From the Guidelines
This patient with CIN 3 who has undergone cervical conization with clear margins should have follow-up cervical cancer screening in 6-12 months with HPV DNA testing, as recommended by the 2006 consensus guidelines 1. The follow-up plan should prioritize the detection of any potential recurrence or persistence of the disease, given that women with high-grade cervical dysplasia remain at elevated risk for recurrent disease and cervical cancer for at least 20 years after treatment, even with negative margins on conization. Key points to consider in the follow-up plan include:
- HPV DNA testing at 6-12 months is an acceptable posttreatment management option for women with CIN 2,3, according to the guidelines 1.
- If the HPV DNA test is negative, routine screening for at least 20 years commencing at 12 months is recommended 1.
- Colposcopy with endocervical sampling is recommended for women who are HPV DNA positive or have a repeat cytology result of ASC-US or greater 1.
- Repeat treatment or hysterectomy based on a positive HPV DNA test alone is unacceptable, emphasizing the need for comprehensive assessment and careful decision-making in the management of recurrent or persistent disease 1. Given the patient's clear margins after conization, the focus should be on surveillance and early detection of any potential recurrence, rather than immediate further treatment. The patient should be counseled about the importance of adhering to the recommended follow-up schedule to ensure early detection of any recurrent disease, highlighting the role of HPV testing in identifying those at higher risk of recurrence 1.
From the Research
Cervical Intraepithelial Neoplasia (CIN) Treatment and Follow-up
- The patient has undergone cervical conization, which showed CIN 3 with all surgical margins free of disease 2, 3, 4, 5.
- Studies have shown that loop electrosurgical excision procedure (LEEP) is a simple and quick procedure for diagnostic conization that can be done without major complications 2.
- However, if the histopathology after LEEP is moderate- to high-grade CIN or invasive cancer, the conization cannot be regarded as a sufficient therapeutic procedure, and further treatment may be needed 2.
Risk of Recurrence
- Positive margins are an independent risk factor for recurrent disease 3.
- HPV testing and co-testing with cytology can help identify patients at risk for recurrence after conization for high-grade CIN 3, 4.
- The patient's margin status is free of disease, which reduces the risk of recurrence 3, 4.
Follow-up Protocols
- Follow-up with HPV and PAP-smear tests after LEEP treatment is important for detecting residual or recurrent disease 3, 4.
- Co-testing is the best option in follow-up protocols after treatment for CIN 2-3, and if margins are free and co-testing is negative at six and 12 months, an 18-month visit could be avoided 3.
- A biopsy-cone interval of greater than 11 weeks may be associated with a higher rate of spontaneous regression of CIN 3 6.