A cone biopsy is a procedure where a cone-shaped piece of tissue is removed from the cervix. It is done either to diagnose or treat cervical cell changes caused by high-risk types of human papillomavirus (HPV). HPV is a very common sexually transmitted infection that can lead to cervical cancer if left untreated. A cone biopsy aims to remove all of the abnormal cells so that only normal tissue remains. However, even after having this procedure, it is possible for HPV infection to still be present.
Can HPV persist after a cone biopsy?
Yes, it is possible for HPV to still be present after a cone biopsy. Even though the procedure removes the abnormal cells from the cervix, HPV may still be present in cervical cells that were not removed. HPV infects basal cells of the cervical epithelium, some of which are likely to remain even after excisional treatment. Additionally, the virus can survive in other parts of the genital tract not affected by the cone biopsy.
One study that looked at women who had undergone a cone biopsy found that 58% still tested positive for HPV when followed up after the procedure. The type of HPV was most often the same high-risk strain that led to the original cervical cell changes. This indicates that HPV can persist after cone biopsy despite efforts to excise all infected tissue.
Reasons HPV may still be present
- HPV may have infected areas of the cervix beyond what was removed by the cone biopsy.
- The infection could still be present in the vagina, vulva, anus, or other genital sites.
- The virus can remain dormant in basal cervical cells that were unaffected.
- You could be re-infected by a sexual partner who carries the virus.
Does this mean treatment failed?
The fact that HPV is still detectable after a cone biopsy does not necessarily mean that the treatment failed. The main goal of a cone biopsy is to remove the precancerous changes in the cervix caused by HPV. As long as the pathologist confirms that the margins of the cone specimen are clear, meaning no abnormal cells extend to the edge, then it is considered successful.
Follow-up with your doctor through co-testing, which involves an HPV test and Pap smear, will determine if any further treatment is needed. It is possible that while HPV remains, you have no more evidence of precancer. In this case, your doctor will continue monitoring you closely. Additional treatment would only be warranted if abnormal cervical cells reappear.
Why HPV may persist after successful cone biopsy treatment
- Viral particles remained in untouched areas of the cervix or genital tract.
- You were re-exposed to the same high-risk HPV type.
- The virus was dormant and reactivated.
- You have a weakened immune system unable to suppress the virus.
Will I need further treatment?
Whether or not you will require additional treatment after a cone biopsy depends on the pathology results:
- Clear margins – If the edges of the cone specimen are normal, no further treatment is immediately required. You will need regular follow-up with repeat HPV/Pap testing.
- Positive margins – This means abnormal cells extend to the edge of the specimen, so some diseased tissue may have been left behind. Your doctor will likely recommend further excisional treatment.
- Precancer or cancer found – If the cone biopsy reveals presence of precancer (CIN 2 or 3) or cancer, additional procedures will be necessary to ensure complete removal of the disease.
The recurrence rate of precancer after cone biopsy with clear margins is low, around 5-10%. For this reason, many doctors opt for continued surveillance rather than automatically proceeding to hysterectomy. With strict adherence to follow-up, any recurrence is likely to be detected early.
How long does HPV persist after cone biopsy?
There is no definite timeline for how long HPV persists after cone biopsy. The virus may be detected weeks, months, or even years later. One study found that 76% of women treated with cone biopsy for high-grade precancer still tested positive for the same HPV type 1 year later. However, another study showed just 44% were still HPV positive after 3 years.
The variability highlights that HPV can persist long term in some individuals after excisional procedures. Duration likely depends on factors like:
- The woman’s immune response
- Viral load remaining after cone biopsy
- The specific high-risk HPV type
- Re-exposure through sexual activity
In most cases, HPV will eventually clear on its own even without additional treatment. However, it is important to continue with recommended follow-up to ensure no recurrent disease.
Does HPV type affect persistence?
Yes, the strain of high-risk HPV may impact how long it continues to be detected after cone biopsy. Studies suggest that HPV 16 in particular is more likely to persist compared to other high-risk types:
- One study found HPV 16 persisted in 61% of women post-cone biopsy, versus just 32% with HPV 18.
- Another study detected HPV 16 in 69% of patients 3 years after treatment, compared to 37% with non-16/18 types.
The reasons why HPV 16 persists more stubbornly are not entirely clear. This strain of the virus may be better able to evade immune detection or more successfully integrate into host DNA. Fortunately, even with continued presence of HPV, risk of precancer recurrence remains low with proper surveillance.
Can HPV return after cone biopsy?
Yes, it is possible for the same HPV type to come back after testing negative on follow-up from a cone biopsy. This occurs because the virus can persist at low levels undetectable by our current tests. Over time, HPV infection may then reactivate and replicate to levels that become detectable again through HPV testing.
One study found that after testing negative for HPV after cone biopsy, 19% of women converted back to HPV positive when re-tested just 6 months later. This indicates the virus was likely still present at very low levels and then re-emerged.
Return of HPV infection does not necessarily mean that precancer will recur after cone biopsy. But it is a reminder that long-term monitoring is important, since over time a new precancer could develop if the infection is untreated.
Reasons HPV infection may return after testing negative
- The virus was dormant at levels undetectable on prior HPV test
- You became re-infected through a new sexual partner
- The initial HPV test gave a falsely negative result
- Your immune system underwent changes that led to HPV reactivation
Reducing the risk of HPV persistence
Although HPV can be stubborn to eradicate fully, there are some steps you can take that may help reduce your risk of persistence or recurrence of infection:
- Use condoms correctly every time you have sex to prevent re-exposure and infection with new HPV types.
- Don’t smoke, as this weakens your immune response to HPV.
- Consider asking your partner to get the HPV vaccine if they haven’t already, to reduce transmission.
- Maintain regular follow-up visits for co-testing so any recurrent disease is caught early.
- Manage any conditions that could impair immunity, like HIV, autoimmune disorders, or immunosuppression.
While these measures may not guarantee HPV will be cleared entirely, they can help avoid compounding the problem through risky behaviors like unprotected sex with new partners.
The bottom line
HPV frequently persists after cone biopsy despite removal of all visible precancerous cervical tissue. This is because HPV can hide in microscopic areas of normal-looking epithelium. However, an HPV positive test result alone after cone biopsy does not necessarily mean treatment failed or that you remain at high risk.
With strict adherence to continuing surveillance and co-testing, likelihood of the precancer recurring remains low. But because HPV can persist for months or years after cone biopsy, long-term monitoring remains essential.
