CLINICAL ARTICLE Risk factors for human papillomavirus persistence among women undergoing cold-knife conization for treatment of high-grade cervical intraepithelial neoplasia Eralp Baser ⁎, Emre Ozgu, Selcuk Erkilinc, Cihan Togrul, Mete Caglar, Tayfun Gungor Department of Gynecologic Oncology, Zekai Tahir Women’s Health Education and Research Hospital, Ankara, Turkey abstract article info Article history: Received 12 August 2013 Received in revised form 11 December 2013 Accepted 26 February 2014 Keywords: Cervical intraepithelial neoplasia Cold-knife conization Human papillomavirus Objective: To investigate the risk factors potentially associated with high-risk human papillomavirus (HPV) per- sistence in women undergoing cold-knife conization (CKC) for treatment of high-grade cervical intraepithelial neoplasia (CIN). Methods: Medical records of women who underwent CKC for treatment of CIN 2/3 between 2007 and 2012 at a tertiary hospital in Ankara, Turkey, were retrospectively analyzed. Cases involving persistent HPV infection after 1 year of follow-up were identified. Using univariate and multivariate analyses, the impact of various factors such as patient age, menopausal status, parity, high-risk HPV type, excised cone dimensions (width, height, and depth), and surgical margin status on high-risk HPV persistence was assessed. Results: A total of 292 women underwent CKC for treatment of CIN 2/3 within the study period. After women with a sub- sequent diagnosis of cervical cancer, subsequent total hysterectomy, and inadequate follow-up data were eliminated, 113 women were eligible for final analysis. High-risk HPV persistence was detected in 24 (21.2%) women, and multivariate analysis revealed that patient age and cone depth were significant independent predic- tors (P b 0.05). Conclusion: High-risk HPV persistence may be encountered after CKC procedures. It is important to evaluate persistent HPV infections after treatment because affected women are at increased risk for disease persistence, recurrence, and progression. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Despite the ongoing research and implementation of newer diag- nostic techniques for early diagnosis, cervical cancer continues to be a major healthcare issue [1]. As of 2008, approximately 530 000 new cases were diagnosed worldwide, and approximately 275 000 deaths were due to cervical cancer [2]. The disease burden is especially promi- nent in low-resource countries. In Turkey, cervical cancer is the eighth most commonly diagnosed malignancy among women and the third most common gynecologic cancer, after ovarian and endometrial cancer [3]. According to Globocan 2008 data, 1443 new cases of cervical cancer were diagnosed and 556 mortalities occurred. The 5-year prevalence was 3998 cases [2]. Persistent infection with high-risk human papillomavirus (HPV) types is an almost-universal causal factor for the development of cervical premalignant lesions and invasive cancer [4]. HPV types are generally split into 2 groups according to their risk of association with malignancy. The most common high-risk types are generally considered to be HPV-16, -18, -31, -33, -35, -39, -45, -51, -52, -56, -58, -59, and -68. The most common low-risk types are considered to be HPV- 6, -11, -40, -42, -43, -44, -53, -54, -61, -72, -73, and -81. HPV-16 and HPV-18 are the most commonly found high-risk types and are associated with approximately 70% of all cases of cervical cancer (HPV-16 is isolated in approximately 50% of cases) [5]. Cervical intraepithelial neoplasia (CIN) 2/3 is the precursor of cervical cancer [6]. Before progression into invasive cancer, there is generally a relatively long time period in which HPV infection can be cleared by the immune system. In cases in which the immune sys- tem fails to clear HPV, a persistent high-risk HPV infection occurs, and the risk of developing CIN 3 (carcinoma in situ) and invasive cancer becomes significant. Because of its persistent nature and high risk of progression to invasive cancer, high-grade CIN is commonly treated, rather than managed expectantly, when encountered. There are a number of treat- ment options for CIN, which can be broadly split into 2 categories: excision and ablation. Excisional treatments are generally referred to as conization procedures, whereby a cone-shaped biopsy specimen is excised from the cervix. Conization can be performed with either a scalpel (cold-knife conization [CKC]) or other energy modalities such as wire loop electrocautery (loop electrosurgical excision proce- dure [LEEP]) or laser. In Turkey, preference regarding these tech- niques is determined by institutional capabilities, patient condition, and surgeon experience. International Journal of Gynecology and Obstetrics 125 (2014) 275–278 ⁎ Corresponding author at: Department of Gynecologic Oncology, Zekai Tahir Burak Women’s Health Education and Research Hospital, 06230, Altindag, Ankara, Turkey. Tel.: +90 530 4602774; fax: +90 312 4268767. E-mail address: eralpbaser@gmail.com (E. Baser). http://dx.doi.org/10.1016/j.ijgo.2013.12.012 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo