Does repeat large loop excision of the transformation zone (LLETZ) achieve a cure for histologically proven persistent HGSIL at margins?

Abstract

Background: Cervical cancer is the second most common malignant neoplasm in women world-wide. CIN is a precursor lesion of cervical cancer and effective treatment of this lesion can prevent progression to cervical cancer. LLETZ has been shown to be effective treatment for CIN lesions with minimal complications. The aim of this study was to establish if repeat LLETZ achieves a cure for histologically proven persistent high grade CIN lesions at margins. Study Design: This was a retrospective quantitative descriptive study, done at the Charlotte Maxeke Johannesburg Academic Hospital colposcopy clinic in South Africa. Data were collected from patient files (1500) seen at the colposcopy clinic for a period of 10 years (2006-2016). These were patients who initially had HGSIL, were treated using LLETZ and the repeat cytology showed persistent HGSIL, so they subsequently had a second LLETZ done. A total of 71 patients met the inclusion criteria. Results: Overall, HGSIL (reported as CIN2, 3 and HGSIL) was found in 74.6% of the women at the second/repeat LLETZ and 22.1% had LGSIL (reported as CIN1 and LGSIL). Ecto-cervical margins were positive in 5 (8.5%) of the patients who had the initial LLETZ biopsy, negative in 3 (5.1%) and unreported in 1 (1.7%). Compared to positive margins in 8 (13.6%), negative margins in 15 (37.3%) and unreported in 3 (5.1%) at the second LLETZ. Endo-cervical margins were positive in 17 (28.8%) of patients who had an initial LLETZ biopsy as compared to 11 (18.6%) at the second LLETZ. This showed an improvement of 35.4% from the first to the second biopsy. In 55.9% of patients, there was both ecto-cervical and endo-cervical margin involvement post the initial LLETZ as compared to 37.3% post repeat LLETZ. This was an improvement of about 33.3% post repeat LLETZ. There was no association between previous ecto-margins status (Pearson chi2 (98) = 106.7434 Pr = 0.257), previous endo-margins status (Pearson chi2 (10) = 2.8432 Pr = 0.985), both ecto and endo-margins status (Pearson chi2 (98) = 109.7042 Pr = 0.197) of the initial LLETZ and repeated LLETZ margin status. The cytology results post LLETZ had 22 (37.3%) patients with persistent HGSIL, 1 (1.7%) ASCUS-H, 21 (35.6%) LGSIL, 2(3.4%) ASCUS and 13 (22.0%) had normal cytology report. There was regression of the lesions in 61.0% of women post second LLETZ. Conclusion: Patients above 35 years of age with positive margins are at high risk or persistent CIN lesions as opposed to younger patient and those with negative margins. Repeat LLETZ offers improvement in margins (endo-and ecto -cervical) status, but it doesn’t offer a complete cure. It reduced the positive margin status and increased negative repeat cytology findings