Elektrocerrahi ile eksizyon sonrası cerrahi sınır pozitif yüksek dereceli servikal intraepitelyal lezyon olgularında lezyonun persistansı ile ilişkili parametreler

Yıl 2021, Cilt: 14 Sayı: 1, 167 - 174, 04.01.2021

Derya Kılıç Ömer Tolga Güler Elif Avşaroğlu Yeliz Arman Karakaya Babür Kaleli Erkan Alataş

https://doi.org/10.31362/patd.822807

Öz

Amaç: Yüksek dereceli servikal intraepitelyal lezyonların (HSIL) tedavisinde eksizyon sonrası cerrahi sınırda HSIL devamlılığı saptanır ise yeniden eksizyon veya 4-6 ay sonra kontrol seçenekleri gündeme gelmektedir. Ancak bu olgularda re-eksizyon materyalinde HSIL’ in sebat edip etmediğini öngörebilen parametreler henüz tanımlanmamıştır. Biz bu çalışmada lezyon persistansı ile ilişkili olabilecek klinik ve histopatolojik parametreleri değerlendirmeyi amaçladık.
Yöntem: Elektrocerrahi ile eksizyonel tedavi sonrası cerrahi sınırda HSIL devamlılığı izlenen ve bu nedenle yeniden eksizyon yapılan olguların bilgileri retrospektif olarak taranmıştır. Hastaların sosyodemografik verileri, başvuru sırasındaki HPV (Human Papilloma Virus) tiplemesi (HPV tip 16/18 veya diğer yüksek riskli tipler), maksimal lezyon çapları, odak sayısı, yüksek dereceli lezyonun derecesi (CIN2 veya CIN3), eksizyonel materyalin maksimal çapı, cerrahi sınır durumu ve derecelendirilmesi (Grade 1: şüpheli veya rölatif olarak tam sınırda olan cerrahi sınır pozitifliği; Grade 2: belirgin cerrahi sınır pozitifliği) ile sonraki eksizyonel işlemde HSIL’in sebat edip etmemesi analiz için kayıt edilmiştir.
Bulgular: Çalışma kriterlerine uyan toplamda 73 hasta belirlendi. Yeniden eksizyon yapılan hastaların 23 (%31.5) tanesinde yüksek dereceli lezyonun sebat ettiği saptandı. Sosyodemografik ve histopatolojik faktörler (yaş, menapoz, sigara kullanımı, başlangıçtaki yüksek riskli HPV tipi, eksizyonun büyüklüğü, histolojik tip (CIN2/ CIN3) lezyon büyüklüğü, lezyonun odak sayısı ve cerrahi sınır pozitifliğinin derecesi) incelendiğinde, rezidüel hastalığın saptandığı ve saptanmadığı gruplar arasında istatistiksel anlamlı farklılık saptanmadı (p=0.116, p=0.750, p=0.601, p=0.092, p=0.719, p=0.501, p=0.699, p=0.131, p=0.884, sırasıyla).
Sonuç: Olguların yaklaşık üçte birinde re-eksizyon materyalinde HSIL’ in sebat ettiği saptanmıştır. Ancak ne klinik özellikler ne de ilk eksizyondaki patolojik bulgular ile lezyonun varlığı arasında anlamlı bir ilişki gösterilememiştir.

Anahtar Kelimeler

Servikal kanser, Yüksek dereceli intraepitelyal neoplazi, Cerrahi sınır, Loop elektrocerrahi eksizyon prosedürü

Destekleyen Kurum

yok

Parameters associated with persistent disease after excisional treatment by electrosurgery in patients with high grade cervical intraepithelial lesion and positive surgical margin

Öz

Purpose: In the treatment of high-grade cervical intraepithelial lesions (HSIL), when HSIL is detected at the surgical margin after excision, re-excision or control after 4-6 months are the management options. However, the parameters that will determine in which patients HSIL will persist in the re-excision materials are not precisely defined. In this study, we aimed to evaluate the relationship between clinical and histopathological parameters, and the persistence of the lesion after electrosurgical excision.
Materials and methods: The information of the patients in colposcopy unit who had HSIL at surgical margin after electrosurgical excisional treatment and were experience re-excision for this reason were retrospectively investigated. In addition, the sociodemographic data of the patients, HPV (Human Papilloma Virus) typing (HPV type 16/18 or other high risk types) at the time of admission, maximal lesion diameter, number of foci, degree of high-grade lesion (CIN2 or CIN3), maximal diameter of excisional material, surgical margin status and grading (Grade 1: suspicious or relatively borderline surgical margin positivity; Grade 2: significant surgical margin positivity), and persistence of HSIL in the subsequent excisional procedure were recorded for analysis.
Results: 73 patients who met the inclusion criteria of the study were identified. High-grade lesions were found to persist in 23 (31.5%) patients who underwent re-excision. When sociodemographic and histopathological factors were analyzed (age, menopause, smoking, initial high-risk HPV type, size of excision, histological type (CIN2 / CIN3) lesion size, lesion focus number, and the degree of surgical margin positivity), no statistical significance was found between the groups with and without residual disease (p=0.116, p=0.750, p=0.601, p=0.092, p=0.719, p=0.501, p=0.699, p=0.131, p=0.884, respectively).
Conclusions: HSIL persisted in approximately one third of the cases with positive surgical margin after re-excision. However, neither clinical features nor pathological findings at the first excision were found to be significantly correlated with persistence.

