Management Of High-Grade Squamous Intraepithelial Lesion Patients With Positive Margin After LEEP Conization

Objective:To identify the risk factors for recurrent and residual diseases in patients with high-grade squamous intraepithelial lesion（HSIL）and positive margin after cervical conization,so as to find the optimal way for managing these patients.Methods:A retrospective study was conducted on 267 cases of a pathologically confirmed HSIL with positive margin following conization by loop electrosurgical excisional procedure（LEEP）between January 2010 and December 2015 in the Department of Obstetrics and Gynecology,Qilu Hospital of Shandong University.The clinical and pathological data of these patients are collected from the computerized medical records.Among the 267 cases with a positive margin,102 cases were selected for regular follow-up every 6 months and the remaining 165 cases were selected for a second surgery（repeat cervical conization or hysterectomy）within 3 months of initial LEEP.We analyzed the association between recurrent or residual diseases and these factors:age,menopausal status,ThinPrep cytologic test（TCT）results,high-risk human papillomavirus（HR-HPV）infection,pathological grades of the margin,number of the involved-margins,and glandular involvement.Results:The mean age of the 267 cases with a positive margin was 38.52±6.0 years old and ranged between 20-70 years.Of these cases,82%（219/267）were nonmenopausal,and 90.6%（242/267）were HR-HPV infected before initial LEEP.The recurrence rate among the 102 cases who underwent follow-up was 17.6%（18/102）.Statistically,atypical squamous cells of undetermined significance cannot exclude HSIL（ASC-H）or higher lesions in the pre-LEEP TCT（p=0.038）,persistent HR-HPV infection at the sixth month post-LEEP（p=0.03）,HSIL-positive margin（p=0.003）and multifocal-involved margin（p=0.002）were significantly associated with recurrent disease,while age（p=0.152）,menopause（p=0.238）,and pre-LEEP HR-HPV infection（p=0.687）were not associated with recurrent disease.The residual rate among the 165 patients who underwent the second surgery was 45.5%（75/165）,of which 15 cases were residual cervical cancer.The residual rate was significantly higher in menopausal women than in non-menopausal women（p=0.02）,in≥ASC-H in the preLEEP TCT than in≤LSIL（p=0.04）,in≥ HSIL-positive margin than in LSIL-positive margin（p<0.001）and in multifocal-involved margin than in focal-involved margin（p<0.001）.No correlation existed between the residual disease and both the age（p=0.06）and the glandular involvement（p=0.73）.Conclusion:The recurrence rate is significantly affected by pre-LEEP TCT results,post-LEEP HR-HPV infection and pathological characteristics of the positive margin.Whereas,menopausal status,pre-LEEP TCT results,pre-LEEP HR-HPV infection and pathological characteristics of the positive margin are correlated with residual disease.For patients with positive margin after LEEP,regular follow-up or second surgery should be selected according to fertility requirement and cytopathological characteristics of positive margin as well as TCT and HR-HPV infection condition.