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Abstract: Four years after LEEP, patient Ms. Zhang had recurrent disease due to persistent non-transformation of HPV16. After the patient was seen and had an extrafascial total hysterectomy + bilateral salpingo-oophorectomy, the pathological results showed cervical adenocarcinoma. Since the cervical adenocarcinoma was stage IA1, Silva A, and there were no other high-risk factors for tumor recurrence, after adequate disease information, the patient made an informed choice to follow up and observe, and no signs of recurrence have been detected.
Basic information】Female, 45 years old
Type of disease】Cervical adenocarcinoma
Hospital】Qilu Hospital of Shandong University
Date of consultation】February 2022
Treatment plan】Surgical treatment (total hysterectomy + bilateral salpingo-oophorectomy)
Treatment Period】7 days of hospitalization, 1 month of outpatient follow-up
Effectiveness of treatment】No sign of recurrence in the current follow-up
I. Initial consultation
This morning, we saw a 45-year-old patient, Ms. Zhang, who had undergone LEEP for focal CIN2 4 years ago in our outpatient clinic under local anesthesia, and no lesion was found on postoperative pathology. After that, TCT and HPV were rechecked annually, in which HPV16 was persistently positive. The TCT in the first and second year after surgery showed no abnormality, but in the third year after surgery, the repeat TCT suggested HSIL and HPV16+, and the doctor who saw her at that time suggested further colposcopy, but the patient chose to refuse further treatment for personal reasons. For further treatment, Ms. Zhang was referred to our hospital. Considering the persistent HPV16 infection for 4 years after LEEP and the obvious lesion cells found on cytology, colposcopy + cervical biopsy + cervical duct scratching was first arranged according to the guidelines for cervical lesions. 5 days later, the pathology results returned: (cervical multipoint) focal LSIL, P16(-); (cervical duct) HSIL/CIN2, P16(+), recurrence of cervical lesions was considered. On follow-up history, the patient denied symptoms of abnormal vaginal discharge, increased leucorrhea and abdominal pain. According to the guidelines for the treatment of cervical lesions, surgery should be preferred because the pathology suggested high-grade cervical precancer HSIL/CIN2, so the patient was admitted to the outpatient clinic with CIN2.
II. Treatment process
After admission, a gynecological examination was firstly arranged for the patient: except for the post-LEEP appearance of the cervix with a smooth surface, blood on palpation(-), erythema and thin white epithelium; no significant abnormalities were found in the vulva, vagina, uterus and both adnexa. Gynecologic ultrasonography was also arranged: no significant abnormalities were found in the uterus and both adnexa, and a small amount of pelvic fluid. The tumor marker SCC was detected: normal range. The patient was firstly advised to repeat the conization procedure first and then decide the follow-up treatment according to the postoperative pathological results. However, taking into account the patient’s age, lack of fertility requirements, and personal desire to preserve the uterus, extrafascial total hysterectomy + bilateral salpingo-oophorectomy was finally performed. Intraoperatively, the uterus was posterior, slightly large, with regular morphology and smooth surface, no abnormal cervical morphology, and no obvious abnormalities in both adnexa.
III. Treatment results
The patient’s surgical procedure was smooth and the postoperative pathological findings suggested cervical adenocarcinoma, which exceeded the preoperative diagnosis. Combined with the fact that the tumor stage was extremely early stage IA1 and the malignancy of Silva A type was relatively low, the patient was fully informed of the condition and the patient opted for close follow-up. The patient recovered well after surgery and was discharged successfully on the 5th day with a length of stay of 7 days, and the patient was instructed to come back to the hospital for a review in 1 month.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but due to the high malignancy of cervical adenocarcinoma, the patient is advised to wait for full recovery after surgery before performing pelvic and abdominal CT examinations. In the meantime, maintain vulvar hygiene, prohibit sexual intercourse and tub bath for 2 months, pay attention to body temperature, vaginal bleeding and abdominal pain, avoid eating spicy and stimulating food, while increasing nutrition appropriately, and follow up at any time if uncomfortable symptoms appear.
V. Personal insight
By understanding the situation of the patient in this case, it can be seen that the treatment for early cervical cancer and precancerous lesions is mainly cervical conization, including cold knife conization and cervical circumferential electrosurgery. However, no matter which conization method is used, patients have the possibility of recurrence of lesions after surgery. Persistent high-risk HPV infection after conization is a high-risk factor for recurrence of lesions. In addition, although repeat cervical conization may preserve part of the cervix and fertility and allow further definitive diagnosis of the severity of recurrent lesions, there is still the possibility of positive cut margins and residual lesions/recurrence. In contrast, hysterectomy, although beneficial in reducing the risk of cervical cancer, may affect pelvic floor function and cause loss of fertility in patients. In conclusion, for patients with recurrent CIN2 and CIN3, the individualized choice of repeat conization or hysterectomy . Repeat conization is the first choice for young, fertile patients with recurrent lesions, and repeat conization is more relevant for those suspected of having higher grade lesions.