International Journal of Gynecology and Obstetrics 129 (2015) 109–113

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CLINICAL ARTICLE

HPV genotyping among women treated for high-grade cervical intraepithelial neoplasia with no lesion in the conization specimen☆ Ágata Rodríguez-Manfredi a, Romy van Baars b, Wim G.V. Quint b, Ma Jesús Sanchez a, Aureli Torné a, Jaume Ordi c,1, Marta del Pino a,⁎,1 a b c

Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clínic-Institut d’Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain DDL Diagnostic Laboratory, Rijswijk, Netherlands Department of Pathology, Centre de Recerca en Salut Internacional de Barcelona, Hospital Clínic, University of Barcelona, Barcelona, Spain

a r t i c l e

i n f o

Article history: Received 26 June 2014 Received in revised form 30 October 2014 Accepted 8 January 2015 Keywords: Cervical intraepithelial neoplasia Histologic negative conization HPV genotyping Loop electrosurgical excision procedure (LEEP)

a b s t r a c t Objective: To evaluate whether specific HPV genotypes or multiple HPV infection are associated with absence of cervical intraepithelial neoplasia (CIN) in the conization specimen. Methods: In a retrospective study, data were reviewed for women treated by conization at a center in Barcelona, Spain, between 2008 and 2011. Women whose pretreatment biopsy showed CIN2/3 with positive p16 staining but had no lesions in the conization specimen were included in the study group if material was sufficient for HPV genotyping. Age-matched control patients who had CIN2/3 in the conization specimen were selected. HPV genotyping was conducted on all histologic specimens. Results: Both groups contained 43 patients. High-risk HPV genotypes were identified in the conization specimens of 14 (33%) women in the study group and of 42 (98%) in the control group (P b 0.001). HPV16/HPV18 was detected in the pretreatment biopsy samples of 27 (63%) women in the study group and 25 (58%) in the control group (P = 0.413). Multiple HPV infections were detected pretreatment in 8 (19%) women in the study group and 9 (21%) in the control group (P = 0.50). Conclusion: No association was found between HPV genotype or multiple HPV infection and absence of lesion in the conization specimen. © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction High-grade cervical intraepithelial neoplasia (grade 2 or 3; hereafter CIN2/3) has a significant risk of progression if not treated [1]. Conization by the loop electrosurgical excision procedure (LEEP) is the main treatment for CIN2/3 lesions [2]. Although LEEP is a safe technique, some studies have highlighted its potential adverse effects, which include hemorrhage, cervical stenosis, subfertility, and pregnancy-related morbidity [3,4]. Accordingly, strict selection of patients is warranted to avoid unnecessary procedures [5]. Despite the use of strict criteria to select women suitable for LEEP, 10%–20% of these patients have no CIN in the cone specimen [6,7]. Few studies have focused on this well documented finding [6–8]. In one previous study [9], women undergoing conization whose pretreatment biopsy sample tested negative for HPV via the Hybrid Capture 2 (HC2) system (Qiagen, Gaithersburg, MD, USA) or who had a low viral load of

☆ Abstract presented at the United States and Canadian Academy of Pathology 103rd Annual Meeting; March 1–8, 2014; San Diego, CA, USA. ⁎ Corresponding author at: Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clínic-Institut d’Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain. Tel.: +34 93 227 54 36; fax: +34 93 227 54 54. E-mail address: [email protected] (M. del Pino). 1 These authors contributed equally.

HPV were found to be at increased risk of having a negative cone specimen. The value of HPV genotyping as a predictor of absence of CIN in the cone specimen has not been previously evaluated. Studies have shown that HPV16 and HPV18 genotypes carry a higher risk of CIN progression [10], and that CIN caused by high-risk genotypes other than HPV16 and HPV18 have a higher probability of regression [11,12]. Data on the risk of progression of a cervical lesion with multiple HPV infection is contradictory. Some studies suggest that the clearance rate is independent of infection with different HPV genotypes [13], whereas others report an increased risk of progression in lesions with multiple HPV genotypes [14]. The aim of the present study was to determine whether specific HPV genotypes or multiple HPV infection are associated with absence of CIN in the conization specimen by performing HPV genotyping for a group of women diagnosed with CIN2/3 before treatment who did not show CIN in the conization specimen and comparing the results with a control group of women for whom CIN2/3 was recorded in the cone specimen. 2. Materials and methods In a retrospective study performed at the Department of Obstetrics and Gynecology of the Hospital Clinic of Barcelona, Spain, data were

http://dx.doi.org/10.1016/j.ijgo.2014.11.009 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

