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ASCCP Colposcopy Standards: Colposcopy Quality Improvement Recommendations for the United States. J Low Genit Tract Dis 2018; 21:242-248. [PMID: 28953113 DOI: 10.1097/lgt.0000000000000342] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The American Society for Colposcopy and Cervical Pathology (ASCCP) Colposcopy Standards recommendations address the role of and approach to colposcopy and biopsy for cervical cancer prevention in the United States. The recommendations were developed by an expert working group appointed by ASCCP's Board of Directors. The ASCCP Quality Improvement Working Group developed evidence-based guidelines to promote best practices and reduce errors in colposcopy and recommended indicators to measure colposcopy quality. MATERIALS AND METHODS The working group performed a systematic review of existing major society and national guidelines and quality indicators. An initial list of potential quality indicators was developed and refined through successive iterative discussions, and draft quality indicators were proposed. The draft recommendations were then reviewed and commented on by the entire Colposcopy Standards Committee, posted online for public comment, and presented at the International Federation for Cervical Pathology and Colposcopy 2017 World Congress for further comment. All comments were considered, additional adjustments made, and the final recommendations approved by the entire Task Force. RESULTS Eleven quality indicators were selected spanning documentation, biopsy protocols, and time intervals between index screening tests and completion of diagnostic evaluation. CONCLUSIONS The proposed quality indicators are intended to serve as a starting point for quality improvement in colposcopy at a time when colposcopy volume is decreasing and individual procedures are becoming technically more difficult to perform.
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Standardized Digital Colposcopy with Dynamic Spectral Imaging for Conservative Patient Management. Case Rep Obstet Gynecol 2017; 2017:5269279. [PMID: 29435378 PMCID: PMC5757110 DOI: 10.1155/2017/5269279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/02/2017] [Indexed: 11/17/2022] Open
Abstract
Background Colposcopy is subjective and management of young patients with high-grade disease is challenging, as treatments may impair subsequent pregnancies and adversely affect obstetric outcomes. Conservative management of selected patients is becoming more popular amongst clinicians; however it requires accurate assessment and documentation. Novel adjunctive technologies for colposcopy could improve patient care and help individualize management decisions by introducing standardization, increasing sensitivity, and improving documentation. Case A nulliparous 27-year-old woman planning pregnancy underwent colposcopy following high-grade cytology. The colposcopic impression was of low-grade changes, whilst the Dynamic Spectral Imaging (DSI) map of the cervix suggested potential high-grade. A DSI-directed biopsy confirmed CIN2. At follow-up, both colposcopy and DSI were suggestive of low-grade disease only, and image comparison confirmed the absence of previously present acetowhite epithelium areas. Histology of the transformation zone following excisional treatment, as per patient's choice, showed no high-grade changes. Conclusion Digital colposcopy with DSI mapping helps standardize colposcopic examinations, increase diagnostic accuracy, and monitor cervical changes over time, improving patient care. When used for longitudinal tracking of disease and when it confirms a negative colposcopy, it can help towards avoiding overtreatment and hence decrease morbidity related to cervical excision.
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Diagnosis of Cervical Precancers by Endocervical Curettage at Colposcopy of Women With Abnormal Cervical Cytology. Obstet Gynecol 2017; 130:1218-1225. [PMID: 29112672 DOI: 10.1097/aog.0000000000002330] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the performance of routine endocervical curettage (ECC) for diagnosing high-grade cervical intraepithelial neoplasia (CIN) 2 or worse and additional precancers not otherwise detected by ectocervical biopsies. METHODS In a secondary analysis of the Biopsy Study, a cross-sectional study conducted between 2009 and 2012 at the University of Oklahoma Health and Sciences Center that found an incremental increase in detection of cervical precancers by multiple biopsies at colposcopy, ECC was performed in most women aged 30 years or older. Cervical intraepithelial neoplasia 2 or worse yield by ECC alone was evaluated in analyses stratified by cervical cytology (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesions [LSIL] compared with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions [ASC-H] or high-grade squamous intraepithelial lesions [HSIL] or worse), colposcopic impression (less than high-grade compared with high-grade), human papillomavirus (HPV)-16 infection status, whether the examination was satisfactory, and by ECC indications per the current guidelines for cervical cancer screening. The diagnostic value of ECC for detecting additional disease was evaluated by the number of lesion-directed ectocervical biopsies. RESULTS Of the 204 women aged 30 years or older, 181 (88.7%) underwent ECC. Overall ECC detected 14.4% CIN 2 or worse (95% CI 10.0-20.2%). Endocervical curettage was more likely to find disease in the endocervix among women with high-grade cytology, positive HPV-16 infection, or high-grade colposcopic impressions (respective P values <.05). Among women with ASC-US or LSIL cytology, those with an unsatisfactory examination had a 13.0% CIN 2 or worse yield on ECC (95% CI 6.1-25.7); when colposcopic examination was normal or satisfactory with visible abnormal lesions, ECC detected less than 5% CIN 2 or worse in the endocervix. An ASC-H or HSIL or worse cytology was associated with a CIN 2 or worse yield of 25.8% by ECC (95% CI 16.6-37.9%). However, ECC found only 3.9% (95% CI 1.9-7.8%) additional CIN 2 or worse beyond the cumulative disease detected by up to four biopsies of visible acetowhite ectocervical lesions. Additional CIN 2 or worse yield by ECC increased when fewer lesion-directed biopsies were taken (P<.05). CONCLUSION The additional yield of CIN 2 or worse by ECC in a colposcopy with up to four ectocervical biopsies was low. Based on our findings, we recommend routine ECC be performed in women aged 45 years old or older with HPV-16 infection and in any woman aged 30 years or older with HSIL or worse or ASC-H cytology, high-grade colposcopic impression, or ASC-US or LSIL cytology and an unsatisfactory examination. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT00339989.
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Marquardt K, Ziemke P. [Munich Nomenclature III: classification according to risk : Follow-up for conspicuous squamous findings]. DER PATHOLOGE 2017; 39:57-64. [PMID: 28993907 DOI: 10.1007/s00292-017-0382-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM The present study evaluates the risk of progression of cytologic diagnoses which do not require immediate therapy but do need follow-up. The presented data can contribute to risk-adapted management strategies, according to Munich Nomenclature III. METHODS Between January 2014 and March 2016, 3396 women were diagnosed as group II-p, IIID1, III-p, IIID2, IVa-p, IVb-p, and V‑p and represent the study population. Follow-up information on all subsequent cytologic and histologic findings were collected up to July 2017. For the initial cytologic diagnosis, the cumulative risk of CIN2+ or CIN3+ and the risk for persistent pathologic findings was calculated. RESULTS The cumulative risk of CIN2+ for initial findings II-p, IIID1, III-p, and IIID2 is calculated as 7.3, 17.1, 46.3, and 62.4%, respectively, after a mean observation period of 24.4, 21.1, 15.6, and 14.3 months. The cumulative risk of CIN3+ (%) is determined as 5.0, 9.3, 37.6, and 45.8. For persistent cytologic diagnoses II-p, IIID1, III-p, and IIID2, the risk of CIN2+ increases significantly after the second result (0 to 3.6, 0.21 to 3.6, 7.2 to 58.3, and 8.1 to 64.7%). Risk of CIN2+ and CIN3+ for group III-p is significantly higher for women <35 years and <30 years compared with women of higher age. There are no significant age-dependent differences for findings II-p, IIID1, and IIID2. CONCLUSIONS The Munich Nomenclature III classifies cytologic findings according to risk. The diagnostic groups of the Munich Nomenclature III provide a solid basis for a risk-adapted clinical management, if the cytologic history of the individual patient is taken into account.
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Affiliation(s)
- K Marquardt
- Praxis für Pathologie, Güstrower Str. 34, 19055, Schwerin, Deutschland.
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A retrospective analysis on 1901 women with high grade cervical intraepithelial neoplasia by colposcopic biopsy. Eur J Obstet Gynecol Reprod Biol 2017; 217:53-58. [DOI: 10.1016/j.ejogrb.2017.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/11/2017] [Accepted: 07/04/2017] [Indexed: 11/22/2022]
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DeNardis SA, Lavin PT, Livingston J, Salter WR, James-Patrick N, Papagiannakis E, Olson CG, Weinberg L. Increased detection of precancerous cervical lesions with adjunctive dynamic spectral imaging. Int J Womens Health 2017; 9:717-725. [PMID: 29033612 PMCID: PMC5628669 DOI: 10.2147/ijwh.s144577] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objective To validate, in US community-based colposcopy clinics, previous reports of increased detection of high-grade cervical intraepithelial neoplasia (CIN2+) with biopsies selected using dynamic spectral imaging (DSI) mapping after standard colposcopy. Study design Cross-sectional observational study of 26 colposcopists across nine clinics recruiting consecutive colposcopy patients. Standard assessment with biopsy selections was completed before seeing the DSI map which was subsequently interpreted and used for additional biopsies per clinical judgment. Primary measure was the number of women with CIN2+ detected by DSI-assisted biopsies, over those detected by standard colposcopy biopsies. Results A total of 887 women were recruited. After exclusions, 881 women and 1,189 biopsies were analyzed. Standard biopsy detected 78 women with CIN2+ and DSI-assisted biopsies another 34, increasing the detection rate from 8.85% to 12.71% (p=0.00016). This was achieved with 16.16% of DSI-assisted biopsies finding CIN2+ compared to 13.24% for the preceding standard biopsies. For secondary specificity analysis, 431 women had only <CIN2 in standard biopsy/ies, a 48.92% rate, while 131 women who underwent no standard biopsy/ies had DSI-assisted biopsy/ies which were all <CIN2, a 35.22% rate (p<0.0001). Conclusion The largest study, to date, of DSI used in colposcopy confirms previously reported increased detection of CIN2+, across multiple US community-based clinics. Based on the improved efficiency of the DSI-assisted biopsies, this increase suggests an improved diagnostic capacity achieved with DSI and cannot be explained solely by the taking of additional biopsies.
