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Am Fam Physician. 2000;61(11):3390-3392

Cervical conization has become an alternative treatment for cervical intraepithelial neoplasia (CIN), thus avoiding hysterectomy. Residual CIN is possible because of incomplete excision of the transformation zone and the presence of CIN extending to the margins of the cone biopsy. The dilemma for the practitioner is following patients with positive cone margins. Options include conservative observation with cytologic sampling and colposcopy, retreatment with another conization, or hysterectomy. Among women with positive cone margins, persistent CIN can range from 5 to 80 percent. Human immunodeficiency virus (HIV)-positive women are at greatest risk for CIN and subsequent failure after any treatment modality. Boardman and associates compared the positive cone margin rate among HIV-positive and HIV-negative women in this cross-sectional study.

A total of 245 women underwent cervical conization (cold knife cone or loop electro-surgical excisional cone) for the following indications: CIN grade 2 or 3, positive endocervical curettage (ECC), cytologic-colposcopic-histologic discrepancy, persistent CIN grade 1 or abnormal cytology with subsequent inadequate colposcopic examination. Cone specimens were excluded if the margins were not evaluable because of cautery artifact. Although all cold knife cone margins were interpretable, 15 to 20 percent of loop cone margins were unevaluable.

HIV-positive women were more likely to undergo conization for an abnormal ECC specimen, persistent CIN grade 1 or a inadequate colposcopic examination. HIV-negative women underwent treatment more often for CIN grade 2 or 3. Rates for CIN grade 2 or 3 in the final conization sample did not differ significantly between the study groups. Of the women undergoing conization, 87 (35.5 percent) had a positive margin on the cone biopsy or a postconization ECC sample. Twenty-two (47.8 percent) of the HIV-positive women had positive cone margins compared with 65 (32.7 percent) of the HIV-negative women. Analysis revealed that HIV-positive women had a two-fold increased risk of having a positive cone biopsy margin compared with HIV-negative women.

Previous studies have recommended more frequent cytologic sampling and prompt referral for colposcopy in HIV-positive women with abnormal cytology. This study addresses the management of these women who undergo conization and are subsequently found to have positive cone biopsy margins. Nearly 50 percent of the HIV-positive women were found to have positive cone margins compared with 33 percent of HIV-negative women, which is consistent with higher treatment failure rates.

The authors conclude that, given the high rate of positive cone biopsy margins, colposcopy and cytologic sampling may be insufficient management in HIV-positive women following excisional procedures on the cervix. Further treatment with another conization or even hysterectomy may provide definitive follow-up. As the life expectancy of HIV-positive women continues to improve, additional long-term studies are warranted to determine optimal management in this population.

editor's note: This study demonstrates that management of immunocompetent and immunodeficient women with CIN may require different treatment strategies. Conservative follow-up of women with positive cone biopsy margins has become popular because of the data in HIV-negative women demonstrating that the majority of the residual CIN in the cone biopsy margins resolves as healing occurs. This is the first study to address the high rate of positive margins in HIV-positive women treated with conization. Long-term follow-up studies are needed to determine optimal management strategies. Until then, we need to provide close scrutiny of postconization progress in this group of women.—b.a.

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