A persistent infection with human papilloma virus (HPV) is identified as a main risk factor for cervical cancer. Further investigation with cytology and colposcopy has been shown to have lower sensitivity than HPV-testing to diagnose CIN2+. In this study we performed a diagnostic excision of the transformation zone (TZ) by loop electrosurgical excision procedure (LEEP) in women with persistent HPV infection with normal Pap-smear to evaluate the eventual proportion of histologically confirmed CIN2+ in the specimen.
We prospectively recruited 91 women with persistent HPV-infection without any abnormalities in cytology. In total 40 women attended a gynecological examination including repeated HPV test, Pap smear, endocervical cytology, colposcopy with biopsies and diagnostic LEEP. Biopsies and the LEEP specimen was subjected to histologic analysis. The HPV test was performed using a multiplex real-time PCR assay (hpViR) as earlier described, which detects the following high-risk HPV types 16,18,31,33,35,39,45,51,52,56,58 and 59 (18 and 45 are detected together, and 33,52 and 58 as one group).
In 19/40 women the HPV infection still persisted at the study visit and 32% (6/19) of those women had CIN2+ in histology of the LEEP specimens. All the cytological samples were normal and none of the punch biopsies confirmed CIN2+ in these women. Of the 21/40 women who had cleared their HPV infection at the study visit all but one with CIN 1 had normal histology of the LEEP specimen.
Our results highlight the high risk of undiagnosed CIN2+ in women with persistent HPV infection combined with a normal gynecological examination, Pap smear, endocervical cytology and colposcopy with biopsies. In such cases LEEP must be kept as a diagnostic and treatment option, at least in women without future desire for pregnancy. Counseling women about the risks and expected effects of the treatment can help them to do an optimal informed choice.