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Affiliation(s)
- Sara A DeNardis
- Department of Obstetrics/Gynecology, University of Central Florida, Orlando, FL, USA
| | - Philip T Lavin
- Boston Biostatistics Research Foundation, Framingham, MA, USA
| | | | | | | | | | | | - Lori Weinberg
- Department of Obstetrics/Gynecology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
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Cytologic-Histologic Discrepancies in Pathology of the Uterine Cervix: Analysis of the Clinical and Pathologic Factors. Adv Anat Pathol 2017; 24:304-309. [PMID: 28777141 DOI: 10.1097/pap.0000000000000165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cytologic-histologic correlation (CHC) represents a documented effort to obtain and compare, when available, gynecologic cytology reports with an interpretation of high-grade squamous intraepithelial lesion or malignancy, with the subsequent histopathology report, and to determine the possible cause of any discrepancy. The correlation is influenced by multiple closely interdependent clinical and pathologic factors. Many of these factors including the sensitivity and accuracy of colposcopy-directed biopsy, the diligence of the colposcopist, and the attributes of the cervical lesion represent "preanalytical" factors which can significantly affect the CHC outcome, but are often less emphasized during CHC process. The status of "gold standard" of cervical biopsy histology will be less "golden" if clinicians miss, during colposcopy, the lesion which had been flagged by cytology. CHC also serves as one of the important assurance tools to monitor and improve the pathology laboratory overall quality, and the ability of the pathologists to enhance their diagnostic interpretation. As pathologists, we should make every effort to improve on CHC, by applying systematic approaches, both in technical laboratory and interpretive diagnosis, which increase yield and reduce diagnostic discrepancies. The widespread use of Human Papilloma Virus testing and p16 immunohistochemistry have significantly enhanced diagnostic accuracy both in cytology and in histology. Herein, we review the intimate relationships and factors that may govern discrepancies between cytology, colposcopy-directed biopsies, and biopsies with subsequent Loop Electroexcision Procedure for cervical squamous intraepithelial lesions. Ultimately the projected risk for high-grade squamous intraepithelial lesion and cancer and the suggested management guidelines are directly tied in with effective CHC.
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Lax SF, Horn LC, Löning T. [Categorization of uterine cervix tumors : What's new in the 2014 WHO classification]. DER PATHOLOGE 2017; 37:573-584. [PMID: 27770187 DOI: 10.1007/s00292-016-0247-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the 2014 WHO classification, squamous cell precursor lesions are classified as low-grade and high-grade intraepithelial lesions. LSIL corresponds to CIN1, HSIL includes CIN2 and CIN3. Only adenocarcinoma in situ (AIS) is accepted as precursor of adenocarcinoma and includes the stratified mucin-producing intraepithelial lesion (SMILE). Although relatively rare, adenocarcinoma and squamous cell carcinoma can be mixed with a poorly differentiated neuroendocrine carcinoma. Most cervical adenocarcinomas are low grade and of endocervical type. Mucinous carcinomas show marked intra- and extracellular mucin production. Almost all squamous cell carcinomas, the vast majority of adenocarcinomas, and many rare carcinoma types are HPV related. For low grade endocervical adenocarcinomas, the pattern-based classification according to Silva should be reported. Neuroendocrine tumors are rare and are classified into low-grade and high-grade, whereby the term carcinoid is still used.
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Affiliation(s)
- S F Lax
- Institut für Pathologie, LKH Graz Süd-West, Standort West, Akademisches Lehrkrankenhaus der Medizinischen Universität Graz, Göstingerstrasse 22, 8020, Graz, Österreich.
| | - L-C Horn
- Institut für Pathologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - T Löning
- Institut für Pathologie, Albertinenkrankenhaus, Hamburg, Deutschland
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Optimization of Classification Strategies of Acetowhite Temporal Patterns towards Improving Diagnostic Performance of Colposcopy. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2017; 2017:5989105. [PMID: 28744318 PMCID: PMC5514345 DOI: 10.1155/2017/5989105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/11/2017] [Accepted: 06/01/2017] [Indexed: 11/17/2022]
Abstract
Efforts have been being made to improve the diagnostic performance of colposcopy, trying to help better diagnose cervical cancer, particularly in developing countries. However, improvements in a number of areas are still necessary, such as the time it takes to process the full digital image of the cervix, the performance of the computing systems used to identify different kinds of tissues, and biopsy sampling. In this paper, we explore three different, well-known automatic classification methods (k-Nearest Neighbors, Naïve Bayes, and C4.5), in addition to different data models that take full advantage of this information and improve the diagnostic performance of colposcopy based on acetowhite temporal patterns. Based on the ROC and PRC area scores, the k-Nearest Neighbors and discrete PLA representation performed better than other methods. The values of sensitivity, specificity, and accuracy reached using this method were 60% (95% CI 50–70), 79% (95% CI 71–86), and 70% (95% CI 60–80), respectively. The acetowhitening phenomenon is not exclusive to high-grade lesions, and we have found acetowhite temporal patterns of epithelial changes that are not precancerous lesions but that are similar to positive ones. These findings need to be considered when developing more robust computing systems in the future.
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Wan QS, Wang T, Zhang KH. Biomedical optical spectroscopy for the early diagnosis of gastrointestinal neoplasms. Tumour Biol 2017; 39:1010428317717984. [PMID: 28671054 DOI: 10.1177/1010428317717984] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Gastrointestinal cancer is a leading contributor to cancer-related morbidity and mortality worldwide. Early diagnosis currently plays a key role in the prognosis of patients with gastrointestinal cancer. Despite the advances in endoscopy over the last decades, missing lesions, undersampling and incorrect sampling in biopsies, as well as invasion still result in a poor diagnostic rate of early gastrointestinal cancers. Accordingly, there is a pressing need to develop non-invasive methods for the early detection of gastrointestinal cancers. Biomedical optical spectroscopy, including infrared spectroscopy, Raman spectroscopy, diffuse scattering spectroscopy and autofluorescence, is capable of providing structural and chemical information about biological specimens with the advantages of non-destruction, non-invasion and reagent-free and waste-free analysis and has thus been widely investigated for the diagnosis of oesophageal, gastric and colorectal cancers. This review will introduce the advances of biomedical optical spectroscopy techniques, highlight their applications for the early detection of gastrointestinal cancers and discuss their limitations.
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Affiliation(s)
- Qin-Si Wan
- Department of Gastroenterology, Jiangxi Institute of Gastroenterology & Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ting Wang
- Department of Gastroenterology, Jiangxi Institute of Gastroenterology & Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Kun-He Zhang
- Department of Gastroenterology, Jiangxi Institute of Gastroenterology & Hepatology, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Hu SY, Zhang WH, Li SM, Li N, Huang MN, Pan QJ, Zhang X, Han Y, Zhao FH, Chen W, Qiao YL. Pooled analysis on the necessity of random 4-quadrant cervical biopsies and endocervical curettage in women with positive screening but negative colposcopy. Medicine (Baltimore) 2017; 96:e6689. [PMID: 28445270 PMCID: PMC5413235 DOI: 10.1097/md.0000000000006689] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 03/28/2017] [Accepted: 03/29/2017] [Indexed: 12/18/2022] Open
Abstract
Controversy remains over whether random cervical biopsies and endocervical curettage (ECC) should be used in women with positive screening but negative colposcopy. Our paper aims to determine the indications for random biopsies and ECC among these screened positive women.Three thousand two hundred thirteen women with any positive screening test result but negative colposcopy, who received random 4-quadrant biopsies, were pooled from 17 population-based cervical cancer screening studies done in China from 1999 to 2008. The detection rates of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and CIN grade 3 or worse (CIN3+) stratified by cytology and high-risk human papillomavirus (HR-HPV) status were assessed, as well as the false negative rates for CIN2+ and CIN3+ by random biopsies without ECC.Compared with women with negative cytology and positive HR-HPV, those with atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion (ASC-US/LSIL) and negative HR-HPV had the equivalent lower risks of CIN2+ and CIN3+, but ascending risks were observed in the groups of ASC-US/LSIL and positive HR-HPV, and atypical glandular cells/atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion/high-grade squamous intraepithelial lesion or worse (AGC/ASC-H/HSIL+). If random biopsies were only taken without ECC, 9.3% of CIN2+ and 18.5% of CIN3+ would have been missed.For women with any positive screening but negative colposcopy, in areas with good cytological infrastructure, it was necessary to perform random biopsies plus ECC on those with cytological ASC-US/LSIL and positive HR-HPV, AGC, ASC-H, or HSIL+. In contrast, those with other results should be followed up.
