Correlates of post loop Electrosurgical Excision Procedure (LEEP) Recurrence of Cervical Intra epithelical Neoplasia
Background: Cervical cancer is the commonest gynaecological malignancy worldwide, with an increased burden of disease in developing countries. Effective cytological screening and follow up intervention programs have been credited for the sharp decline in its prevalence in Europe and North America. This has not been the case in the developing world where resources and infrastructure have proved insufficient to offer quality screening and appropriate follow-up. Real gains will require sustainable effective treatment of pre-malignant lesions and early management of disease recurrences. Adequate knowledge on factors associated with disease recurrence after treatment is essential in identifying high risk clients and their management. Outpatient therapy employing methods such as Loop Electrosurgical Excision Procedure (LEEP) combined with proper follow up is appropriate for dealing with colposcopy aided visible lesions on the ectocervix when invasive cancer and endocervical involvement have been ruled out. Objectives: 1) To determine the post LEEP recurrence rate of lesions 2:CIN2 at KNH 2) To determine factors associated with recurrence of CIN2 disease post LEEP at KNH. 3) To describe early post LEEP complications at KNH. 4) To determine the rate of return visits post LEEP at KNH gynaecology clinic between January 2008 and December 2010. Methods This was a retrospective cohort study. Case records for all women who had LEEP between January 1 st 2008 and December 31 st 2010 at KNH's clinic 18 and 66 were retrieved and reviewed. By these criteria, 124 file records were eligible and therefore included. The socio-demographic, clinical, cytological and histological data were extracted using a structured questionnaire. The post LEEP return visits and dysplasia surveillance findings were recorded and analysis done to identify recurrence of: CIN2 lesions, associated risk factors, complications and follow up rates. Results: A total of 124 cases were recruited, out of this (90)72.6% returned for their LEEP histopathology results; (52) 41.9% had at least one post LEEP Pap smear cytology done, (21)16.9% had two post LEEP Pap smear cytology tests done and 7(5.6%) had three Pap smear tests done. A recurrence rate of CIN2 lesions among women who were followed up with at least a single pap smear cytology reporting a HSIL and confirmed on colposcopy was 21.2% . Recurrence was strongly associated with HIV infection (p value 0.014) and a histological diagnosis of CIN3 on both colposcopic biopsy and LEEP (p value 0.017 RR 4.533), No major short term complications were reported after LEEP. Pap smear cytology results indicating High grade lesions were in 86.8% of cases confirmed to be CIN2 on histopathology. Conclusion The recurrence rate for :::CIN2 lesions among women who were followed up with Pap smear cytology after LEEP treatment for CIN2 is higher than the average regional and international findings; the return rate for post LEEP Pap smear screening was low. A higher recurrence rate was noted in women with HIV infection and CIN3 lesions on colposcopic biopsy or LEEP histopathology results. The procedure was associated with minimal complication. Recommendation A standard post LEEP follow up protocol that identifies the risk factors for recurrence of High grade Lesions in its scheme and incorporates an active client re-call component should be developed and adopted by KNH. This will achieve early diagnosis and management of recurrences, promote uniformity in follow up plans among clinicians and improve patient return rates.