Research article

Predictors of persistent cytologic abnormalities after treatment of cervical intraepithelial neoplasia in Soweto, South Africa: a cohort study in a HIV high prevalence population

Yasmin Adam^1,2 , Cyril J van Gelderen^1,2 , Guy de Bruyn³ , James A McIntyre³ , Diane A Turton^2,4 and Neil A Martinson^3,5

¹  Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Hospital, Johannesburg, South Africa

²  University of the Witwatersrand, Johannesburg, South Africa

³  Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg South Africa

⁴  National Health Laboratory Service, Johannesburg, South Africa

⁵  Johns Hopkins University School of Medicine, Baltimore, USA

author email corresponding author email

BMC Cancer 2008, 8:211doi:10.1186/1471-2407-8-211

Published:	25 July 2008

Abstract

Background

In the presence of both HIV infection and cervical intraepithelial neoplasia (CIN), the risk of cancer development despite treatment may be greater. We investigated clinical predictors of persistent cytological abnormalities in women who had had a large loop excision of the transformation zone (LLETZ).

Methods

Women with high grade squamous intraepithelial lesions or worse (HSIL), less severe abnormalities which persisted and any abnormality in women who are HIV-infected, were referred to the colposcopy clinic. HIV infection was ascertained by self-report. A LLETZ was performed on all patients with HSIL or higher on Papanicolaou (Pap) smear or colposcopy, LSIL or higher in patients who are HIV-infected, where the colposcopy is inadequate, and when there was a discrepancy between colposcopy and cytology by one or more grades. Women with abnormal follow-up smears were compared to those with normal smears. We examined the association between abnormal follow-up smears and demographic and clinical predictors using logistic regression

Results

The median time between LLETZ and first follow-up Pap smear was rather short at 122 days. Persistent cytological abnormalities occurred in 49% of our patients after LLETZ. Predictors of persistence included the presence of disease at both margins and HIV infection. Among the latter, disease at the excision margins and CD4+ cell count were important predictors. In these women, disease at the endocervical margin, both margins, and disease only at the ectocervical margin were associated with increased odds of persistent abnormalities on follow-up cervical smear.

Conclusion

We showed extremely high risk of cytological abnormality at follow-up after treatment more so in patients with incomplete excision and in the presence of immunocompromise. It remains uncertain whether recurrent CIN is a surrogate marker for invasive cervical cancer.