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Affiliation(s)
| | | | | | - Nan Li
- Department of Gynecological Oncology
| | | | | | - Xun Zhang
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Han
- Department of Gynecological Oncology
| | | | - Wen Chen
- Department of Cancer Epidemiology
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Macdonald MC, Brown BH, Lyon RE, Healey TJ, Palmer JE, Tidy JA. Influence of high risk HPV genotype on colposcopic performance: A large prospective study demonstrates improved detection of disease with ZedScan I , particularly in non-HPV 16 patients. Eur J Obstet Gynecol Reprod Biol 2017; 211:194-198. [DOI: 10.1016/j.ejogrb.2017.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 01/18/2017] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
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A model to evaluate the costs and clinical effectiveness of human papilloma virus screening compared with annual papanicolaou cytology in Germany. Eur J Obstet Gynecol Reprod Biol 2017; 212:132-139. [PMID: 28363186 DOI: 10.1016/j.ejogrb.2017.03.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/17/2017] [Accepted: 03/18/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We modelled human papilloma virus (HPV) primary screening scenarios compared with Pap cytology to evaluate clinical effectiveness and projected annual costs in Germany. STUDY DESIGN A Markov cohort model was built to compare the budget impact of annual Pap cytology with different 5-yearly HPV screening scenarios: (1) a positive HPV test followed by Pap cytology; (2) a positive HPV test followed by p16/Ki-67 dual-stained cytology; (3) a positive HPV test followed by colposcopy if HPV-16/18-positive or p16/Ki-67 dual-stained cytology if positive for other subtypes; (4) co-testing with HPV and Pap. Screening scenarios were based on a 10-year horizon. RESULTS All HPV screening scenarios in the model were associated with fewer deaths from missed diagnosis of cervical cancer compared with Pap screening; 10-year totals n=172-344 (1.5-3 per 100,000) versus n=477 (4.1 per 100,000), respectively. Total annual costs were lower with HPV screening than Pap cytology. The projected average annual cost for HPV screening ranged from €117 million to €136 million compared with €177 million for Pap screening, representing annual savings of €41-60 million. The greatest clinical impact was achieved with primary HPV screening (with genotyping) followed by colposcopy for HPV 16/18-positive women or p16/Ki-67 dual-stained cytology for women positive for other HPV subtypes. CONCLUSION Screening strategies including primary HPV testing for high-risk subtypes (HPV-16/18) in conjunction with p16/Ki-67 dual-stained cytology can improve the detection of cervical cancer at a lower total annual cost than conventional Pap cytology screening.
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Baasland I, Hagen B, Vogt C, Valla M, Romundstad PR. Colposcopy and additive diagnostic value of biopsies from colposcopy-negative areas to detect cervical dysplasia. Acta Obstet Gynecol Scand 2017; 95:1258-1263. [PMID: 27564523 PMCID: PMC5129518 DOI: 10.1111/aogs.13009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 08/23/2016] [Indexed: 11/26/2022]
Abstract
Introduction We evaluated colposcopy in the routine diagnostic workup of women with abnormal cervical cytology, as well as the diagnostic value of endocervical curettage material and biopsies taken from colposcopy‐positive and colposcopy‐negative quadrants of the cervix. Material and methods This cross‐sectional study included 297 nonpregnant women with abnormal cervical cytology and no prior treatment for cervical dysplasia or cancer. All women underwent gynecological examination, colposcopy, endocervical curettage, and had cervical biopsies taken. Colposcopy was considered satisfactory if the squamocolumnar junction was fully visible, and biopsies were taken from all four quadrants of the cervix, regardless of colposcopy results. Results In all, 130 of the women in our study had satisfactory colposcopy results and were diagnosed with cervical intraepithelial neoplasia grade 2 or worse (CIN2+), 61% via a colposcopy‐positive biopsy and 39% via a colposcopy‐negative biopsy. Eighty‐seven of them had positive colposcopy results, but CIN2+ was histologically verified from colposcopy‐positive biopsies in 91% (n = 79) and from colposcopy‐negative biopsies in 9% (n = 8). The remaining 43 women with CIN2+ had negative colposcopy findings, so their diagnosis was verified in colposcopy‐negative biopsies. The sensitivity of colposcopy alone to detect CIN2+ was 61% (95% CI 52–69). Conclusions In the present study, colposcopy was not a stand‐alone diagnostic method. Colposcopy‐negative biopsies had a clear additive value, identifying a substantial proportion of women with both positive and negative colposcopy results with treatment‐worthy cervical dysplasia. Endocervical curettage material had little diagnostic value in this study.
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Affiliation(s)
- Ingrid Baasland
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Bjørn Hagen
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Christina Vogt
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Pathology and Medical Genetics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marit Valla
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Pathology and Medical Genetics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Pål R Romundstad
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
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Benevolo M, Donà MG, Ravenda PS, Chiocca S. Anal human papillomavirus infection: prevalence, diagnosis and treatment of related lesions. Expert Rev Anti Infect Ther 2016; 14:465-77. [PMID: 27050294 DOI: 10.1586/14787210.2016.1174065] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Human papillomavirus (HPV) infection is mostly asymptomatic, but may also have many diverse clinical signs encompassing benign ano-genital lesions, and carcinomas. Recently, interest has also particularly focused on anal cancer since, over the last decades, its incidence has been greatly increasing in developed countries, both in women and men and is drastically higher in specific risk groups, such as men who have sex with men (MSM) and HIV-1 infected individuals. Approximately 88% of anal cancer cases worldwide are associated with HPV infection. This review summarizes our current understanding of anal HPV infection, discussing its epidemiology and risk factors in various populations, and the state of the art in the detection of anal HPV infection and its related lesions through both cytology and histology. Finally, we discuss the clinical management and therapy for these lesions.
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Affiliation(s)
- Maria Benevolo
- a Pathology Department , Regina Elena National Cancer Institute, IRCCS , Rome , Italy
| | - Maria Gabriella Donà
- b Sexually Transmitted Infection (STI) Unit , San Gallicano Dermatologic Institute, IRCCS , Rome , Italy
| | - Paola Simona Ravenda
- c Unit of Gastrointestinal and Neuroendocrine Tumours , European Institute of Oncology , Milan , Italy
| | - Susanna Chiocca
- d Department of Experimental Oncology , European Institute of Oncology (IEO) , Milan , Italy
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High-Grade Cervical Intraepithelial Neoplasia Detected by Colposcopy-Directed or Random Biopsy Relative to Age, Cytology, Human Papillomavirus 16, and Lesion Size. J Low Genit Tract Dis 2016; 20:207-12. [DOI: 10.1097/lgt.0000000000000184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Regression and Progression Predictors of CIN2 in Women Younger Than 25 Years. J Low Genit Tract Dis 2016; 20:213-7. [DOI: 10.1097/lgt.0000000000000215] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pedersen K, Sørbye SW, Kristiansen IS, Burger EA. Using novel biomarkers to triage young adult women with minor cervical lesions: a cost-effectiveness analysis. BJOG 2016; 124:474-484. [PMID: 27264207 DOI: 10.1111/1471-0528.14135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the short-term consequences and cost-effectiveness associated with the use of novel biomarkers to triage young adult women with minor cervical cytological lesions. DESIGN Model-based economic evaluation using primary epidemiological data from Norway, supplemented with data from European and American clinical trials. SETTING Organised cervical cancer screening in Norway. POPULATION Women aged 25-33 years with minor cervical cytological lesions detected at their primary screening test. METHODS We expanded an existing simulation model to compare 12 triage strategies involving alternative biomarkers (i.e. reflex human papillomavirus (HPV) DNA/mRNA testing, genotyping, and dual staining) with the current Norwegian triage guidelines. MAIN OUTCOME MEASURES The number of high-grade precancers detected and resource use (e.g. monetary costs and colposcopy referrals) for a single screening round (3 years) for each triage strategy. Cost-efficiency, defined as the additional cost per additional precancer detected of each strategy compared with the next most costly strategy. RESULTS Five strategies were identified as cost-efficient, and are projected to increase the precancer detection rate between 18 and 57%, compared with current guidelines; however, the strategies did not uniformly require additional resources. Strategies involving HPV mRNA testing required fewer resources, whereas HPV DNA-based strategies detected >50% more precancers, but were more costly and required twice as many colposcopy referrals compared with the current guidelines. CONCLUSION Strategies involving biomarkers to triage younger women with minor cervical cytological lesions have the potential to detect additional precancers, yet the optimal strategy depends on the resources available as well as decision-makers' and women's acceptance of additional screening procedures. TWEETABLE ABSTRACT Women with minor cervical lesions may be triaged more accurately and effectively using novel biomarkers.
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Affiliation(s)
- K Pedersen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - S W Sørbye
- Department of Clinical Pathology, University Hospital of North Norway, Tromsø, Norway
| | - I S Kristiansen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - E A Burger
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Basu P, Muwonge R, Mittal S, Banerjee D, Ghosh I, Panda C, Mandal R, Sankaranarayanan R. Implications of semi-quantitative HPV viral load estimation by Hybrid capture 2 in colposcopy practice. J Med Screen 2016; 23:104-10. [PMID: 26566949 DOI: 10.1177/0969141315606483] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/25/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE High viral load of oncogenic human papillomavirus (HPV) significantly increases risk of CIN 2 or worse (CIN 2+) lesions. Semi-quantitative estimation of oncogenic HPV viral load by Hybrid Capture 2 (HC2) correlates well with viral load estimated by real-time polymerase chain reaction. We correlated viral load estimated by HC2 with colposcopy and histology diagnosis, to determine if high viral load could detect the CIN 2+ lesions missed by colposcopy in HPV positive women. METHODS Using HPV testing by HC2, 39,728 women were screened. Positive results were categorized into low-positive, intermediate, and high viral load groups, based on relative light unit/cut-off ratios. HPV-positive and some HPV-negative women underwent colposcopy and biopsy. RESULTS A total of 278 CIN 2+ lesions were detected. Detection rate of CIN 2+ was significantly higher in intermediate and high viral load groups. Nearly half (48.3%) of CIN 2+ and 80.4% of CIN 3+ lesions missed or under-diagnosed by colposcopy had viral load in intermediate to high ranges. Risk of CIN 2+ in the high viral load group was 46 times higher than HPV-negative women, even when colposcopy was apparently normal. DISCUSSION Women with intermediate or high viral load should have multiple punch biopsies, even if colposcopy is apparently normal or suggests low grade lesions. Women with high viral load and suspected low grade lesion on colposcopy may be considered for 'see-and-treat', as their risk of CIN 2+ is nearly 200 times higher than HPV-negative women.