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reviewed for all women treated by LEEP conization from January 1, 2008 to December 31, 2011. The study was approved by the center’s institutional ethical review board. All patients provided written consent for the use of biological specimens for research purposes after clinical procedures were completed. All women who fulfilled the following criteria were included in the study group: pretreatment biopsy showed CIN2/3 with positive p16 staining; no CIN in the conization specimen, confirmed by negative p16 staining; and sufficient material in the paraffin blocks of both the pretreatment biopsy sample and the conization specimen for HPV genotyping. For every woman in the study group, a control was randomly selected with stratification by age from all patients in the study period whose pretreatment biopsy showed CIN2/3 with positive p16 staining and who had CIN2/3 in the LEEP specimen, confirmed by positive p16 staining. The way in which patients with high-grade squamous intraepithelial lesions (H-SILs) referred to the study institution are managed has been previously reported [9]. The criteria for LEEP of H-SILs were diagnosis of CIN2/3 after colposcopically directed biopsy and/or endocervical curettage, or a repeated cytologic result of H-SIL (two or more positive cervical smears separated by 6 months) [7]. After treatment, follow-up visits were scheduled every 6 months. Cytology, high-risk HPV testing by HC2, and colposcopy—with colposcopically directed biopsy or endocervical curettage if indicated—were performed at each visit. H-SIL persistence and/or recurrence, lowgrade squamous intraepithelial lesion (L-SIL) persistence and/or recurrence, and regression have been previously defined [9]. Briefly, women were deemed to have persistent/recurrent H-SIL during follow-up when histology showed CIN2/3 or cytology showed H-SIL repeatedly. Women were deemed to have persistent/recurrent L-SIL when histology showed CIN1; cytology showed atypical squamous cells or L-SIL, or one cytology assessment showed H-SIL without histologic high-grade lesion confirmation; or a high-risk HPV test was positive with normal cytology and/or a negative histologic result. Regression was defined as a negative cytologic result, a negative high-risk HPV test, and, if obtained, a negative biopsy sample. Cervical samples were collected with a cytobrush and stored in PreservCyt (Hologic, Marlborough, MA, USA) for the cervical smear

and high-risk HPV testing. Liquid-based cytology (Thin Prep, Hologic, Bedford, MA, USA) slides were prepared in accordance with the manufacturer’s protocol and stained via the Papanicolaou method [15]. Detection of high-risk HPV on cytologic samples was performed via the HC2 system [8]. An HPV load of less than 10 relative light units (RLUs) was considered as a low viral load [9]. All pretreatment biopsies were stained for p16. In the study group, p16 staining was performed in all blocks of the conization specimen, and one block representative of the transformation zone was selected for HPV genotyping. In the control group, the block showing the most extensive representation of the lesion was selected for p16 staining. Immunohistochemistry was performed with Autostainer Link 48 (Dako, Carpinteria, CA, USA) using the EnVision system (Dako). p16 was detected by using the CINtec histology kit (clone E6H4; Roche, Heidelberg, Germany) in accordance with the manufacturer’s protocol. Cases with continuous staining of cells of the basal and parabasal layers were considered to be positive [16]. DNA was extracted by overnight incubation in proteinase K solution at 70 °C. Subsequently, proteinase K was heat-inactivated at 95 °C for 10 minutes, and 10 μL of isolated DNA was used for HPV detection and genotyping by SPF10 PCR-DEIA-LiPA 25 (version 1; Labo Biomedical Products, Rijswijk, Netherlands) [17]. Among the samples that were positive for DEIA, those showing no result on the LiPA25 strip were attributed to an untypeable genotype (HPVX). DEIA-negative samples were tested for the absence of PCR inhibition by repeating the PCR and DEIA test on a DNA sample that was diluted 10-fold. Data analyses were performed with SPSS version 18.0 (SPSS Inc, Chicago, IL, USA). Student t test or analysis of variance was used to compare quantitative variables. Qualitative variables were compared via the χ2 test. P ≤ 0.05 was considered statistically significant. The κ value with a 95% confidence interval (CI) was calculated as a measure of agreement between the HPV genotypes observed in the pretreatment biopsy sample and those in the conization specimen. HPV genotype concordance between the pretreatment biopsy and the conization specimen was analyzed and classified as follows: identical if all genotypes in the pretreatment biopsy were the same as in the conization specimen; compatible when the analysis showed at least

