Positive Surgical Margin At Cervical Conization For High-grade Squamous Intraepithelial Lesion: Does It Matter?

Abstract

Background and Aims: Our study aimed to assess the significance of positive margin in the outcome of women following conization for high-grade squamous intraepithelial lesion (HSIL). Methods: All women evaluated for abnormal cervical smear at a single institution were prospectively entered into a database. The database was queried for all women who had a conization performed for HSIL between 1st January 2013 and 31st December 2015. Factors retrieved from the database included demographics and pathology results. Chi-square test was used with significance defined at p<0.05. Results: 291 women were identified, of which 119 (40.9%) had positive margin. The median age was 38 years. Loop electrosurgical excision procedure was performed in 286 women and cold knife cone in 5 women. Median follow-up was 30 months with 27 (9.3%) women lost to follow-up. Overall, the risk of persistence/recurrence was 6.8%. Positive margin and glandular involvement were associated with statistically higher risk of persistence/recurrence compared with negative margin or absent of glandular involvement (14.3% vs 0.6%, p=0.0001; 9.0% vs 0%, p=0.0277 respectively). Risk of persistence/recurrence increases with more quadrants (Q) being involved by squamous intraepithelial lesion (1Q=4.3%; 2Q=4.8%; 3Q=6.3%; 4Q=11.5%). Positive margin was associated with statistically higher risk of subsequent abnormal smear (40.3% vs 23.8%, p=0.0046), requiring further colposcopy (23.5% vs 8.1%, p=0.0006) and conization (11.8% vs 2.5%, p=0.0041) compared with negative margin. Ten women had hysterectomy (1 for microinvasion, 4 had coexisting adenocarcinoma in-situ, 4 for persistence/recurrence of HSIL of which 1 had invasive squamous cell carcinoma and 1 for symptomatic fibroid). Two women developed vaginal HSIL. Conclusions: In our population, most women (85.7%) with positive margin did not have persistence/recurrence of HSIL, of which the option of close follow-up with cytology may be reasonable. Repeat conization may be considered in selected women with positive margin, glandular involvement and extensive HSIL and those who are unable to comply with follow-up.