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Affiliation(s)
- Partha Basu
- Screening Group, Early Detection & Prevention Section, International Agency for Research on Cancer, Lyon, France
| | - Richard Muwonge
- Screening Group, Early Detection & Prevention Section, International Agency for Research on Cancer, Lyon, France
| | | | | | - Ishita Ghosh
- Chittaranjan National Cancer Institute, Kolkata, India
| | - Chinmay Panda
- Chittaranjan National Cancer Institute, Kolkata, India
| | | | - Rengaswamy Sankaranarayanan
- Screening Group, Early Detection & Prevention Section, International Agency for Research on Cancer, Lyon, France
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Liu AH, Gold MA, Schiffman M, Smith KM, Zuna RE, Dunn ST, Gage JC, Walker JL, Wentzensen N. Comparison of Colposcopic Impression Based on Live Colposcopy and Evaluation of Static Digital Images. J Low Genit Tract Dis 2016; 20:154-61. [PMID: 27015261 PMCID: PMC4808516 DOI: 10.1097/lgt.0000000000000194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the agreement and compare diagnostic accuracy of colposcopic impressions from live colposcopy versus evaluation of static digital images. MATERIALS AND METHODS Live impressions and corresponding static images obtained during colposcopy of 690 women were independently compared. Diagnostic accuracy was calculated for colposcopic impressions from both methods, varying hypothetical thresholds for colposcopically directed cervical biopsies (acetowhitening or worse, low grade or worse, high grade or worse). Stratified analyses investigated the impact of referral cytology, human papillomavirus 16 infection, and age on colposcopic impression. RESULTS Overall agreement between live and static colposcopic visualization was 43.0% (κ = 0.20; 95% CI = 0.14-0.26) over normal, acetowhitening, low-grade, and high-grade impressions. Classification of acetowhitening or worse impressions showed the highest agreement (92.2%; κ = 0.39; 95% CI = 0.21-0.57); both methods achieved more than 95% sensitivity for CIN 2+. Agreement between live and static colposcopic visualization was 69.3% for rating low-grade or worse impressions (κ = 0.23; 95% CI = 0.14-0.33) and 71% when rating high-grade impressions (κ = 0.33; 95% CI = 0.24-0.42). Live colposcopic impressions were more likely to be rated low grade or worse (p < .01; odds ratio = 3.5; 95% CI = 2.4-5.0), yielding higher sensitivity for CIN 2+ at this threshold than static image assessment (95.4% vs 79.8%, p < .01). Overall, colposcopic impressions were more likely rated high grade on live assessment among women referred with high-grade cytology (odds ratio = 3.3; 95% CI = 1.8-6.4), significantly improving the sensitivity for CIN 2+ (66.3% vs 48.5%, p < .01). CONCLUSIONS Colposcopic impressions of acetowhitening or worse are highly sensitive for identifying cervical precancers and reproducible on static image-based pattern recognition.
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Affiliation(s)
- Angela H Liu
- 1Division of Cancer Epidemiology and Genetics, National Cancer Institute; 2Tulsa Cancer Institutes and University of Oklahoma School of Community Medicine; and 3University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Long KC, Menon R, Bastawrous A, Billingham R. Screening, Surveillance, and Treatment of Anal Intraepithelial Neoplasia. Clin Colon Rectal Surg 2016; 29:57-64. [PMID: 26929753 DOI: 10.1055/s-0035-1570394] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of anal intraepithelial neoplasia has been increasing, especially in high-risk patients, including men who have sex with men, human immunodeficiency virus positive patients, and those who are immunosuppressed. Several studies with long-term follow-up have suggested that rate of progression from high-grade squamous intraepithelial lesions to invasive anal cancer is ∼ 5%. This number is considerably higher for those at high risk. Anal cytology has been used to attempt to screen high-risk patients for disease; however, it has been shown to have very little correlation to actual histology. Patients with lesions should undergo history and physical exam including digital rectal exam and standard anoscopy. High-resolution anoscopy can be considered as well, although it is of questionable time and cost-effectiveness. Nonoperative treatments include expectant surveillance and topical imiquimod or 5-fluorouracil. Operative therapies include wide local excision and targeted ablation with electrocautery, infrared coagulation, or cryotherapy. Recurrence rates remain high regardless of treatment delivered and surveillance is paramount, although optimal surveillance regimens have yet to be established.
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Affiliation(s)
- Kevin C Long
- Swedish Colon and Rectal Clinic, Swedish Medical Center Department of Surgery, Seattle, Washington
| | - Raman Menon
- Swedish Colon and Rectal Clinic, Swedish Medical Center Department of Surgery, Seattle, Washington
| | - Amir Bastawrous
- Swedish Colon and Rectal Clinic, Swedish Medical Center Department of Surgery, Seattle, Washington
| | - Richard Billingham
- Swedish Colon and Rectal Clinic, Swedish Medical Center Department of Surgery, Seattle, Washington
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Sander B, Wong WWL, Yeung MW, Ormanidhi O, Atkin K, Murphy J, Krahn M, Deeks SL. The cost-utility of integrated cervical cancer prevention strategies in the Ontario setting - Can we do better? Vaccine 2016; 34:1936-44. [PMID: 26892739 DOI: 10.1016/j.vaccine.2016.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/15/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION A universal, publicly funded, school-based human papillomavirus (HPV) vaccination program in grade eight girls was initiated in Ontario in 2007. We present a cost-utility analysis of integrated cervical cancer prevention programs from the healthcare payer perspective. METHODS Our analysis was based on linked HPV transmission and disease history models. We obtained data from the literature, provincial surveys and Ontario population-based linked health administrative datasets. We modeled combinations of vaccination and screening strategies. We considered vaccination based on the Ontario experience, as well as conservative and optimistic scenarios, varying coverage, vaccine effectiveness and duration of protection. We considered 900 screening scenarios (screening start age: 21-70 years, screening interval: 3-20 years; 1-year time steps). The current schedule screens every 3 years starting at age 21 years. We examined (1) first vaccinated cohort (low herd-immunity), and (2) steady state, i.e. all cohorts were vaccinated (high herd-immunity). RESULTS Adding vaccination to the current screening schedule was cost-effective (<C$10,000/quality-adjusted life year (QALY)) across all scenarios. Delaying screening start and/or extending screening intervals increased both expected QALYs and cost, and increased overall NHB for screening schedules with a start age of 25-35 years and 3-10-year intervals for most scenarios. CONCLUSION Delaying screening start age and/or extending screening intervals in vaccinated cohorts is likely to be cost-effective. Consideration should be given to both the short- and long-term implications of health policy decisions, particularly for infectious disease interventions that require long time intervals to reach steady state.
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Affiliation(s)
- Beate Sander
- Public Health Ontario, Canada; University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Canada.
| | - William W L Wong
- University of Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Canada
| | | | - Orges Ormanidhi
- Toronto Health Economics and Technology Assessment Collaborative, Canada
| | | | - Joan Murphy
- University of Toronto, Canada; Cancer Care Ontario, Canada; University Health Network, Toronto, Canada
| | - Murray Krahn
- University of Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Toronto Health Economics and Technology Assessment Collaborative, Canada; University Health Network, Toronto, Canada
| | - Shelley L Deeks
- Public Health Ontario, Canada; University of Toronto, Canada
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Pedersen K, Sørbye SW, Burger EA, Lönnberg S, Kristiansen IS. Using Decision-Analytic Modeling to Isolate Interventions That Are Feasible, Efficient and Optimal: An Application from the Norwegian Cervical Cancer Screening Program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:1088-1097. [PMID: 26686795 DOI: 10.1016/j.jval.2015.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 07/10/2015] [Accepted: 08/03/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Decision makers often need to simultaneously consider multiple criteria or outcomes when deciding whether to adopt new health interventions. OBJECTIVES Using decision analysis within the context of cervical cancer screening in Norway, we aimed to aid decision makers in identifying a subset of relevant strategies that are simultaneously efficient, feasible, and optimal. METHODS We developed an age-stratified probabilistic decision tree model following a cohort of women attending primary screening through one screening round. We enumerated detected precancers (i.e., cervical intraepithelial neoplasia of grade 2 or more severe (CIN2+)), colposcopies performed, and monetary costs associated with 10 alternative triage algorithms for women with abnormal cytology results. As efficiency metrics, we calculated incremental cost-effectiveness, and harm-benefit, ratios, defined as the additional costs, or the additional number of colposcopies, per additional CIN2+ detected. We estimated capacity requirements and uncertainty surrounding which strategy is optimal according to the decision rule, involving willingness to pay (monetary or resources consumed per added benefit). RESULTS For ages 25 to 33 years, we eliminated four strategies that did not fall on either efficiency frontier, while one strategy was efficient with respect to both efficiency metrics. Compared with current practice in Norway, two strategies detected more precancers at lower monetary costs, but some required more colposcopies. Similar results were found for women aged 34 to 69 years. CONCLUSIONS Improving the effectiveness and efficiency of cervical cancer screening may necessitate additional resources. Although efficient and feasible, both society and individuals must specify their willingness to accept the additional resources and perceived harms required to increase effectiveness before a strategy can be considered optimal.
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Affiliation(s)
- Kine Pedersen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | | | - Emily Annika Burger
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway; Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Stefan Lönnberg
- The Norwegian Cervical Cancer Screening Program, The Cancer Registry of Norway, Oslo, Norway
| | - Ivar Sønbø Kristiansen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Abstract
Diagnostic interpretation of a cervical biopsy is a key element in the decision to treat or not to treat a woman with an abnormal screening test. This study assesses the variability of these diagnostic interpretations on a population basis using the New Mexico HPV Pap Registry database. An experienced panel of gynecologic pathologists reviewed a stratified random sample of 6272 biopsies, which was then extrapolated to the entire population of 21,297 biopsies read by the community pathologists. Diagnoses by the community and panel pathologists were compared, and paired diagnoses were correlated with positivity for human papillomavirus 16 (HPV16) and any high-risk HPV as objective measures of progressive potential. Panel agreement with the community diagnosis was 38.2% for cervical intraepithelial neoplasia grade 1 (CIN1), 38.0% for CIN grade 2 (CIN2), 68.0% for CIN grade 3 (CIN3), and 70.6% for cancer. The κ value was 0.46 overall but higher for dichotomous categorization based on CIN2 or CIN3 cutoff points (0.68 and 0.67, respectively). On a population basis, there were fewer CIN1 and more negative diagnoses in the panel review but similar proportions of CIN2 and CIN3. HPV16 and high-risk HPV positivity increased with disease severity, but panel review did not improve the correlation of higher-grade disease with these objective measures. In this population-based study of the variability in cervical diagnoses, we noted significant variability in the community and panel diagnoses, especially for CIN2, the threshold for excisional treatment. New biomarkers are needed to more accurately stratify precursor lesions according to their malignant potential.