Women treated by LEEP conization 2008–2010 (n=687)

Women with no lesion in the

Women with lesion in the

LEEP specimen (n=110)

LEEP specimen (n=577)

Excluded

Excluded

-

Pretreatment biopsy of CIN1 (n=51)

-

Pretreatment biopsy of CIN1 (n=139)

-

p16-positive foci in the conization specimen (n=6)

-

No residual tissue for HPV genotyping in the paraffin block of the biopsy (n=3)

-

Negative p16 staining result in the pretreatment biopsy (n=1)

-

No residual tissue for HPV genotyping in the paraffin block of the biopsy (n=9)

1:1 random agematched selection of control group

Women included in

Women included in

study group (n=43)

control group (n=43)

HPV genotyping of the pretreatment

HPV genotyping of the pretreatment

biopsy and the conization specimen

biopsy and the conization specimen

Fig. 1. Flow chart showing the study design and selection of study and control groups.

Á. Rodríguez-Manfredi et al. / International Journal of Gynecology and Obstetrics 129 (2015) 109–113 Table 1 Pretreatment cytology and biopsy results.a Test Cytology L-SIL H-SIL Biopsy CIN2 CIN3

Study group (n = 43)

Control group (n = 43)

8 (19) 35 (81)

3 (7) 40 (93)

27 (63) 16 (37)

17 (40) 26 (60)

P valueb 0.098

0.026

Abbreviations: L-SIL, low-grade squamous intraepithelial lesion; H-SIL, high-grade squamous intraepithelial lesion; CIN2, cervical intraepithelial neoplasia grade 2; CIN3, cervical intraepithelial neoplasia grade 3. a Values are given as number (percentage) unless indicated otherwise. b By Pearson χ2 test.

one identical genotype in both samples; and discordant if there were no similarities between the genotypes found in the biopsy and those in the conization specimen. In lesions infected by multiple HPV types, a case was considered as concordant when at least one HPV type was identified in both samples. When no concordance was observed between HPV types, the most frequent HPV type was considered as the causative agent [18]. HPVnegative samples were excluded from the agreement analysis. When identical or compatible HPV genotypes were found between the biopsy and the conization specimen, HPV agreement was defined as slight (κ b 0.200), weak (0.200 b κ b 0.401), moderate (0.400 b κ b 0.601), strong (0.600 b κ b 0.801), near perfect (0.800 b κ b 0.99), and perfect (κ = 1.000) [19]. Univariate logistic regression was performed to identify independent prognostic factors of the risk of absence of CIN in the conization specimen, with the odds ratio (OR) reported as an estimate of relative risk.

3. Results Both groups contained 43 patients (Fig. 1). The mean age of the patients in the study and the control groups was 37.1 ± 10.5 years and 37.0 ± 9.8 years, respectively (P = 0.594). The mean time between the pretreatment biopsy and surgical treatment was 3.6 ± 3.4 months in the study group and 3.3 ± 2.4 months in the control group (P = 0.571). CIN2 was the most frequent diagnosis in the pretreatment biopsy in the study group, whereas the frequency of CIN3 was greater in the control group (P = 0.026) (Table 1).

