Case Conference April 12 th 2017

12-Apr-2017, Divisi Ginekologi Onkologi RSCM

Mrs. A

Cervical intraepithelial neoplasia

PPDS: Nicholas Marco AH Hutauruk (T3B, Oncology Rotation)

 

CASE DESCRIPTION (13 February 2017)

Mrs R, P3A2, came to the colposcopy clinic for routine follow up. Patient had no symptoms, currently she has no vaginal bleeding nor vaginal discharge. Patient had menopause since 18 years ago. The history of patient is as follows:

-       16 December 2016     : Pap smear result HSIL, AGUS à planned for colposcopy

-       22 December 2016     : Colposcopy à Unsatisfied colposcopy finding

-       5 January 2017           : LBC result HSIL and HPV DNA High risk type 57

                                      (Low risk negative)

-       5 January 2017           : Colposcopy à Unsatisfactory colposcopy finding,

                                   Performed LLETZ  2 cm at 2 part of cervix (1,8 cm & 0,8 cm)

-       19 January 2017         : Pathology result  

                                      Speciment I à CIN 3 with glandular involvement

                                      (micro invasive was not found)

                                      Speciment II à CIN 1 with HPV infection

-       23 February 2017       : Colposcopy à Unsatisfactory colposcopy finding,

                                      Patient planned for 1 month follow up

-       6 April 2017                : Cervix was smooth, CIN 3 post LLETZ 3 months

Colposcopy à normal colposcopy finding

 

Planned 2 week follow up for LBC & HPV DNA result 

INTRODUCTION

 

Cervical intraepithelial neoplasia (CIN) is a precursor lesion of cervical cancer and is histologically classified as CIN 1, CIN 2, or CIN 3. The proportion of the thickness of the epithelium showing mature and differentiated cells is used for grading CIN. More severe  degrees of CIN are likely to have a greater proportion of the thickness of epithelium composed of undifferentiated cells, with only a narrow layer of mature differentiated cells on the surface^1,2.

Endocervical glandular involvement (EGI) was more often associated with CIN 2/3 than with CIN 1. This result may influence the preference for the type of surgical procedure used for patients with cytological diagnosis of CIN 2 and 3³.

 Cervical intraepithelial neoplasia (CIN) 2 and 3 are managed in the same way due to the histologic distinction between them is poorly reproducible. Excisional treatment is mainly used to treat CIN 2/3, which might progress to invasive cervical cancer if it’s left untreated^2,3.

There are two main excisional modalities: loop electrosurgical excision procedure (LEEP) or large loop excision of the transformation zone (LLETZ) and cold-knife conization (CKC). 2012 ASCCP guidelines do not make any recommendations indicating CKC or LEEP as the optimal therapy option^1,2.

 

 

CLINICAL QUESTION

 

In the management of CIN 3 with glandular involvement, does large loop excision of the transformation zone (LLETZ) have a lower recurrence rate compared to Conization ?

RESULT

A meta-analysis by Jiang et al on 20 studies comparing LLETZ and CKC. The CKC group had slightly lower recurrence rate than those in LLETZ/LEEP group (RR =1.75, 95% CI =0.99–3.11, P=0.06), but it was not statistically significant. There were also no significant differences in  positive margin rate (RR =1.45; 95% CI =0.85–2.49, P=0.17) and residual disease rate (RR =1.15, 95% CI =0.73–1.81, P=0.48)².

 

 

DISCUSSION

The one of main problems of treating CIN is disease recurrence. In 5 years follow up after treatment there is still risk of recurrence for 8 years or more. Another study showed that recurrences occurred after 5–31 months in 7.1% and 11.2% of the patients who underwent LEEP and CKC, respectively, and had negative histological findings on surgical specimens. Even though there is a trend regarding recurrence rate in LEEP/LLETZ, it was not statistically significant^2,4.

 

The association between the rate of positive margins with the method of treatment has remained unclear. LLETZ/LEEP was previously associated with a higher incidence of positive margins, which might be because of the significantly deeper conization of CKC and the removal of occult endocervical lesions. However, even though the median resected cone volume after LLETZ was significantly smaller [1.6 cm³ (0.8–2.9)] than after CKC [2.1 cm³ (1.4–3.5)] (p < 0.0001), complete resection rates were comparable in both groups².

 

Increasing age has been identified as a possible pre-surgical predictor of persistence/recurrence in some studies. Shin et al study found that in patients aged > 45 years, the LLETZ/ LEEP group had significantly higher rate of nonnegative surgical margins compared with the CKC group. This result suggests that the use of LLETZ/LEEP might not be recommended if achieving complete negative margin is the only consideration, especially for older women. It is still unclear why older women may be more likely to experience persistence/recurrence. One possible reason may be altered immunity or positive selection overtime toward viruses with a higher oncogenic risk^2,3,5.

 

LEEP/LLETZ is as effective as CKC with regard to recurrence rate. In fact, a clinical judgement should also put into consideration when choosing method of excision^3,5.

 

 

CONCLUSION

There is no significant difference regarding residual and recurrence rate in LLETZ/LEEP compared with CKC for treating CIN 3 with glandular involvement.

  

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