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An alternative approach for estimating the accuracy of colposcopy in detecting cervical precancer. PLoS One 2015; 10:e0126573. [PMID: 25962157 PMCID: PMC4427274 DOI: 10.1371/journal.pone.0126573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/06/2015] [Indexed: 11/19/2022] Open
Abstract
Introduction Since colposcopy helps to detect cervical cancer in its precancerous stages, as new strategies and technologies are developed for the clinical management of cervical neoplasia, precisely determining the accuracy of colposcopy is important for characterizing its continued role. Our objective was to employ a more precise methodology to estimate of the accuracy of colposcopy to better reflect clinical practice. Study design For each patient, we compared the worst histology result among colposcopically positive sites to the worst histology result among all sites biopsied, thereby more accurately determining the number of patients that would have been underdiagnosed by colposcopy than previously estimated. Materials and Methods We utilized data from a clinical trial in which 850 diagnostic patients had been enrolled. Seven hundred and ninety-eight of the 850 patients had been examined by colposcopy, and biopsy samples were taken at colposcopically normal and abnormal sites. Our endpoints of interest were the percentages of patients underdiagnosed, and sensitivity and specificity of colposcopy. Results With the threshold of low-grade squamous intraepithelial lesions for positive colposcopy and histology diagnoses, the sensitivity of colposcopy decreased from our previous assessment of 87.0% to 74.0%, while specificity remained the same. The drop in sensitivity was the result of histologically positive sites that were diagnosed as negative by colposcopy. Thus, 28.4% of the 798 patients in this diagnostic group would have had their condition underdiagnosed by colposcopy in the clinic. Conclusions In utilizing biopsies at multiple sites of the cervix, we present a more precise methodology for determining the accuracy of colposcopy. The true accuracy of colposcopy is lower than previously estimated. Nevertheless, our results reinforce previous conclusions that colposcopy has an important role in the diagnosis of cervical precancer.
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Kabaca C, Koleli I, Sariibrahim B, Karateke A, Gurbuz A, Kapudere B, Cetiner H, Cesur S. Is cervical punch biopsy enough for the management of low-grade cervical intraepithelial neoplasia? J Low Genit Tract Dis 2015; 18:240-5. [PMID: 24633166 DOI: 10.1097/lgt.0b013e3182aa08f6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This study aimed to analyze the correlation between the histopathologic results of excisional procedure and cervical punch biopsy and to investigate the accuracy rates of colposcopic punch biopsy and cervical cytology to detect cervical intraepithelial neoplasia (CIN) grade 2 and/or more severe lesions (CIN 2+). MATERIALS AND METHODS Two hundred six patients who underwent excisional procedure in the gynecologic oncology clinic of the Zeynep Kamil Women and Children Diseases Education and Research Hospital between 2004 and 2011 were enrolled in a retrospective study. RESULTS The correlation between the pathologic findings gained by excisional procedure and punch biopsy was weak ( p = .0001, κ = 0.03). The overall concordance rate between the pathologic findings of cervical biopsy and excisional procedure was 57.29%. The rates of detecting more severe lesions by excisional procedure when compared to biopsies (biopsy underestimation) were 71.42%, 22.91%, 37.03%, and 12.72% for biopsy results with negative, CIN 1, CIN 2, and CIN 3/adenocarcinoma in situ lesions, respectively. Similarly, the rates of less severe lesions diagnosed by excisional procedure when compared to biopsies (biopsy overestimation) were 29.16%, 40.74%, and 15.45% for biopsy results with CIN 1, CIN 2, and CIN 3/adenocarcinoma in situ lesions, respectively. The rate of CIN 2+ lesions after excisional procedure in cases with previous biopsy results with either negative or CIN 1 was 27.27%. CONCLUSIONS Our results suggested that colposcopy-directed biopsy was neither a good diagnostic nor a reliable management method. We think that the indications of conization should be enlarged to avoid overlooking high-grade lesions.
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Affiliation(s)
- Canan Kabaca
- Departments of 1Gynecologic Oncology, and 2Pathology, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
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Song Y, Zhao YQ, Zhang X, Liu XY, Li L, Pan QJ, Shen GH, Zhao FH, Chen F, Chen W, Qiao YL. Random biopsy in colposcopy-negative quadrant is not effective in women with positive colposcopy in practice. Cancer Epidemiol 2015; 39:237-41. [PMID: 25684646 DOI: 10.1016/j.canep.2015.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 01/07/2015] [Accepted: 01/11/2015] [Indexed: 10/24/2022]
Abstract
AIM To assess the efficacy of random biopsy in diagnosing those high-grade squamous intraepithelial lesions or carcinomas (HSIL+) missed by colposcopy-directed biopsy, and to identify the scenarios of cervical cancer screening when random biopsy is necessary. PATIENTS/INTERVENTIONS Data from 1997 women who participated in the Shanxi Province Cervical Cancer Screening Study I (SPOCCS I) were reviewed. Each woman received human papillomavirus (HPV) testing with the second-generation hybrid capture, liquid-based cytology, four-quadrant biopsy and endocervical curettage. The final diagnosis was based on the most severe pathological result obtained. The efficacy of random biopsy and colposcopy-directed biopsy was evaluated on the basis of the final pathological results. RESULTS For women with severe cytological abnormalities (HSIL+) and negative colposcopy, the yield of HSIL+ diagnosed by random biopsy was 25%. On the other hand, the yield of HSIL+ diagnosed by random biopsies in the negative quadrant was no more than 4% when the colposcopy was positive, regardless of the cytological findings. For women with negative HPV, no HSIL+ was found by random biopsy. For women with severe cytological abnormalities (HSIL+) and positive HPV, the yield of HSIL+ diagnosed by random biopsy was 35% when colposcopy was negative. For women with low-grade intraepithelial lesion (LSIL) and positive HPV, the yield of HSIL+ diagnosed by random biopsy was 12.5% when colposcopy was negative. CONCLUSION Random biopsy is not effective in the negative quadrant in women with positive colposcopy, but should be performed in women with cytological HSIL+ but negative colposcopy, or in those with cytological LSIL or HGSL+ and positive HPV but negative colposcopy.
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Affiliation(s)
- Yan Song
- Department of Pathology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yu-Qian Zhao
- Department of Cancer Epidemiology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xun Zhang
- Department of Pathology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Xiao-Yang Liu
- Department of Pathology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ling Li
- Department of Pathology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qin-Jing Pan
- Department of Pathology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Gui-Hua Shen
- Department of Pathology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fang-Hui Zhao
- Department of Cancer Epidemiology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Feng Chen
- Department of Cancer Epidemiology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wen Chen
- Department of Cancer Epidemiology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - You-Lin Qiao
- Department of Cancer Epidemiology, Cancer Institute & Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Abstract
OBJECTIVE A post hoc analysis to determine the diagnostic yield of random biopsy in detecting high-grade cervical disease in women with negative colposcopy. METHODS The ATHENA (Addressing the Need for Advanced HPV Diagnostics) trial screened more than 47,000 women with cytology and high-risk human papillomavirus (HPV) DNA genotyping. Colposcopy was performed in all women with abnormal cytology or positive HPV results. A single random biopsy was taken at the squamocolumnar junction if colposcopy was adequate and no lesions were identified. RESULTS The random biopsy diagnosed 20.9% (81/388, 95% confidence interval [CI] 16.9-25.3%) and 18.9% (45/238, 95% CI 14.1-24.5%) of the total cervical intraepithelial neoplasia (CIN) grade 2 or worse and grade 3 or worse, respectively. This additional disease was detected in both HPV 16 or 18+ and for 12 other high-risk HPV+ women. For HPV 16 or 18, the absolute risk for detection of CIN 2 or worse on random biopsy in the overall population was 13.1% (40/305, 95% CI 9.8-17.4%) and 8.2% (25/305, 95% CI 5.6-11.8%) for CIN 3 or worse. By contrast, the absolute risk for 12 other high-risk HPV+ women was 3.5% (29/820, 95% CI 2.5-5%) and 1.7% (14/820, 95% CI 1.0-2.8%) for CIN 2 or worse and CIN 3 or worse, respectively. CONCLUSION A single random biopsy increased the detection of high-grade disease when no lesions were visualized at colposcopy. The absolute risks of disease associated with the random biopsy were highest for women positive for genotype 16 or 18. Our study supports performing a random biopsy in women undergoing colposcopy without visible lesions, particularly in those positive for HPV 16 or 18. LEVEL OF EVIDENCE : II.