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For two women from the study group and two from the control group, there was insufficient cytologic material for pretreatment HPV testing by HC2. Two (5%) women in the study group and none in the control group had a negative pretreatment HC2 test (P = 0.314). The mean viral load in the cytologic samples was lower in the study group (457.1 RLU) than in the control group (804.2 RLU; P = 0.040). Low viral load was not associated with absence of CIN in the cone specimen (data not shown). In both groups, all pretreatment biopsy samples, except one from the control group, were positive for HPV via SPF10 PCR. There was no significant difference in the number of women whose pretreatment biopsy samples were positive for HPV16/HPV18 between the study group and control group (27 [63%] vs 25 [58%]; P = 0.413). The conization specimen was positive for high-risk HPV in only 13 (30%) women from the study group, compared with 42 (98%) patients from the control group (P b 0.001). Tables 2 and 3 show the correlation between the HPV genotypes identified in the pretreatment biopsy and those in the conization specimen for the study and control groups, respectively. Among the HPVpositive conization specimens, identical or concordant HPV genotypes were found between the pretreatment biopsy and the conization specimen for 8 (57%) of 14 patients in the study group and 36 (86%) of 42 in the control group (P = 0.017). HPV genotype agreement was slight (κ = 0.15 [95% CI, 0.01–0.29]) in the study group and strong (κ = 0.78 [95% CI, 0.55–0.86]) in the control group. Multiple HPV infection in the pretreatment biopsy was found in 8 (19%) women from the study group and 9 (21%) from the control group (P = 0.50). HPV16 was identified in most of the multiple infections in both the study and control groups (5/8 [63%] and 5/9 [56%], respectively). Multiple infection was identified in the conization specimen in 4 (9%) women in the study group and 7 (16%) in the control group (P = 0.260). Univariate logistic regression analysis showed that women whose pretreatment biopsy sample showed CIN2 were more likely than were those with CIN3 to show no CIN in the conization specimen (P = 0.003) (Table 4). No other factors were associated with absence of CIN in the conization specimen. The mean follow-up after treatment was 15.3 ± 8.8 months in the study group and 14.7 ± 8.7 months in the control group (P = 0.706). Two (5%) patients from the study group and 1 (2%) from the control group were lost to follow-up. None of the patients showed persistent or recurrent H-SIL. However, 10 (24%) of the 41 patients from the study group and 11 (26%) of the 42 from the control group had persistent or recurrent LSIL (P = 0.526). No association was observed between

Table 2 Correlation between the principal HPV genotype in the pretreatment biopsy and in the conization specimen for the study group.a,b Conization specimen No HPV HPV16 HPV18 HPV31 HPV33 HPV35 HPV52 HPV54 HPV56 HPV58 HPV66 X Total (n = 43)

Pretreatment biopsy No HPV

HPV16

HPV18

HPV31

HPV33

HPV35

HPV52

HPV54

HPV56

HPV58

HPV66

X

0 0 0 0 0 0 0 0 0 0 0 0 0

15 6 0 0 0 0 0 1 1 0 1 1 25 (58)

1 0 0 0 0 0 0 0 0 0 0 1 2 (5)

1 0 0 1 0 0 0 0 0 0 0 0 2 (5)

2 0 0 0 0 0 0 0 0 0 0 1 3 (7)

1 0 0 0 0 0 0 0 0 0 0 0 1 (2)

3 0 0 0 0 0 1 0 0 0 0 0 4 (9)

0 0 0 0 0 0 0 0 0 0 0 0 0

1 0 0 0 0 0 0 0 0 0 0 0 1 (2)

5 0 0 0 0 0 0 0 0 0 0 0 5 (12)

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

Total (n = 43) 29 (67) 6 (14) 0 (0) 1 (2) 0 (0) 0 (0) 1 (2) 1 (2) 1 (2) 0 1 (2) 3 (7) 43 (100)

Abbreviation: X, untypeable HPV. a The study group comprised women with no cervical intraepithelial neoplasia in the conization specimen. For lesions infected by multiple types, only one type was considered as the main cause of the lesion and included in the table. When one HPV type was identified in both samples, the case was considered as concordant, and this type was considered as the main cause of the lesion. When no concordance between HPV types was observed, the most frequent HPV type was considered as the causative agent and was included in the table. b All HPV genotypes shown are high risk, except HPV54.

