Does Repeat Large Loop Excision of the Transformation Zone Achieve a Cure for Histologically Proven Persistent High Grade Squamous Intra-epithelial Lesion at Margins?

Background: Cervical cancer is the second most common malignant neoplasm in women world-wide. Cervical Intra-epithelial Neoplasia (CIN) is a precursor lesion of cervical cancer and effective treatment of this lesion by Large Loop Excision of the Transformation Zone (LLETZ), can prevent progression to cervical cancer. Objectives: The aim of this study was to establish if repeat LLETZ achieves a cure for histologically proven persistent high grade CIN lesions at margins. Methods: A retrospective quantitative descriptive study, done at the Charlotte Maxeke Johannesburg Academic Hospital colposcopy clinic, South Africa. Data was collected from patient files (1500) over a period of 10 years (2006-2016). Patients who initially had HGSIL, then were treated using LLETZ and the repeat cytology showed persistent HGSIL then subsequently had a second LLETZ done. A total of 71 patients met the inclusion criteria. Results: 74,6% of the women had HGSIL (CIN 2, 3 and HGSIL) at the second/repeat LLETZ and 22.1% had LGSIL (CIN1 and LGSIL). Ecto-cervical margins were positive in 5 (8.5%) of the patients who had the initial LLETZ biopsy, negative in 3 (5.1%) and unreported in 1 (1.7%). This was as compared to positive margins in 8 (13.6%), negative margins in 15 (37.3%) and unreported in 3 (5.1%) at the second (repeat) LLETZ. Endo-cervical margins were positive in 17 (28.8%) of patients who had an initial LLETZ biopsy as compared to 11 (18.6%) at the second LLETZ. This showed an improvement of 35.4% from the first to the second biopsy. In 55.9% of patients, there was both ecto-cervical and endo-cervical margin involvement post the initial LLETZ as compared to 37.3% post repeat LLETZ. This was an improvement of about 33.3% post repeat LLETZ. There was no association between previous ecto-margins status (Pearson chi2 (98) = 106.7434 Pr = 0.257), previous endo-margins status (Pearson chi2 (10) = 2.8432 Pr = 0.985), both ecto and endo-margins status (Pearson chi2 (98) = 109.7042 Pr = 0.197) of the initial LLETZ and repeated LLETZ margin status. The cytology results post LLETZ had 22 (37.3%) patients with persistent HGSIL, 1 (1.7%) ASCUS-H, 21 (35.6%) LGSIL, 2 (3.4%) ASCUS and 13 (22.0%) had normal cytology report. There was regression to less severe form of the lesions in 61.0% of women post second LLETZ. Conclusion: Patients above 35 years of age with positive margins are at high risk or persistent CIN lesions as opposed to younger patient and those with negative margins. Repeat LLETZ offers improvement in margins (endo- and ecto - cervical) status, but doesn't offer a complete cure. It reduced the positive margin status and increased negative repeat cytology findings.