Diagnostic excision of the cervix in women over 40 years with human papilloma virus persistency and normal cytology

Abstract

Objective Persistent infection with human papillomavirus (HPV) is recognized as the main risk factor of cervical cancer. Investigation via cytology and colposcopy have lower sensitivity than HPV testing in the diagnosis of high-grade cervical intraepithelial neoplasia (CIN2+). Despite normal cytology and colposcopy findings women with persistent HPV infection have an increased risk of CIN2+. The aim of the study was to evaluate the proportion of histologically confirmed CIN2+ in women with persistent HPV infection and normal Pap smears. Study design From April 2013 until March 2016 we prospectively recruited 91 women over 40 years with persistent HPV infection without any abnormalities in cytology. Of these, 40 women attended a gynecological examination including an HPV test, Pap smear, endocervical cytology, colposcopy with biopsies and diagnostic loop electrosurgical excision procedure (LEEP). Biopsy and LEEP samples were subjected to histological examination Results CIN2+ was verified by histological examination of the LEEP sample in 6/40 (15%) of the women. All the cytological samples were normal and none of the biopsies confirmed CIN2+. Only 19/40 women still had a persistent HPV infection at the study visit. None of the 21/40 women who had cleared their HPV infection at the study visit had CIN2+ in histology of the LEEP sample. Conclusions A persistent HPV infection needs to be monitored despite normal Pap smears, since 6/40 (15%) women older than 40 years, was revealed to have an undiagnosed CIN2+ when LEEP was performed. Counseling women regarding the risk of cervical cancer and the expected effect of an eventual LEEP can help them to make an optimal informed choice.

Incidence of HPV and HPV related dysplasia in elderly women in Sweden

“…The routine for follow up of HPV-related CIN 1 or HPV persistence with or without dysplasia is with a new HPV test and cytology or colposcopy with biopsies. In a recent study from Uppsala, diagnostic conization showed a high frequency of dysplasia in HPV-positive women, where 15% (6/40) of women older than 40 years of age, were revealed to have an undiagnosed CIN2+ when LEEP was performed [25].…”

Incidence of oncogenic HPV and HPV-related dysplasia five years after a negative HPV test by self-sampling in elderly women

“…Even if HSIL or cervical cancer were not found in this study, it is impossible to ensure that neither were present, since the transformation zone was not visible during the colposcopy, and biopsies were randomly collected. A recent study showed that a persistent HPV infection needs to be monitored despite benign cytology and colposcopy, since 6/19 (32%) women with a persistent and ongoing HPV infection were revealed to have an undiagnosed CIN2 + when LEEP was performed [ 32 ]. The PPV is an indicator of the significance of having a persistent HPV infection for the risk to have dysplasia.…”

“…Another weakness is that there was no data on sexual partners during the last 5 years which could have explained some of the cases with HPV positivity. Finally, the histological data were obtained by, in many cases, randomly collected cervical biopsies, which means that there might have been HSIL or cervical cancer in the invisible part of the cervix, in analogy with what has been seen in the study by Aarnio et al [ 32 ]. In these cases, it might have been advisable to perform diagnostic conization.…”

Incidence of Oncogenic HPV and HPV-Related Dysplasia Five Years After a Negative HPV Test by Self-Sampling in Elderly Women

“…Even if HSIL or cervical cancer were not found in this study it is impossible to ensure that neither were present, since the transformation zone was not visible during the colposcopy, and biopsies were randomly collected. A recent study showed that a persistent HPV infection needs to be monitored despite benign cytology and colposcopy, since 6/19 (32%) women with a persistent and ongoing HPV infection were revealed to have an undiagnosed CIN2+ when LEEP was performed (33). The PPV is an indicator of the signi cance of having a persistent HPV infection for the risk to have dysplasia.…”

“…Another weakness is that there was no data on sexual partners during the last 5 years which could have explained some of the cases with HPV positivity. Finally, the histological data were obtained by, in many cases, randomly collected cervical biopsies, which means that there might have been HSIL or cervical cancer in the invisible part of the cervix, in analogy with what has been seen in the study by Aarnio et al (33). In these cases, it might have been advisable to perform diagnostic conization.…”