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Table 3 Correlation between the principal HPV genotype in the pretreatment biopsy and in the conization specimen for the control group.a,b Conization specimen

Pretreatment biopsy No HPV

HPV16

HPV18

HPV31

HPV33

HPV35

HPV52

HPV53

HPV58

HPV68

X

No HPV HPV16 HPV18 HPV31 HPV33 HPV35 HPV52 HPV53 HPV58 HPV68 X Total (n = 43)

0 0 0 0 0 1 0 0 0 0 0 1 (2)

1 20 0 0 1 0 1 0 0 0 0 23 (53)

0 0 2 0 0 0 0 0 0 0 0 2 (5)

0 2 0 1 0 0 0 0 0 0 0 3 (7)

0 0 0 0 4 0 0 0 0 0 0 4 (9)

0 0 0 0 0 3 0 0 0 0 0 3 (7)

0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 2 0 0 0 2 (5)

0 0 0 0 0 0 0 0 2 0 0 2 (5)

0 0 0 0 0 0 0 0 0 1 0 1 (2)

0 0 1 0 0 0 0 0 0 0 1 2 (5)

Total (n = 43) 1 (2) 22 (51) 3 (7) 1 (2) 5 (12) 4 (9) 1 (2) 2 (5) 2 (5) 1 (2) 1 (2) 43 (100)

Abbreviation: X, untypeable HPV. a The control group comprised women with cervical intraepithelial neoplasia in the conization specimen. For lesions infected by multiple types, only one type was considered as the main cause of the lesion and included in the table. When one HPV type was identified in both samples, the case was considered as concordant, and this type was considered as the main cause of the lesion. When no concordance between HPV types was observed, the most frequent HPV type was considered as the causative agent and was included in the table. b All HPV genotypes are high risk.

pretreatment high-risk HPV genotypes or viral load as determined by HC2 (b10 RLU vs ≥ 10 RLU) and persistent and/or recurrent disease after treatment (data not shown). Nevertheless, a higher pretreatment mean viral load was observed among women who developed persistent and/or recurrent disease than among those showing no such lesions (690.9 RLU vs 2.6 RLU; P b 0.001). 4. Discussion The present study has shown that HPV genotypes do not differ between women whose pretreatment biopsy sample was positive for CIN2/3 but who had no lesion in the conization specimen and those who showed CIN2/3 in both specimens. Specifically, the incidence of HPV16/HPV18-positive samples was similar in both groups, indicating that a high percentage of lesions with high-risk HPV infections of any genotype had regressed before treatment in the study group. The results suggest that HPV genotyping of the pretreatment biopsy does not provide relevant information in terms of predicting absence of CIN in the cone specimen. The main strength of the study is its comprehensive analysis of HPV genotypes among patients with a pretreatment biopsy showing histologically confirmed CIN2/3 but a conization specimen showing no residual CIN. The main limitation is the low number of women in the

Table 4 Univariate logistic regression analysis for the prediction of absence of CIN2/3 in the conization specimen.a Factor Cytology H-SIL L-SIL Biopsy CIN3 CIN2 Genotype HPV16/HPV18 Non-HPV16/HPV18 Multiple HPV co-infection No Yes

Odds ratio (95% CI)

P value

1 3.1 (0.7–12.4)

0.119

1 2.6 (1.1–6.2)

0.003

1 0.9 (0.4–2.1)

0.826

1 1.2 (0.4–3.4)

0.787

Abbreviations: CIN2, cervical intraepithelial neoplasia grade 2; CIN3, cervical intraepithelial neoplasia grade 3; CI, confidence interval; H-SIL, high-grade squamous intraepithelial lesion; L-SIL, low-grade squamous intraepithelial lesion. a From diagnostic tests performed in the pretreatment biopsy, including cytology, biopsy, HPV viral load in relative light units by hybrid capture 2, HPV genotypes, and the presence of multiple HPV co-infection.