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Garner D. Clinical application of DNA ploidy to cervical cancer screening: A review. World J Clin Oncol 2014; 5:931-65. [PMID: 25493231 PMCID: PMC4259955 DOI: 10.5306/wjco.v5.i5.931] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 04/21/2014] [Accepted: 05/16/2014] [Indexed: 02/06/2023] Open
Abstract
Screening for cervical cancer with DNA ploidy assessment by automated quantitative image cytometry has spread throughout China over the past decade and now an estimated 1 million tests per year are done there. Compared to conventional liquid based cytology, DNA ploidy has competitive accuracy with much higher throughput per technician. DNA ploidy has the enormous advantage that it is an objective technology that can be taught in typically 2 or 3 wk, unlike qualitative cytology, and so it can enable screening in places that lack sufficient qualified cytotechnologists and cytopathologists for conventional cytology. Most papers on experience with application of the technology to cervical cancer screening over the past decade were published in the Chinese language. This review aims to provide a consistent framework for analysis of screening data and to summarize some of the work published from 2005 to the end of 2013. Of particular interest are a few studies comparing DNA ploidy with testing for high risk human papilloma virus (hrHPV) which suggest that DNA ploidy is at least equivalent, easier and less expensive than hrHPV testing. There may also be patient management benefits to combining hrHPV testing with DNA ploidy. Some knowledge gaps are identified and some suggestions are made for future research directions.
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Reuschenbach M, Wentzensen N, Dijkstra MG, von Knebel Doeberitz M, Arbyn M. p16INK4a immunohistochemistry in cervical biopsy specimens: A systematic review and meta-analysis of the interobserver agreement. Am J Clin Pathol 2014; 142:767-72. [PMID: 25389329 DOI: 10.1309/ajcp3tphv4trizek] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES The interpretation of cervical biopsy specimens guides management of women with suspected cervical cancer precursors. However, morphologic evaluation is subjective and has low interobserver agreement. Addition of p16(INK4a) immunohistochemistry may improve interpretation. METHODS We performed a systematic review and meta-analysis of published data on interobserver agreement of p16(INK4a) positivity using p16(INK4a) immunohistochemistry and of cervical intraepithelial neoplasia grade 2 (CIN2+) and CIN grade 3 (CIN3+) classification using H&E morphology in conjunction with p16(INK4a) in comparison with H&E morphology alone. RESULTS The literature search revealed five eligible articles. The results show strong agreement of pathologists' interpretation of cervical biopsy specimens as p16(INK4a) positive or negative (pooled κ = 0.90; 95% confidence interval [CI], 0.88-0.92) and significantly higher agreement for a CIN2+ diagnosis with H&E morphology in conjunction with p16(INK4a) (κ = 0.73; 95% CI, 0.67-0.79) compared with H&E morphology alone (κ = 0.41; 95% CI, 0.17-0.65). Also, a slightly higher agreement for CIN3+ can be observed (κ = 0.66; 95% CI, 0.39-0.94 for H&E morphology in conjunction with p16(INK4a) and κ = 0.61; 95% CI, 0.44-0.78 for H&E morphology alone), but this difference was not statistically significant. CONCLUSIONS The published literature indicates improved interobserver agreement of the diagnosis of CIN2+ with the conjunctive use of H&E morphology with p16(INK4a) immunohistochemistry compared with H&E morphology alone.
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Affiliation(s)
- Miriam Reuschenbach
- Department of Applied Tumor Biology, Institute of Pathology, University of Heidelberg and Clinical Cooperation Unit, German Cancer Research Center, Heidelberg, Germany
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Maaike G. Dijkstra
- Department of Pathology, VU University Medical Center, Amsterdam, the Netherlands
| | - Magnus von Knebel Doeberitz
- Department of Applied Tumor Biology, Institute of Pathology, University of Heidelberg and Clinical Cooperation Unit, German Cancer Research Center, Heidelberg, Germany
| | - Marc Arbyn
- Unit of Cancer Epidemiology, Scientific Institute of Public Health, Brussels, Belgium
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Wentzensen N, Walker JL, Gold MA, Smith KM, Zuna RE, Mathews C, Dunn ST, Zhang R, Moxley K, Bishop E, Tenney M, Nugent E, Graubard BI, Wacholder S, Schiffman M. Multiple biopsies and detection of cervical cancer precursors at colposcopy. J Clin Oncol 2014; 33:83-9. [PMID: 25422481 DOI: 10.1200/jco.2014.55.9948] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Women with abnormal cervical cancer screening results are referred to colposcopy and biopsy for diagnosis of cervical cancer precursors (high-grade squamous intraepithelial lesions [HSILs]). Colposcopy with a single biopsy can miss identification of HSILs. No systematic study has quantified the improved detection of HSIL by taking multiple lesion-directed biopsies. METHODS The Biopsy Study was an observational study of 690 women referred to colposcopy after abnormal cervical cancer screening results. Up to four directed biopsies were taken from distinct acetowhite lesions and ranked by colposcopic impression. A nondirected biopsy of a normal-appearing area was added if fewer than four directed biopsies were taken. HSIL identified by any biopsy was the reference standard of disease used to evaluate the incremental yield and sensitivity of multiple biopsies. RESULTS In the overall population, sensitivities for detecting HSIL increased from 60.6% (95% CI, 54.8% to 66.6%) from a single biopsy to 85.6% (95% CI, 80.3% to 90.2%) after two biopsies and to 95.6% (95% CI, 91.3% to 99.2%) after three biopsies. A significant increase in sensitivity of multiple biopsies was observed in all subgroups. The highest increase in yield of HSIL was observed for women with a high-grade colposcopic impression, HSIL cytology, and human papillomavirus (HPV) type 16 positivity. Only 2% of all HSILs diagnosed in the participants were detected by biopsies of normal-appearing transformation zone. CONCLUSION Collection of additional lesion-directed biopsies during colposcopy increased detection of histologic HSIL, regardless of patient characteristics. Taking additional biopsies when multiple lesions are present should become the standard practice of colposcopic biopsy.
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Affiliation(s)
- Nicolas Wentzensen
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK.
| | - Joan L Walker
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Michael A Gold
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Katie M Smith
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Rosemary E Zuna
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Cara Mathews
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - S Terence Dunn
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Roy Zhang
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Katherine Moxley
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Erin Bishop
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Meaghan Tenney
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Elizabeth Nugent
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Barry I Graubard
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Sholom Wacholder
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
| | - Mark Schiffman
- Nicolas Wentzensen, Barry I. Graubard, Sholom Wacholder, and Mark Schiffman, National Cancer Institute, Bethesda, MD; Joan L. Walker, Katie M. Smith, Rosemary E. Zuna, Cara Mathews, S. Terence Dunn, Roy Zhang, Katherine Moxley, Erin Bishop, Meaghan Tenney, and Elizabeth Nugent, University of Oklahoma Health Sciences Center, Oklahoma City; and Michael A. Gold, Tulsa Cancer Institute and University of Oklahoma School of Community Medicine, Tulsa, OK
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85
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Clinical relevance of objectifying colposcopy. Arch Gynecol Obstet 2014; 291:907-15. [DOI: 10.1007/s00404-014-3518-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
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86
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Maniar KP, Nayar R. HPV-related squamous neoplasia of the lower anogenital tract: an update and review of recent guidelines. Adv Anat Pathol 2014; 21:341-58. [PMID: 25105936 DOI: 10.1097/pap.0000000000000035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Squamous cell carcinomas of the lower anogenital tract that are related to human papillomavirus (HPV) infection represent a significant disease burden worldwide. The diagnosis and management of their noninvasive precursors has been the subject of extensive study and debate over several decades, accompanied by an evolving understanding of HPV biology. Recent new consensus recommendations for the pathologic diagnosis of these precursor lesions were published in 2012, the result of the Lower Anogenital Squamous Terminology project cosponsored by the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Most salient among the new guidelines are the recommendation to switch to a 2-tiered nomenclature (high-grade squamous intraepithelial lesion and low-grade squamous intraepithelial lesion) rather than the traditional 3-tiered "intraepithelial neoplasia" terminology, and the recommendation to expand use of the immunohistochemical marker p16 to distinguish between low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion/intraepithelial neoplasia 2. The goals of the project were to align diagnostic terminology with our knowledge of HPV biology, increase reproducibility, consolidate diverse systems of nomenclature, and ultimately better determine a patient's true cancer risk. The clinical guidelines for screening and management of cervical intraepithelial neoplasia have also been recently updated, most notably with a lengthening of screening intervals. In this review, we focus on the new guidelines put forth for pathologic diagnosis of HPV-related anogenital neoplasia, with discussion of the evidence behind them and their potential implications. We also provide an update on relevant biomarkers, clinical recommendations, and the newest developments relating to cervical neoplasia.
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87
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Optimizing biopsy procedures during colposcopy for women with abnormal cervical cancer screening results: a multicenter prospective study. Int J Clin Oncol 2014; 20:579-85. [PMID: 25145298 DOI: 10.1007/s10147-014-0739-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 08/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND In cervical cancer screening programs, women with abnormal cytology results are referred to colposcopy for histological diagnosis. This study was designed to evaluate the sensitivity of colposcopic procedures for detecting cervical cancer and its precursor, cervical intraepithelial neoplasia (CIN). METHODS Women referred to colposcopy for abnormal cytology were enrolled from four hospitals. Gynecologists were required to take a colposcopy-guided biopsy from the worst of the abnormal-looking areas as a first biopsy. They were also asked to take ≥ 3 cervical specimens including by endocervical curettage (ECC). Random biopsies were performed at the gynecologist's discretion. We analyzed 827 biopsy results from 255 women who were diagnosed by central pathologists as having histology of CIN or cancer. RESULTS In this study, 78.1% of diagnoses of CIN grade 2 or worse (CIN2+) (the threshold that would trigger intensive management) were obtained from a first colposcopy-guided biopsy. The additional diagnostic utility of second and third colposcopy-guided biopsies was 16.4 and 1.8%, respectively. The combined sensitivity of two colposcopy-directed biopsies for CIN2+ detection was >90%, regardless of the colposcopist. Random biopsies and ECC increased the diagnostic yield of CIN2+ lesions otherwise missed by colposcopy-guided biopsies alone, but only by 1.2 and 2.4%, respectively. Random biopsies were more useful for women referred after low-grade abnormal cytology (P = 0.01). The utility of ECC was greatest among women with unsatisfactory colposcopy (P = 0.03) or aged ≥ 40 years (P = 0.02). CONCLUSIONS Our data suggest that at least two colposcopy-directed biopsies should be taken for histological diagnosis. Random biopsies and ECC are recommended for special populations.
