Samir Saidi

The impact of primary human papillomavirus screening on negative loop excision histology following biopsy‐proven high‐grade cervical intra‐epithelial lesions: A review from a large tertiary colposcopy unit

BackgroundThe renewed National Cervical Screening Program incorporating primary human papillomavirus (HPV) screening was implemented in Australia in December 2017. In a previous study conducted in the UK, primary HPV screening was found to be associated with a 25% reduction in the incidence of negative histology following loop electrosurgery excision procedure (LEEP).AimTo examine the change in incidence and associated risk factors for a negative LEEP with introduction of primary HPV screening.Materials and MethodsA retrospective review of the records of all patients undergoing a LEEP excision for biopsy‐proven high‐grade cervical intra‐epithelial lesions between 1 January 2014 and 30 June 2019 in a specialised centre.ResultsThere were 1123 patients who underwent a LEEP included in the analysis. The incidence of a negative LEEP specimen was 7.5% (59/784) and 5.3% (18/339) in the pre‐ and post‐HPV screening cohort. More patients in the post‐HPV screening group had low‐grade cytology on referral (P < 0.001), smaller cervical lesions on colposcopy (P = 0.012) and longer biopsy to treatment interval (P = 0.020). Primary HPV screening was associated with a significant reduction in the incidence of a negative LEEP specimen in a propensity matched cohort (11.2% to 5.1%, P = 0.006) and a 41% (P = 0.045) decreased relative risk of a negative LEEP on multivariate analysis.ConclusionsPrimary HPV screening results in a lower incidence of negative LEEP histology, despite a longer biopsy to treatment wait time and higher proportion of low‐grade cytology at triage.

An Australian, single‐centre study of surgical management outcomes for early‐stage cervical cancer

BackgroundThe Laparoscopic Approach to Cervical Cancer (LACC) trial is the first phase III randomised, multicentred trial to compare oncologic outcomes associated with open radical hysterectomy vs minimally invasive surgery (MIS) for treatment of early cervical cancer.AimTo evaluate our surgical experience in patients with early cervical cancer.Methods and MaterialsThe Lifehouse Gynaecologic Oncology database was queried based upon the eligibility criteria of the LACC study and included all FIGO 2009 stage (1A1 with lymph vascular space invasion, 1A2, 1B1) cervical cancer women from 2008–2018. Patients were also included in our study if they had abdominal radical trachelectomy (ART), laparoscopic radical hysterectomy (TLRH) and robotic radical trachelectomy (RRT).ResultsForty‐six women were identified with four exclusions. Thirty‐seven women had stage 1B1 disease, 24 had a squamous cell carcinoma, 15 had an adenocarcinoma and three had an adenosquamous carcinoma of the cervix. Of the 42 eligible patients, 32 underwent an open abdominal approach (26 total abdominal radical hysterectomy (TARH), six ART) and ten a MIS approach (nine TLRH and one RRT) with a mean follow‐up of 4.8 years. All 42 women had a pelvic lymph node dissection, eight women had nodal metastases and 16 patients received adjuvant chemoradiation. Two of the nine women in the laparoscopic radical hysterectomy group had a recurrence. Both had adenocarcinoma, stage 1B1 disease. There were no recurrences in the TARH group or radical trachelectomy groups.ConclusionOur data, albeit limited in number, have reflected the results of the LACC trial that MIS was associated with a lower disease‐free survival than open radical hysterectomy.

Follow‐up after treatment of high‐grade cervical dysplasia: The utility of six‐month colposcopy and cytology and routine 12‐month colposcopy