study group. The relatively low rate of absence of CIN in the conization specimen after CIN2/3 diagnosis in a previous biopsy and the strict inclusion criteria resulted in this low number of cases. It has been suggested that regression of CIN2/3 occurs in up to 20% of cases within a mean time of 12.8 months [20]. Although patients were randomly selected for the control group to avoid possible selection biases between CIN2 and CIN3 cases, CIN2 lesions were more frequent in the study group and there might be a higher probability of regression in these lesions than with CIN3. These results are in keeping with previous studies showing that CIN2, in addition to other factors such as young age and a long interval between pretreatment biopsy and LEEP, have been associated with increased rates of regression [21]. However, there was no significant difference in the time between pretreatment biopsy and conization between the two groups in the present study— the interval was approximately 3 months, which is a short time for HPV clearance [22]. In a previous HC2-based study of patients with a pretreatment biopsy showing any grade of CIN [9], a relationship was observed between low viral load or an HPV-negative result pretreatment and an increased rate of absence of CIN in the cone specimen. In the present study of women with pretreatment CIN2/3 only, this correlation was not confirmed. However, the mean viral load in women with an absence of lesion in the conization specimen was significantly lower than that in women with a lesion in the cone specimen, suggesting that the small sample size might lead to underestimation of the differences. In the study group, 33% of the conization specimens were positive for HPV, whereas 67% were negative for high-risk HPV genotypes, demonstrating clearance of both the lesion and the infection. Only 8 (57%) of the 14 conization specimens that were positive for high-risk HPV presented genotypes identical or compatible to those identified in the preceding biopsy. Therefore, there were six cases in which the high-risk HPV genotype in the pretreatment biopsy was discordant with that in the cone specimen, suggesting clearance of the high-risk HPV genotypes and the related lesion, and thereafter acquisition of a new HPV infection. In the control group, by contrast, 98% of the conization specimens were positive for high-risk HPV genotypes. Moreover, the concordance of HPV genotypes between the pre-treatment biopsy and the conization specimen was considerably higher in the control group (86%), which probably reflects HPV persistence. In the present study, HPV16 was the most common genotype in both groups. No association was found between any HPV genotype and absence of CIN in the cone specimen. Previous studies have suggested that women with non-HPV16 or non-HPV18 high-risk HPV infections should be managed more conservatively [10]. In the present series, the short interval between diagnosis and treatment, and the small

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number of patients in the study group might have resulted in underestimation of the rate of lesion regression for women with non-HPV16/ HPV18 high-risk HPV infections [22]. The percentages of women with multiple HPV infection in the study and the control groups (19% and 21%, respectively) were similar to those reported previously [20,23]. Some studies have shown that multiple HPV infection could increase the risk of progression of cervical lesions [14]. However, this finding has not been supported by other studies [24], in line with the present results. No differences were observed in the rate of persistence and/or recurrence after treatment between the two groups. Additionally, there were no differences in HPV genotypes (non-HPV16/HPV18 vs HPV16/HPV18) or HPV viral load determined by HC2 analysis (≤10 RLU vs N 10 RLU). In a previous study of patients with pretreatment CIN2/3 and CIN1 [9], low viral load or a negative HPV test pretreatment was found to indicate a lower risk of persistent and/or recurrent CIN. In the present study of patients with histologically confirmed CIN2/3, low viral load pretreatment was not associated with a lower risk of persistent and/or recurrent CIN. However, women with persistent and/or recurrent CIN showed a significantly higher mean pretreatment viral load than did those without persistence and/or recurrence, which is in line with previous studies [25]. In conclusion, the present study suggests that pretreatment HPV genotyping does not provide additional information that could modify the clinical management of patients with CIN2/3 lesions. Further studies with a larger number of patients are warranted to increase the statistical power and to avoid potential bias in the results. Acknowledgments The study was partly supported by Instituto de Salud Carlos III (ICSIII)-Fondos de Investigación Sanitaria and ERDF “one way to Europe” (PS09/1084, PI09/1524, PI12/1165, PI12/1231). Conflict of interest The authors have no conflicts of interest. References [1] McCredie MR, Sharples KJ, Paul C, Baranyai J, Medley G, Jones RW, et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol 2008;9(5):425–34. [2] Paraskevaidis E, Koliopoulos G, Alamanos Y, Malamou-Mitsi V, Lolis ED, Kitchener HC. Human papillomavirus testing and the outcome of treatment for cervical intraepithelial neoplasia. Obstet Gynecol 2001;98(5 Pt 1):833–6. [3] Andía D, Mozo de Rosales F, Villasante A, Rivero B, Díez J, Pérez C. Pregnancy outcome in patients treated with cervical conization for cervical intraepithelial neoplasia. Int J Gynecol Obstet 2011;112(3):225–8. [4] Bevis KS, Biggio JR. Cervical conization and the risk of preterm delivery. Am J Obstet Gynecol 2011;205(1):19–27.

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HPV genotyping among women treated for high-grade cervical intraepithelial neoplasia with no lesion in the conization specimen.

To evaluate whether specific HPV genotypes or multiple HPV infection are associated with absence of cervical intraepithelial neoplasia (CIN) in the co...
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