Predicting Persistent/Recurrent Disease in the Cervix After Excisional Biopsy

Sanjay M. Ramchandani, MD; Karen L. Houck, MD; Enrique Hernandez, MD; John P. Gaughan, PhD

Disclosures
In This Article

Results

The median age of the 152 patients was 35 years, with a mean of 34 and a range of 17 to 71 years. The median gravidity was 3 and the median parity was 2. The majority (83%) of the patients were parous. Race distribution was: 67% black, 16% white, 11% Hispanic, and 6% other or unknown.

The conization specimen had no pathology in 26 (17%) cases. It had CIN 1 in 21 (14%). CIN 2 or 3 was present in 94 (62%), and microinvasive or invasive carcinoma was identified in 11 (7%). The endocervical margin was positive in 30 (20%) of the 152 cases and the ectocervical margin was positive in 38 (25%). Twenty (13%) of the 152 ECC specimens obtained at the time of conization were positive for dysplasia or carcinoma. In 29 (19%) of the 152 ECC specimens there was not enough tissue for histopathologic diagnosis.

Thirty-three of the 152 patients underwent a hysterectomy within 12 months of the conization. Ten had a repeat conization and 17 had a cervical biopsy with or without ECC. In addition to follow-up colposcopy and cervical cytology, 4 had an ECC. The follow-up of the other 88 patients consisted of cervical cytology and colposcopy only (ie, no biopsies were obtained). Persistent/recurrent dysplasia or cancer was seen in 41 (27%) of the 152 cases (15 CIN 1, 22 CIN 2/3, 4 carcinoma). Persistent/recurrent disease was detected by hysterectomy in 18 cases (3 CIN 1, 11 CIN 2/3, 4 carcinoma), repeat conization in 7 (3 CIN 1, 4 CIN 2/3), cervical biopsy in 2 (both with CIN 1), and cervical cytology in 14 (7 CIN 1, 7 CIN 2/3).

Table 1 presents a summary of the presence or absence of persistent/recurrent disease in patients with positive, negative or "tissue insufficient for diagnosis" on ECC. Persistent/recurrent dysplasia or cancer was present in 16 of 20 patients (80%) with a positive ECC. Nineteen of 103 patients (18.5%) with a negative ECC and 6 of 29 patients (20.7%) with insufficient tissue for histopathologic diagnosis had persistent/recurrent disease.

Persistent/recurrent dysplasia or cancer was detected in 20 of 30 patients (66.7%) with positive endocervical margins in the cervical conization specimen. Twenty-one of 122 patients (17.2%) with negative endocervical margins had persistent/recurrent disease. Eighteen of 38 patients (47.4%) with positive ectocervical margins had persistent/recurrent dysplasia or cancer. Twenty-three of 114 patients (20.2%) with negative ectocervical margins had persistent/recurrent disease. Persistent/recurrent disease was present in 26 of 52 patients (50%) with positive endocervical and/or ectocervical margins. Persistent/recurrent disease was found in 15 of 100 patients with negative endocervical and ectocervical margins.

Table 2 presents a summary of the presence or absence of persistent/recurrent cervical neoplasia as it relates to the status of the ECC specimens and the endocervical margin. Thirteen of 13 patients (100%) with both a positive ECC and positive endocervical margins had persistent/recurrent disease. Persistent/recurrent disease was detected in 13 of 91 patients (14.3%) with a negative ECC and a negative endocervical margin. Three of 7 patients (42.9%) with positive ECC and negative endocervical margins had persistent/recurrent cervical neoplasia. Six of 12 patients (50%) with negative ECC and positive endocervical margin had persistent/recurrent disease. Persistent/recurrent cervical neoplasia was detected in 1 of 5 patients (20%) with insufficient tissue for diagnosis on ECC and positive endocervical margin. Five of 24 patients (20.8%) with insufficient tissue for diagnosis on endocervical curettage and negative endocervical margins had persistent/recurrent disease.

The sensitivity of the ECC at time of conization to detect persistent/recurrent disease is 0.46 (95% confidence interval [CI]: 0.29, 0.63). The specificity is 0.96 (95% CI: 0.88, 0.99). The positive predictive value is 0.80 (95% CI: 0.56, 0.93), and the negative predictive value is 0.82 (95% CI: 0.72, 0.88). The sensitivity of the endocervical and/or ectocervical margin status to predict persistent/recurrent disease is 0.63 (95% CI: 0.47, 0.77). The specificity is 0.77 (95% CI: 0.67, 0.84). The positive predictive value is 0.50 (95% CI: 0.36, 0.64), and the negative predictive value is 0.85 (95% CI: 0.36. 0.64).

In patients with normal or CIN 1 findings on the conization specimen, 7.7% and 9.5%, respectively, had persistent/recurrent disease (3 CIN 1, 1 CIN2/3). In patients with CIN 2/3 or cancer diagnosis on the conization, 33% and 54.5%, respectively, had persistent/recurrent disease. More than 90% of patients with normal or CIN 1 on the conization did not have persistent/recurrent disease. As the severity of cervical neoplasia in the conization specimen increases, there is an increase in the percentage of patients who have persistent/recurrent disease.

Using univariate logistic regression, a positive endocervical margin (odds ratio [OR], 9.618; 95% CI: 3.939, 23.488), positive ectocervical margin (OR, 3.561; 95% CI: 1.626, 7.799), positive ECC specimens (OR, 17.683; 95% CI: 5.308, 58.912), and histopathologic diagnosis (OR, 2.730 per grade; 95% CI: 1.507, 4.947) were all individually significantly associated with the presence of persistent/recurrent disease. Age of the patient at the time of cervical conization was not significantly associated with the presence of persistent/recurrent disease (OR, 1.008; 95% CI: 0.975, 1.042).

In the multivariate stepwise logistic regression analysis, the endocervical margin status and the ECC specimen findings together, ECC specimens (OR, 8.710; 95% CI: 2.302, 32.958) and endocervical margin (OR, 9.170; 95% CI: 2.887, 29.125) were significant predictors of persistent/recurrent disease having adjusted for the other variable.

Four variables (endocervical margin status, ectocervical margin status, ECC specimen findings, and histopathologic diagnosis in the conization specimen) were combined in a multivariate stepwise logistic regression to estimate the incremental risk of persistent/recurrent disease for each factor independent of (adjusted for) the other factors. Based on this analysis, endocervical margin (OR, 6.761; 95% CI: 2.657, 17.202) and histopathologic diagnosis in the conization specimen (OR, 1.930, 95% CI: 1.038, 3.59) significantly predicted the occurrence of persistent/recurrent disease. Adding the results of the ECC specimens to the histopathologic diagnosis and the endocervical margin status did not add incremental value to the ability of predicting persistent/recurrent cervical neoplasia.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....