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88
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Spinillo A, Gardella B, Chiesa A, Cesari S, Alberizzi P, Silini EM. Diagnostic accuracy of colposcopy in relation to human papillomavirus genotypes and multiple infection. Gynecol Oncol 2014; 134:527-33. [PMID: 25026638 DOI: 10.1016/j.ygyno.2014.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 07/04/2014] [Accepted: 07/06/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the diagnostic accuracy of colposcopy for cervical intraepithelial neoplasia grade 3 or worse (CIN3+) in relation to the detection of human papillomavirus (HPV) type 16 and multiple HPV infection. METHODS A cohort study of 2526 subjects attending a colposcopic service because of cytological abnormalities. HPV genotypes were identified using the INNO-LIPA genotyping system. RESULTS The final colposcopic/pathological diagnoses were as follows: 1282 (50.8%) negative, 709 (28.1%) CIN1, 169 (6.7%) CIN2, 318 (12.6%) CIN3 and 48 (1.9%) invasive cervical cancer, respectively. Among women with ASCUS/LSIL, assuming any colposcopic abnormality as a cut-off, there were no significant differences in the sensitivities (83.8%, 95% CI=76-89.6 as compared to 84.1%, 95% CI=73.2-91.1, p=0.9) and ROC curves (0.61, 95% CI=0.58-0.65 as compared to 0.59, 95% CI=0.54-0.64, p=0.5) in the detection of CIN3+ lesions between subjects with single and multiple high-risk infection, and between subjects infected by HPV16 (83.1%, 95% CI=73.7-89.7, ROC=0.59, 95% CI=0.54-063) or other high-risk HPVs (84.7%, 95% CI=75.6-90.8, ROC=0.62, 95% CI=0.58-0.66, p=0.8 and p=0.6 compared to HPV16). After correction for confounders, the odds ratios of CIN3+ associated with any abnormal colposcopic findings were 2.47 (95%CI=1.44-4.23, p=0.001) among HPV16 positive, 3.34 (95% CI=2.16-5.42, p<0.001) among other high-risk HPVs and 1.3 (95% CI=0.72-2.48, p=0.36) among subjects with negative/low-risk HPVs. CONCLUSION In routine clinical practice, multiple infection or HPV16 positivity did not affect colposcopic accuracy in the diagnosis of CIN3+ lesions. The sensitivity of colposcopy was poor among subjects who were uninfected or infected by low-risk HPV genotypes.
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Affiliation(s)
- Arsenio Spinillo
- Department of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy.
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Alessia Chiesa
- Department of Obstetrics and Gynecology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Stefania Cesari
- Department of Pathology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Paola Alberizzi
- Department of Pathology, University of Pavia, IRCCS Fondazione Policlinico San Matteo, Italy
| | - Enrico Maria Silini
- Department of Biomedical, Biotechnological and Translational Sciences, Unit of Surgical Pathology and Center for Molecular and Translational Oncology (COMT), University of Parma, Italy
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[Immunocytochemistry of p16(INK4a) and Ki-67 as adjunctive method for routine gynecological cytology of mild and moderate dysplasia]. DER PATHOLOGE 2014; 34:323-8. [PMID: 22752390 DOI: 10.1007/s00292-012-1613-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Especially the cytological diagnoses of mild and moderate dysplasia are often followed by unnecessary stigmatization of patients and uncertainty in further clinical follow-up and therapy. Data from 222 patients including additional investigations by high-risk human papillomavirus (HPV) testing and combined immunocytochemistry for p16(INK4a) and Ki-67 were documented, including cytological and histological follow-up. Overall for cytology, high risk HPV testing and dual staining the following characteristics concerning the presence of cervical intraepithelial neoplasia (CIN) 2+ were calculated (in %): sensitivity 100, 95.8 and 92.4, specificity -, 23.3 and 72.8, positive predictive value 53.6, 59.1 and 79.7, negative predictive value -, 82.8 and 89.3, respectively.There was a statistically significant advantage for higher specificity and positive predictive value for dual staining, especially for cytological diagnosis of low grade dysplasia. An objective individual risk stratification of patients with cytology of mild or moderate dysplasia is not available but the uncertainty in the management of these patients will be clearly reduced.
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90
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Kinney W, Hunt WC, Dinkelspiel H, Robertson M, Cuzick J, Wheeler CM. Cervical excisional treatment of young women: a population-based study. Gynecol Oncol 2014; 132:628-35. [PMID: 24395062 PMCID: PMC3992337 DOI: 10.1016/j.ygyno.2013.12.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 12/23/2013] [Accepted: 12/26/2013] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Assessment of cytology and biopsy results preceding cervical excisional treatment and their association with excisional histology, to evaluate compliance with treatment recommendations and the potential effect of revisions in cervical histology terminology and usage. METHOD Data from a unique statewide population-based screening registry was used to describe the use and histologic outcomes of cervical excisional procedures in the year following an abnormal cervical screening cytology. RESULTS From 2007 to 2011, LEEP rates decreased 87%, 45%, and 16% for women aged 15-20, 21-24, and 25-29 years, respectively. Reductions were attributable to an overall decline in cervical screening and colposcopy, and a decrease in LEEP following a diagnosis of less than cervical intraepithelial neoplasia grade 2 ( 0.7) for women aged 30-39 years. Irrespective of age, CIN2 was the most common histologic antecedent of excisional treatment (42%), with most (80%) preceded by CONCLUSION Cervical excisions are an unavoidable consequence of cervical screening. Adherence to treatment guidelines stipulating conservative follow-up of young women with biopsies ≤CIN2 could significantly decrease the number of excisional procedures and associated harms. This opportunity will be lost if cervical intraepithelial neoplasia grade 3 (CIN3) and some or all of CIN2 are merged into a single histologic category, as has been recently recommended in the United States.
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Affiliation(s)
- Walter Kinney
- Department of Women's Health and Division of Gynecologic Oncology, The Permanente Medical Group, Oakland, CA, USA
| | - William C Hunt
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Helen Dinkelspiel
- Division of Gynecologic Oncology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Michael Robertson
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jack Cuzick
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Cosette M Wheeler
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA; Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
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Luyten A, Buttmann-Schweiger N, Luyten K, Mauritz C, Reinecke-Lüthge A, Pietralla M, Meijer CJLM, Petry KU. Early detection of CIN3 and cervical cancer during long-term follow-up using HPV/Pap smear co-testing and risk-adapted follow-up in a locally organised screening programme. Int J Cancer 2014; 135:1408-16. [PMID: 24519782 DOI: 10.1002/ijc.28783] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 01/08/2014] [Indexed: 11/07/2022]
Abstract
We evaluated compliance with human papillomavirus (HPV) testing and risk-adapted patient pathways and monitored changes in high-grade cervical disease during long-term follow-up. Women aged >30 years attending routine screening for cervical cancer were managed according to results from first-round screening tests (cytology and high-risk HPV; Hybrid Capture 2). Between February 2006 and January 2011, 19,795 of 19,947 women agreed to participate, of whom 4,067 proceeded to a second screening round 5 years after recruitment. Predefined endpoints were compliance, grade 3 cervical intraepithelial neoplasia or cancer (CIN3+), new HPV infection, HPV persistence and abnormal smears in round 2. A total of 765 of 19,795 women (3.9%) in round 1 and 41 of 4,067 (1.0%) in round 2 were referred for colposcopy. Compliance rates with colposcopy were 93.1 and 92.7%, respectively, while histological assessment was performed in 680 of 712 (95.5%) and 36 of 38 (94.7%), respectively. CIN3+ rates were 172 of 19,795 (0.87%; 95% confidence intervals: 0.7-1.0) in round 1 and 2 of 4,064 (0.05%; 95% confidence intervals: 0.006-0.2) in round 2; the difference was statistically significant (Fisher's exact test, p<0.001). After 5 years, the incidence of new HPV infection was 124 of 3,906 (3.2%) and HPV persistence was observed in 22 of 161 (13.7%). Locally organised HPV/cytology co-testing is feasible and acceptable to women. Risk-adapted management rapidly detected a high rate of prevalent CIN3+, while the subsequent long-term risk of new high-grade cervical disease was surprisingly low. It remains unclear if this phenomenon is explained by CIN3 mostly occurring early in life or by modifying the natural course of HPV infection with colposcopy and histological assessment.
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Affiliation(s)
- Alexander Luyten
- Department of Gynaecology and Obstetrics, Klinikum Wolfsburg, Wolfsburg, Germany
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Diedrich JT, Felix JC, Lonky NM. Contribution of Exocervical Biopsy, Endocervical Curettage, and Colposcopic Grading in Diagnosing High-Grade Cervical Intraepithelial Neoplasia. J Low Genit Tract Dis 2014; 20:52-6. [PMID: 24477170 DOI: 10.1097/lgt.0b013e3182a5296e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the utility of random biopsy and endocervical curettage (ECC) during colposcopy among women who ultimately underwent cervical excisional biopsy. MATERIALS AND METHODS In a retrospective observational study, the charts were reviewed of every patient who underwent cervical excisional procedure performed between June 2010 and August 2011, including the antecedent colposcopic examination and any pathological specimens. A random sample of 15% all pathologic specimens was reviewed. Practice of biopsy, use of ECC, demographic factors, referral cytology results, lesion distribution, and size were assessed for correlation with high-grade cervical intraepithelial neoplasia 2 or worse (CIN 2+). RESULTS A total of 555 patients were included in our analysis. Of them, 333 (60%) had CIN 2+ on colposcopy or excision. CIN 2+ was most likely in younger women and those referred for high-grade cytology. Among 111 women with no visual lesion seen at colposcopy, 66 underwent ECC alone, 33 had ECC and random biopsy, 9 were referred straight to excision, and 3 underwent random biopsy alone. Of the 99 who underwent ECC, this was consistent with the highest-grade lesion in 68% of cases. Among the 36 with random biopsy, this was consistent with the highest-grade lesion in 72% of cases.At the time of colposcopy, there were 326 who had CIN 2+ diagnosed with satisfactory colposcopy. Biopsy and ECC were performed in 278 cases. In 235 cases, biopsy alone showed CIN 2+; in 43, the biopsy and ECC both showed CIN 2+. In the remaining 48 cases, CIN 2+ was diagnosed with ECC alone. CONCLUSIONS In those ultimately treated with excision, younger women and those whose referral cytology was high-grade both were at higher risk of high-grade histology. Random biopsy and ECC (even among satisfactory colposcopy) were significantly associated with disclosure of high-grade pathology.
