, Silverberg MJ, Bauer HM, Hurley LB, Manos MM (2015). Cytology and Human Papillomavirus Co-Test Results Preceding Incident High-Grade Cervical Intraepithelial Neoplasia. PLoS ONE. 10(3): e0118938. doi: 10.1371/journal.pone.0118938.
https://doi.org/10.1371/journal.pone.011...
who detected 16.5% after a co-testing study (15.5% in our series). The false negatives of the HPV testing were detected by cytology and verified with the biopsy and the immunohistochemical technique of p16INK4a (1717. Ordi J, García S, del Pino M, Landolfi S, Alonso I, Quintó L, et al. p16 INK4a immunostaining identifies occult CIN lesions in HPV-positive women. Int J Gynecol Pathol. 2009;28:90-97.. They are explained by rare HPV genotypes (low or undetermined risk)1818. Petry KU, Cox JT, Johnson K, Quint W, Ridder R, Sideri M, et al. Evaluating HPV negative CIN2+ in the ATHENA trial. International Journal of Cancer 2016;138:2932-2939. or by the machines´ sensitivity threshold . This technique also helps in the detection of hidden or minimal CIN2+ and positive HPV testing44. Darragh TM, Colgan TJ, Thomas Cox J, Heller DS, Henry MR, Luff RD, et al; Members of the LAST Project Work Groups. The Lower Anogenital Squamous Terminology Standardization project for HPV-associated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Int J Gynecol Pathol. 2013;32:76-115., for CIN2 and CIN3 classification1919. Reuschenbach M, Wentzensen N, Dijkstra MG, von Knebel Doeberitz M, Arbyn M. p16INK4a immunohistochemistry in cervical biopsy specimens: a systematic review and meta-analysis of the interobserver agreement. Am J Clin Pathol. 2014;142:767-72. and for margins evaluation particularly when erosion or artifact are found2020. Kim TH, Han JH, Shin E, Noh JH, Kim HS, Song YS. Clinical Implication of p16, Ki-67, and Proliferating Cell Nuclear Antigen Expression in Cervical Neoplasia: Improvement of Diagnostic Accuracy for High-grade Squamous Intraepithelial Lesion and Prediction of Resection Margin Involvement on Conization Specimen. J Cancer Prev. 2015;20:70-7.. An accurrate diagnosis is very important because treatment can lead to later obstetric problems, so overtreatment should be avoided. CIN3 is for some the true high-grade intraepithelial neoplasia while a large part of the CIN2 regress2121. Castle PE, Schiffman M, Wheeler CM, Solomon D. Evidence for frequent regression of cervical intraepithelial neoplasia-grade 2. Obstet Gynecol. 2009;113:18-25.). However, CIN2 is the treatment threshold and our study has followed this classification1919. Reuschenbach M, Wentzensen N, Dijkstra MG, von Knebel Doeberitz M, Arbyn M. p16INK4a immunohistochemistry in cervical biopsy specimens: a systematic review and meta-analysis of the interobserver agreement. Am J Clin Pathol. 2014;142:767-72.), so that the results of CIN2 are shown separately to facilitate other comparisons.

In the study of the sensitivity of the tests, the purpose is to detect positive cases in healthy population and to find invasive HPV-negative carcinomas is less important. The test choice is important to evaluate the results and its application for future screening with a hrHPV DNA as primary screening testing33. Jeronimo J, Castle PE, Temin S, Shastri SS. Secondary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline Summary. Published online ahead of print October 12, 2016. J Glob Oncol. doi: 10.1200/JGO.2016.006577.
https://doi.org/10.1200/JGO.2016.006577...
and 16 and 18 genotyping as an appropriate choice for positive cases triage1212. Luttmer R, Berkhof J, Dijkstra MG, Kemenade FJ, Snijders PJF, Heideman DAM, et al. Comparing triage algorithms using HPV DNA genotyping, HPV E7mRNA detection and cytology in high-risk HPV DNA-positive women. J Clin Virol. 2015;67:59-66.. The HPV testing change was due to an easier use of Cobas, genotyping 16/18 in one step and its approval by the FDA for co-testing in 2011. Although it was a limitation in the statistical study of genotyped cases, it allowed us to verify negative HPV cases with both tests. The sensitivity of the HPV testing was superior to that of cytology even with these negative HPV cases. Intraepithelial neoplasms are typically from young women and invasive cancer develops in the third decade and a later age11. Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55:244-265.. Numerous studies have shown that HPV prevalence gradually decreases 2-8% in the population over 40 years of age; and persists in older than 50 showing a more indeterminate risk of cervical cancer in that group in most studies11. Bosch FX, Lorincz A, Muñoz N, Meijer CJ, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55:244-265.. The average age of HSIL is about 12 years before than the invasive cases. The 9 cases of invasive carcinoma in patients under 45 years old found in our study refer mostly to microinvasive cases.

