Loop electrosurgical excision procedure (LEEP) plus top hat for HIV‐infected women with endocervical intraepithelial neoplasia in Kenya

Abstract

Objective To determine the utility of detecting endocervical cervical intraepithelial neoplasia (CIN) 2+ with endocervical curettage (ECC) and treating with loop electrosurgical excision procedure (LEEP) plus top hat (+TH) among women with HIV. Methods Cytology was followed by coloscopy‐directed biopsy if participants had HSIL or ASC‐H and biopsy plus ECC if there were glandular cells present. CIN2/3 on ECC and/or inadequate colposcopy (ENL) was treated with LEEP+TH, while CIN2/3 on ectocervix (ECL) received LEEP alone. Recurrent CIN2+ were compared over a 2‐year follow‐up. Results Of 5330 participants, 160 underwent ECC, 98 were CIN2/3 on ECC, and 77 received LEEP+TH. ECC detected 15 (9%) more women with CIN2/3 than biopsy alone. Women were more likely to have ENL if they were older (≥45 vs <35 years) (adjusted relative risk [aRR] 2.14; P = 0.009) and on antiretroviral treatment longer (≥2 vs <2 years) (aRR 3.97; P < 0.001). Over the 2‐year follow‐up, 35 (29%) ENL had recurrent CIN2+ after TH compared to 19 (24%) ECL after LEEP (hazard ratio 1.32; 95% confidence interval 0.75–2.31; P = 0.338). Conclusion Among HIV‐infected women, adding ECC did not increase detection of pre‐cancerous disease significantly and treatment with LEEP+TH for ENL was comparable to treatment with LEEP for ECL.

Recurrent High-Grade Squamous Intraepithelial Lesion After Loop Excision Procedure Versus Loop Procedure With Top Hat

“…A study looking at immunosuppressed patients with HIV found no difference in recurrence rates between LEEP-SP and LEEP-TH, suggesting that even in this high-risk population there may be no benefit to the addition of a top hat. 20 Finally, excisional procedures in general only remove cervical tissue and cannot fully remove all HPV-infected cells, which can also impact recurrence risk.…”

“…Our study identified women who may be at higher risk for undergoing an additional excision, specifically patients who were older, immunosuppressed, had a positive ECS at colposcopy and at time of LEEP, and had an initial HSIL cytology. A study looking at immunosuppressed patients with HIV found no difference in recurrence rates between LEEP-SP and LEEP-TH, suggesting that even in this high-risk population there may be no benefit to the addition of a top hat 20 . Finally, excisional procedures in general only remove cervical tissue and cannot fully remove all HPV-infected cells, which can also impact recurrence risk.…”