Anahtar Kelimeler

Cervical cancer, High-grade intraepithelial neoplasia, Surgical margin, Loop electrosurgical excision procedure

Kaynakça

• 1) Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68(6):394-424. doi:10.3322/caac.21492
• 2) McCredie MRE, Sharples KJ, Paul C, et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol 2008;9(5):425-434. doi:10.1016/S1470-2045(08)70103-7
• 3) Dos Santos Melli PP, Duarte G, Quintana SM. Multivariate analysis of risk factors for the persistence of high-grade squamous intraepithelial lesions following loop electrosurgical excision procedure. Int J Gynaecol Obstet 2016;133(2):234-237. doi:10.1016/j.ijgo.2015.09.020
• 4) Kawano K, Tsuda N, Nishio S, et al. Identification of appropriate cone length to avoid positive cone margin in high grade cervical intraepithelial neoplasia. J Gynecol Oncol 2016;27(5):e54. doi:10.3802/jgo.2016.27.e54
• 5) Andrade CEMC, Scapulatempo-Neto C, Longatto-Filho A, et al. Prognostic scores after surgical treatment for cervical intraepithelial neoplasia: a proposed model and possible implications for post-operative follow-up. Acta Obstet Gynecol Scand 2014;93(9):941-948. doi:10.1111/aogs.12446
• 6) Oliveira CA de, Russomano FB, Gomes Júnior SC dos S, Corrêa F de M. Risk of persistent high-grade squamous intraepithelial lesion after electrosurgical excisional treatment with positive margins: a meta-analysis. Sao Paulo Med J 2012;130(2):119-125. doi:10.1590/s1516-31802012000200009
• 7) 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):985-993. doi:10.1016/S1470-2045(07)70283-8
• 8) Massad LS, Einstein MH, Huh WK, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol 2013;121(4):829-846. doi:10.1097/AOG.0b013e3182883a34
• 9) Simoens C, Goffin F, Simon P, et al. Adverse obstetrical outcomes after treatment of precancerous cervical lesions: a Belgian multicentre study. BJOG 2012;119(10):1247-1255. doi:10.1111/j.1471-0528.2012.03429.x
• 10) Kilic D, Guler T, Atigan A, et al. Predictors of Human papillomavirus (HPV) persistence after treatment of high grade cervical lesions; does cervical cytology have any prognostic value in primary HPV screening? Ann Diagn Pathol 2020;49:151626. doi:10.1016/j.anndiagpath.2020.151626
• 11) Miyoshi Y, Miyatake T, Ueda Y, et al. Prediction, based on resection margins, of long-term outcome of cervical intraepithelial neoplasia 3 treated by Shimodaira-Taniguchi conization. Arch Gynecol Obstet 2012;285(5):1427-1432. doi:10.1007/s00404-011-2147-8
• 12) Tasci T, Turan T, Ureyen I, 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(2):115-118. doi:10.1097/LGT.0000000000000079
• 13) Monsonego J, Cox JT, Behrens C, et al. Prevalence of high-risk human papilloma virus genotypes and associated risk of cervical precancerous lesions in a large U.S. screening population: data from the ATHENA trial. Gynecol Oncol 2015;137(1):47-54. doi:10.1016/j.ygyno.2015.01.551
• 14) Gultekin M, Dundar S, Keskinkilic B, et al. How to triage HPV positive cases: Results of four million females. Gynecologic Oncology Published online April 30, 2020. doi:10.1016/j.ygyno.2020.04.698
• 15) Gultekin M, Zayifoglu Karaca M, Kucukyildiz I, et al. Initial results of population based cervical cancer screening program using HPV testing in one million Turkish women. Int J Cancer 2018;142(9):1952-1958. doi:10.1002/ijc.31212
• 16) Cuzick J, Wheeler C. Need for expanded HPV genotyping for cervical screening. Papillomavirus Res 2016;2:112-115. doi:10.1016/j.pvr.2016.05.004
• 17) Diaz ES, Aoyama C, Baquing MA, et al. Predictors of residual carcinoma or carcinoma-in-situ at hysterectomy following cervical conization with positive margins. Gynecol Oncol 2014;132(1):76-80. doi:10.1016/j.ygyno.2013.11.019
• 18) Fu Y, Chen C, Feng S, et al. Residual disease and risk factors in patients with high-grade cervical intraepithelial neoplasia and positive margins after initial conization. Ther Clin Risk Manag 2015;11:851-856. doi:10.2147/TCRM.S81802
• 19) van der Heijden E, Lopes AD, Bryant A, Bekkers R, Galaal K. Follow-up strategies after treatment (large loop excision of the transformation zone (LLETZ)) for cervical intraepithelial neoplasia (CIN): Impact of human papillomavirus (HPV) test. Cochrane Database Syst Rev 2015;1:CD010757. doi:10.1002/14651858.CD010757.pub2