BackgroundAustralian Cervical Screening Program guidelines no longer recommend colposcopy and cytology at six months following treatment of cervical intraepithelial neoplasia (CIN2/3) and a co‐test of cure can be performed at 12 months without colposcopy.AimsTo determine the usefulness of six‐month colposcopy and cytology and routine colposcopy with co‐testing at 12 months in detecting persistent or recurrent disease in patients treated for CIN2/3.Materials and MethodsWe conducted a review of all patients with histologically proven CIN2/3 who underwent a cervical excisional procedure between March 2012 and March 2017 in one specialised centre.ResultsWe examined 1215 cases and 750 remained after exclusions for analysis. At six months (722 cases, 96.2%) seven of 42 (16.7%) patients with high‐grade cytology had a high‐grade colposcopy and 24 of 42 (57.1%) had a normal colposcopy. Persistent CIN2/3 was diagnosed in 12 cases (1.7%) and only 1/3 had a high‐grade colposcopy. Cytology was more useful than colposcopy in detecting persistent disease. At 12 months (638 cases, 85%) routine colposcopy at the time of co‐testing had a high false positive rate with all high‐grade changes negative on biopsy and co‐test. Recurrent CIN2/3 was diagnosed in five cases, and four had normal colposcopy at co‐testing.ConclusionsThere may be a delay in detection of persistent/recurrent CIN2/3 in a small number of cases without six‐month colposcopy and cytology; however, it is not likely to negatively impact overall clinical outcome. Co‐testing at 12 months following treatment of CIN2/3 without colposcopy is safe and routine colposcopy at collection of the co‐test can be omitted.

Identifying risk factors for post‐operative bleeding in women undergoing loop electrosurgical excision procedure for cervical dysplasia

BackgroundLoop electrosurgical excision is a procedure utilised in the treatment of high‐grade squamous intraepithelial lesion (HSIL) of the cervix. Post‐operatively women may experience immediate and/or delayed per vaginal bleeding.AimsThe objective of this prospective pilot study was to assess the feasibility of identifying and quantifying patients' subjective experiences of post‐operative bleeding following a loop electrosurgical excision procedure (LEEP) for HSIL. In addition, an analysis of demographical, lifestyle and surgical factors was undertaken to assess for any statistically significant correlation with post‐operative bleeding.Materials and MethodsThis study included 110 patients who underwent a LEEP for biopsy‐proven or suspected HSIL between 2017 and 2020. Subjective data were collected from weekly post‐operative surveys and correlated with procedural data. Primary outcome assessed was the subjective rate of bleeding experienced. Baseline demographics were age, body mass index (BMI), specimen size, human papilloma virus variant and histopathology. Other variables of interest collected were exercise intensity, and alcohol intake.ResultsNo association of statistical significance was discovered between age, BMI, or day of menstrual cycle. There was a statistically significant association between exercise intensity or specimen size (greater than the median) and increased bleeding, primarily in the first 2 weeks.ConclusionsWomen who undergo intense or prolonged exercise in the post‐operative period may experience heavier bleeding particularly in the first 2 weeks post‐LEEP. Heavy bleeding was also associated with a larger specimen size. There was no correlation between BMI, age or any other demographical factor.

Patient expectations and experiences with loop electrosurgical excision procedure in inpatient and outpatient settings

BackgroundLoop electrosurgical excision procedure (LEEP) for high‐grade squamous intraepithelial lesion is performed in both an inpatient setting under general anaesthesia and an outpatient setting under local anaesthesia. Efficacy and safety are comparable and outpatient LEEP may save time and cost in the Australian setting.AimsWe aim to compare patient satisfaction with inpatient LEEP compared to outpatient LEEP for Australian best practice.Materials and MethodsThis was a prospective quantitative and qualitative cohort study. An online questionnaire was sent to patients undergoing inpatient and outpatient LEEP to assess satisfaction with the procedure. Further histopathological and demographic data were also collected from the medical records. Groups were compared using Fischer's exact test and pain scores were compared using non‐parametric tests.ResultsNinety‐three outpatients and 52 inpatients responded to the survey. No difference was found between groups with regard to rate of positive histopathological margins or number of passes required. Outpatients found the procedure to be more convenient than inpatients (P = 0.007), and experienced more pain during the procedure than the inpatient group (P < 0.001). There was no significant difference in pain scores following the procedure or post‐procedure anxiety.ConclusionsOutpatient LEEP is an acceptable and well‐tolerated procedure, comparable to inpatient LEEP. Regardless of the option chosen, patients are highly likely to be satisfied with their choice. Increased efforts should be made to reduce pre‐procedural anxiety, which may in turn reduce expectations and experiences of pain.