Risk factors for cervical intraepithelial neoplasia recurrence after loop electrosurgical excision p

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Risk factors for cervical intraepithelial
neoplasia recurrence after loop electrosurgical
excision procedure in HIV-1-infected and
non-infected women

• Maria Inês Miranda LIMA (1)
• Victor Hugo MELO (2)
• Celso Pedro TAFURI (1)
• Luiza Miranda LIMA (3)
• Angela Cristina Labanca ARAÚJO (1)
• Mark Drew Crosland GUIMARÃES (1)

• (1) School of Medicine, Federal University of
  Minas Gerais, Belo Horizonte, Brazil
• (2) Belo Horizonte City Health Department
• (3) Medical Science School of Medicine

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Background

• CERVICAL CANCER
• High incidence of Cervical Cancer in Brazil
• (22/100,000 women in 2005)
• Cervical Intraepithelial Neoplasia (CIN) is a
  precursor of cervical cancer and is highly
  associated with HPV infection
• Early Dx of CIN can prevent new cases of CC
• (Cytology, Colposcopy, Biopsy)
• LEEP (Electrosurgical Excision Procedure) has
  been extensively used in Brazil

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Background

• AIDS epidemic in Brazil (up to 2005 370,000
  cases)
• Women
• Heterosexual transmission
• Lower income and education
• HIV Cervical cancer
• Higher incidence of CIN and CC among HIV positive
  women
• Evidence of higher incidence of recurrence of CIN
  among HIV positive women
• There is no published data in Brazil regarding
  recurrence of CIN comparing HIV positive and
  negative women

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Objective

• To assess factors associated with recurrence of
  cervical intraepithelial neoplasia after
  conization by LEEP in HIV infected and
  non-infected women

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Methods

• DYNAMIC COHORT STUDY
• Population
• Public Cervical Pathology Referral Service, Belo
  Horizonte, Brazil
• Referred from other public primary care units or
  HIV services
• Screening criteria
• Abnormal cytology (Bethesda,1999)
• OR
• Normal cytology with Positive Schiller test

• Colposcopy
• Biopsy

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Methods

• Elegibility criteria for LEEP
• Age gt 18 years old
• Informed consent
• Dx of Cervical Intraepithelial Neoplasia (CIN)
• HSIL lesions or persistent LSIL lesions for HIV
  negative women
• HSIL or LSIL for HIV positive women
• Exclusions
• Pregnant women
• Other Dx Cervicitis, Invasive Cancer,
  Micro-invasive Cancer

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Methods

• Recurrence of CIN
• First recurrence
• Cytology and Colposcopy
• If abnormal or normal with positive Schiller
  test
• Biopsy
• HSIL lesions or persistent LSIL lesions

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Methods

• Statistical analysis
• Cox Proportional Hazard Model (Univariate and
  Multivariate)
• Kaplan-Meier Survival Curves
• Variables of interest HIV status, Histology,
  Glandular involvement, Margins, Number of sex
  partners, Age, Smoking Hx, HPV, Viral Load and
  CD4 Cell count.

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Results
n ( ) or Mean SCREENED AND
BIOPSIED 206 (100) EXCLUDED 5 (
2) PARTICIPANTS 201 ( 98) BIOPSIED DURING
FOLLOW-UP 73 ( 36) Cumulative incidence
40 ( 20) Incidence / 1,000 women-months
10.2 Mean number of visits 4.6 Mean
Time of follow-up (Median) 19.4 (18.6)
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Results
Variable n () Age (gt 35y.o.) 126 (63) Nu
mber of lifetime partners (lt 6) 142 (71) Smoking
Hx 68 (34) HIV Positive
94 (47) Cytology (HSIL) 62 (31) Biopsy
(HSIL) 114 (57) Histopathology (HSIL)
129 (64) Positive margins 45 (24) Glandular
involvement 21 (10)
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Results Multivariate Analysis

• Variable RH (95 CI) p-Value
• HIV Status (Pos) 3.00 (1.38 6.48) 0.005
• Glandular involvement 3.46 (1.71 7.01) 0.000
• Positive Margin 2.04 (1.05 3.98) 0.035
• RHRelative Hazard

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Positive margins and glandular involvement
Normal Duct
Positive margin
Positive margin
Glandular involvement
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Conclusions

• The incidence of CIN recurrence in this
  population is high.
• HIV infection, positive margins and glandular
  involvement are independent co-factors.
• More careful follow-up of these women is
  necessary, specially among HIV positive ones.
• Histopathology indicates HPV infection in over
  95.
• However, PCR is recommended for sub-typing and is
  currently under way.
• Adherence to ARVT and Viral load will be further
  explored among HIV positive women.