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Affiliation(s)
- Justin Thomas Diedrich
- 1Department of Obstetrics and Gynecology, University of California, Irvine; 2Department of Gynecologic Pathology, University of Southern California, Los Angeles; and 3Department of Obstetrics and Gynecology, Kaiser Permanente, Anaheim, CA
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Ziemke P, Marquardt K, Griesser H. Predictive value of the combined p16 and Ki-67 immunocytochemistry in low-grade squamous intraepithelial lesions. Acta Cytol 2014; 58:489-94. [PMID: 25342512 DOI: 10.1159/000367838] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 08/25/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The reliability of cytological diagnoses, especially for low-grade squamous intraepithelial lesions (LSIL), is limited. This leads to uncertainty in patient management. The application of adjunctive biomarkers is meant to improve this situation. Therefore, we examined the prognostic value of p16/Ki-67 immunostaining of LSIL cytology specimens. STUDY DESIGN We analyzed the p16(INK4a) and Ki-67 immunocytochemistry (CINtec® PLUS, dual stain) of 260 patients with LSIL. Cytology and dual-stain results were correlated with histology at the time of treatment or with cytological follow-up. RESULTS After an average duration of 24.9 months (1-58) and a histology rate of 36.2% [cervical intraepithelial neoplasia, grade 2 or higher (CIN2+) as positive], the statistical evaluation for cytology and dual stain resulted in a sensitivity of 98.3 and 90.0%, respectively, a specificity of 74.5% for dual stain, a positive predictive value (PPV) of 22.8 and 51.4%, and a negative predictive value (NPV) of 96.1% for dual stain. CONCLUSION The combined immunocytochemical investigation of p16(INK4a) and Ki-67 leads to a significantly better PPV and a very good NPV for CIN2+ in LSIL, especially in women 30 years of age and older. An objective individualized prognosis may not be achieved with p16(INK4a)/Ki-67. Statistical data from our study, however, indicate that patient management can be significantly improved by the application of combined p16/Ki-67 immunocytochemistry as an adjunct to cytology.
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Affiliation(s)
- Peter Ziemke
- Institute of Pathology, Potsdam-Bornstedt, Germany
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Lazcano-Ponce E, Lőrincz AT, Torres L, Salmerón J, Cruz A, Rojas R, Hernández P, Hernández M. Specimen self-collection and HPV DNA screening in a pilot study of 100,242 women. Int J Cancer 2013; 135:109-16. [DOI: 10.1002/ijc.28639] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 10/07/2013] [Accepted: 11/11/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Eduardo Lazcano-Ponce
- Centro de Investigacion en Salud Poblacional; Instituto Nacional de Salud Pública de México. Cuernavaca Morelos; México
| | - Attila T. Lőrincz
- Centre for Cancer Prevention; Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine, Queen Mary University of London; London United Kingdom
| | - Leticia Torres
- Centro de Investigacion en Salud Poblacional; Instituto Nacional de Salud Pública de México. Cuernavaca Morelos; México
| | - Jorge Salmerón
- Centro de Investigacion en Salud Poblacional; Instituto Nacional de Salud Pública de México. Cuernavaca Morelos; México
- Unidad de Investigacion Epidemiologica y en Servicios de Salud; Instituto Mexicano del Seguro Social; Cuernavaca Morelos México
| | - Aurelio Cruz
- Centro de Investigacion en Salud Poblacional; Instituto Nacional de Salud Pública de México. Cuernavaca Morelos; México
| | - Rosalba Rojas
- Centro de Investigacion en Salud Poblacional; Instituto Nacional de Salud Pública de México. Cuernavaca Morelos; México
| | - Pilar Hernández
- Centro de Investigacion en Salud Poblacional; Instituto Nacional de Salud Pública de México. Cuernavaca Morelos; México
| | - Mauricio Hernández
- Centro de Investigacion en Salud Poblacional; Instituto Nacional de Salud Pública de México. Cuernavaca Morelos; México
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Abstract
Diagnosis, follow up, and treatment of anal intraepithelial neoplasia are complex and not standardized. This may be partly caused by poor communication of biopsy and cytology findings between pathologists and clinicians as a result of a disparate and confusing terminology used to classify these lesions. This article focuses on general aspects of epidemiology and on clarifying the current terminology of intraepithelial squamous neoplasia, its relationship with human papilloma virus infection, and the current methods that exist to diagnose and treat this condition.
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97
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Exploiting biospectroscopy as a novel screening tool for cervical cancer: towards a framework to validate its accuracy in a routine clinical setting. Bioanalysis 2013; 5:2697-711. [DOI: 10.4155/bio.13.233] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Biospectroscopy is an emerging field that harnesses the platform of physical sciences with computational analysis in order to shed novel insights on biological questions. An area where this approach seems to have potential is in screening or diagnostic clinical settings, where there is an urgent need for new approaches to objectively interrogate large numbers of samples in an objective fashion with acceptable levels of sensitivity and specificity. This review outlines the benefits of biospectroscopy in screening for precancer lesions of the cervix due to its ability to separate different grades of dysplasia. It evaluates the feasibility of introducing this technique into cervical screening programs on the basis of its ability to identify biomarkers of progression within derived spectra (‘biochemical‑cell fingerprints’).
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98
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Koo YJ, Hahn HS, Lee IH, Lim KT, Lee KH, Kim HS, Kim TJ, Chun YK, Kim HS, Hong SR. Dual immunostaining of cervical cytology specimens with atypical squamous cells for p16/Ki-67 does not exclude the existence of a high-grade squamous intraepithelial lesion. Virchows Arch 2013; 463:689-96. [PMID: 24081504 DOI: 10.1007/s00428-013-1483-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/03/2013] [Accepted: 09/17/2013] [Indexed: 11/24/2022]
Abstract
This study was conducted to evaluate the accuracy of p16/Ki-67 dual immunostaining compared to high-risk human papillomavirus (HR-HPV) DNA testing for cervical intraepithelial neoplasia (CIN) in women with atypical squamous cells, cytology not excluding high-grade squamous intraepithelial lesion (ASC-H). Data were collected from 73 patients diagnosed to have ASC-H on a Pap smear who were HPV genotyped and had histological examination of a cervical biopsy. The CINtecPLUS kit was used on residual liquid-based material, and the immunoreactivity of dual-stained cells was graded according to the number as follows: G1 (1-5 positive cells), G2 (6-10), G3 (11-20), and G4 (> 20). Accuracy was evaluated based on the histological examination of colposcopy-guided biopsy or cervical conization on follow-up. Of the 70 patients with available data, positive p16/Ki-67 was associated with histological severity as follows: 15% in negative histology, 67% in CIN 1, 90% in CIN 2, and 100% in CIN 3. The average grade of positive p16/Ki-67 staining also increased from 0.2 in histologically negative cases to 1.2 in CIN 1, 2.4 in CIN 2, and 2.9 in CIN 3 (p < 0.01). For patients with CIN 2 or higher, p16/Ki-67 had a sensitivity of 94.6% and a specificity of 75.8%, while HR-HPV testing showed a sensitivity of 67.6% and a specificity of 66.7%. p16/Ki-67 immunostaining demonstrated better accuracy than HR-HPV for detecting CIN 2 or higher in patients with ASC-H cytology. Given the higher concordance with histological diagnosis, the grading system of positive p16/Ki-67 can be a useful adjunct for predicting high-grade lesions in clinical practice.
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Affiliation(s)
- Yu-Jin Koo
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Kwandong University College of Medicine, Seoul, South Korea
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Human papillomavirus in high-grade cervical lesions: Austrian data of a European multicentre study. Wien Klin Wochenschr 2013; 125:591-9. [DOI: 10.1007/s00508-013-0403-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 07/07/2013] [Indexed: 10/26/2022]
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Nuño T, García F. The Lower Anogenital Squamous Terminology Project and its implications for clinical care. Obstet Gynecol Clin North Am 2013; 40:225-33. [PMID: 23732027 PMCID: PMC3741685 DOI: 10.1016/j.ogc.2013.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Based on a growing need for unified terminology to describe the pathologic and clinical spectrum of lesions, the American Society for Colposcopy and Cervical Pathology and the College of American Pathologists Pathology and Laboratory Quality Center convened the Lower Anogenital Squamous Terminology (LAST) Project to reassess and harmonize the terminology used to describe human papillomavirus-associated squamous lesions of the lower anogenital tract as manifested in a variety of end organs. The distinction between cancer precursors and those without malignant potential leads to consistency in the interpretation of management guidelines and the therapeutic options.
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Affiliation(s)
- Tomas Nuño
- The Clinical Outcomes and Comparative Effectiveness Research Fellowship Program, The Arizona Cancer Center, Center of Excellence in Women's Health, University of Arizona, Tucson, AZ 85724-5024, USA
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