The finding that foreign patients have a higher risk of CIN2+, especially those of Romanian origin, is explained by the high incidence of cervical cancer in Romania (39.4 cases per 100,000 inhabitants per year)2222. Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, et al. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Romania. Summary Report 2016-02-26. and in other eastern countries of Europe2323. Arbyn M, Antoine J, Magi M, Smailyte G, Stengrevics A, Suteu O, et al. Trends in cervical cancer incidence and mortality in the Baltic countries, Bulgaria and Romania. Int J Cancer. 2011;128:1899-1907.. The high incidence is attributed to the failure of the screening programs in these countries, both organized and opportunistic.

The conization with LLEP is the most widespread treatment and there are very few differences with the cases treated with cold knife2424. Santesso N, Mustafa RA, Wiercioch W, Kehar R, Gandhi S, Chen Y, et al. Systematic reviews and meta-analyses of benefits and harms of cryotherapy, LEEP, and cold knife conization to treat cervical intraepithelial neoplasia. Int J Gynecol Obstet. 2015;132:266-71.). The conization quality indicators would be the finding of CIN2+ in more than 85% of the cases treated and clear margins in more than 80% of the conizations55. Puig-Tintoré LM, Cortés J, Castellsague X, Torné A, Ordi J, de Sanjosé S et al. Prevención del cáncer de cuello uterino ante la vacunación frente al virus del papiloma humano. Prog Obstet Ginecol. 2006;49 (Extraordinario 2).,1010. Oncoguía SEGO: Prevención del cáncer de cuello de útero. Guías de práctica clínica en cáncer ginecológico y mamario. Publicaciones SEGO, Octubre 2014.,2525. Moss EL, Arbyn M, Dollery E, Leeson S, Petry KU, Nieminen P, et al. European Federation of Colposcopy quality standards Delphi consultation. Eur J Obstet Gynecol Reprod Biol. 2013;170:255-8.. It is not specified how the cones with ulcerated margins are classified, nor the affected margin cones and free endocervical curettage. In our study, the results show data very close to the proposed indicator in Oncoguía from 2014 SEGO.

After a mean follow-up of 29.5 months the number of patients with residual disease after treatment is low, and it is within the range cited in the reference protocol that we apply1010. Oncoguía SEGO: Prevención del cáncer de cuello de útero. Guías de práctica clínica en cáncer ginecológico y mamario. Publicaciones SEGO, Octubre 2014. (average 15% and range between 5 and 25% ). The association of age (over 45 years old) with positive margin that we find in our study is reflected in other publications. The association of age, tumor size and depth of the cone with positive margin has been published by Bae2626. Bae HS, Chung YW, Kim T, Lee KW, Song JY. The appropriate cone depth to avoid endocervical margin involvement is dependent on age and disease severity. Acta Obstet Gynecol Scand. 2013;92:185-92.. Tasci2727. Tasci T, Turan T, Ureyen I, Karalok A, Kalyoncu R, Boran N, et al. Is there any predictor for residual disease after cervical conization with positive surgical margins for HSIL or microinvasive cervical cancer? J Low Genit Tract Dis. 2015;19:115-8. associates it with the affectation of two or more quadrants (up to 80% margin involvement if more than two quadrants are affected). Güdücü2828. Güdücü N, Sidar G, Bassüllü N, Türkmen I, Dünder I. Endocervical glandular involvement, multicentricity, and extent of the disease are features of high-grade cervical intraepithelial neoplasia. Ann Diagn Pathol. 2013;17(4):345-6. found association between positive margin and more than two thirds of the LEEP specimen involvement, and also with glandular endocervical involvement and multicentricity (in CIN3 specimens) but not with age.

We do not find an explanation for the “paradoxical” association between positive margin and a single quadrant involvement which may be due to the difficulty of locating small lesions. We have also found no explanation for the finding that the genotypes 16/18 are associated with less extension of the lesion (involvement of one quadrant versus more than one).

Whereas authors found an association between the genotype 16/18 and residual disease2929. Kang WD, Ju UC, Kim SM. A human papillomavirus (HPV)-16 or HPV-18 genotype is a reliable predictor of residual disease in a subsequent hysterectomy following a loop electrosurgical excision procedure for cervical intraepithelial neoplasia 3. J Gynecol Oncol. 2016;27:e2. doi: 10.3802/jgo.2016.27.e2.
https://doi.org/10.3802/jgo.2016.27.e2...
, our finding shows only a trend in our series without being significant, probably because of smaller sample size in follow-up. Kliemann3030. Kliemann LM, Silva M, Reinheimer M, Rivoire WA, Capp E, Dos Reis R. Minimal cold knife conization height for high-grade cervical squamous intraepithelial lesion treatment. Eur J Obstet Gynecol Reprod Biol. 2012;165:342-6. finds an association between the extension of the lesion and the positive margin. The sizes it refers to are 6.12 ± 3.25mm vs. 10.6 ± 4.45mm that clearly are greater than ours (3.4mm in HSIL and 6.8mm in the invasive). Pirtea3131. Pirtea L, Grigoras D, Matusz P, Pirtea M, Moleriu L, Tudor A, et al. Age and HPV type as risk factors for HPV persistence after loop excision in patients with high grade cervical lesions: an observational study. BMC Surgery. 2016;16:70. also finds an association between genotype 16 and age (greater than 36.5 years old) in the follow-up of patients conizised by HSIL.

The follow-up of patients with HPV testing, with or without cytology, is recommended for its sensitivity, specificity and accuracy of results3232. Mariani L, Sandri MT, Preti M, Origoni M, Costa S, Cristoforoni P, et al. HPV-Testing in Follow-up of Patients Treated for CIN2+ Lesions. J Cancer. 2016; 7(1):107-114. doi: 10.7150/jca.13503.
https://doi.org/10.7150/jca.13503...
. It is also known that positive margin is associated with post-treatment virus persistence1010. Oncoguía SEGO: Prevención del cáncer de cuello de útero. Guías de práctica clínica en cáncer ginecológico y mamario. Publicaciones SEGO, Octubre 2014., as in our study. Residual disease despite clear margin can be attributed to lesion multifocality appearing in 23% of cases with clear margins.

The number of invasive cases has not decreased in recent years which is probably explained by the program´s increased coverage alongside the attendance of foreign patients from countries with ineffective screening programmes, who have contributed to the increase in invasive carcinomas (35.3 % of invasive cases are in woman from foreign countries).

The limitations of this study have neither included the findings of colposcopy, even being aware of its usefulness, nor data on vaccination. The use of two different techniques for the determination of HPV is another limitation of this study.

The study shows the applicability of the current recommendations and the effectiveness of the co-testing in diagnosis and follow-up. In addition, a round of co-testing, monitored and supported in Primary Care, serves as a reference for applying future protocols based on primary testing with hrHPV. The increase in sensitivity has resulted in an increase in conizations with small lesions and microinvasive carcinomas and has achieved the cure of most of the patients, which is the purpose of screening.

The implementation of the hrHPV DNA test in the Health Sector of Barbastro, has meant an increase in the number of HSIL detected and invasive of which a 50% are in incipient stage; attributable to the greater sensitivity of the HPV testing.

Genotype 16 is mainly responsible for invasive carcinomas and most pre-invasive carcinomas.

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ACKNOWLEDGMENTS

The authors thank Diego Ablanedo for his valuable contribution in English translation.

  • Suggested citation:

    Oncins Torres R, Aragón Sanz MA, Clemente Roldán E, Comes García MD, Muñiz Unamunzaga G, Guardia Dodorico L, Vallés Gallego V. Study of conizations of the cervix after five years of cervical cancer screening with co-testing. Rev Esp de Salud Pública.2018;92: October 2 e201810045.

Publication Dates

  • Publication in this collection
    26 Oct 2020
  • Date of issue
    2018

History

  • Received
    23 Aug 2017
  • Accepted
    18 June 2018
Ministerio de Sanidad, Consumo y Bienestar social Madrid - Madrid - Spain
E-mail: resp@mscbs.es