The fate of cervical dysplasia

One-step detection and genotyping of human papillomavirus in cervical samples by reverse hybridization

This study describes a nonisotopic polymerase chain reaction-reverse hybridization-based method (PCR-RH) for the one-step detection and genotyping of anogenital human papillomavirus (HPV) in a microwell format. HPV DNA was amplified and labeled by PCR using GP5+/GP6+ primers. Labeled amplicons were hybridized to 20 HPV type-specific capture probes anchored to the surface of plastic microwells and detected by an immunoenzymatic assay. Assay sensitivity was <50 pg labeled amplicon, and no cross-reactivity was observed, as determined by hybridizing serial dilutions of labeled PCR products to either matched or mismatched capture probes. The assay was tested on 66 clinical samples (23 specimens with normal histology, I fibropapilloma, 26 cervical intraepithelial neoplasia grade 1 [CIN1], 9 CIN2, and 7 CIN3) and compared with a method based on restriction fragment length polymorphism (RFLP) of PCR products. PCR-RH and PCR-RFLP performed equally well on clinical samples. The overall HPV detection rate was similar: 65.1% (43/66) for PCR-RH and 57.6% (38/66) for PCR-RFLP. HPV DNA was found in all CIN2 and CIN3 samples by both methods; however, PCR-RH detected more positives among normal biopsy samples and CINI cases. Overall, there was good agreement between the two genotyping methods, but RH yielded fewer cases with undetermined HPV genotype.

Spontaneous evolution of intraepithelial lesions according to the grade and type of the implicated human papillomavirus (HPV)

Because of the fact that any meaningful classification should bear a close relationship to the biological behavior of the lesions, the usefulness of all new classifications of cervical precancer lesions can only be established by well controlled prospective follow-up studies. However, several methodological and conceptual problems are encountered in the natural history studies conducted during the past several decades. While reviewing the available prospective follow-up studies on cervical intraepithelial neoplasia (CIN), Ostör (1993) found 3529 cases of CIN 1, of which 57% showed regression, persistence was found in 32%, progression to CIN III in 11%, and progression to invasive cancer in 1% of cases. The corresponding figures for CIN II were 43%, 35%, 22%, and 5%, respectively. The recognition of the association between human papillomavirus (HPV) and CIN has further complicated the assessment of the natural history of cervical precancer lesions. Results from the early prospective follow-up studies are remarkably consistent, however. Progression from HPV-NCIN (i.e., koilocytosis without CIN) to CIN I or greater was reported for 18 (8%) of 232 women followed by Syrjänen et al. for an average of 25 months, for 26 (8%) of 314 women followed by de Brux et al. (1981) for 15 to 18 months, and for 113 (13%) of 846 women followed for up to six years by Mitchell et al. During a 42-month follow-up period, 10% progression rate was found in 1269 women with HPV-CIN I, and in 17% of 762 women with HPV-CIN II by de Brux et al. (1983). The spontaneous regression rates were 53% and 39% in these cohorts, respectively. This is fully consonant with our experience from an almost 14-year follow-up of 530 women in Kuopio, where the spontaneous regression rate seems to increase in parallel with the extent of the follow-up time, currently being 66.7% for HPV-NCIN and 55.7% for HPV-CIN I. The figures for progression are 6.3% and 14.2%, respectively. It is obvious that the probability of a cervical precancer lesion to progress into an invasive disease increases with the severity of the atypia. Another distinct prognostic factor is HPV type, HPV 16 lesions possessing a significantly higher risk for progression than infections by other HPV types. The follow-up data also indicate, however, that even the high grade lesions may spontaneously regress, which should have important implications in therapy. The continuous problem still remains; these natural history observations only apply to a large series of women but are of little help in predicting the disease outcome in individual women.

Decision analysis for best management of mildly dyskaryotic smear

Should a woman with a mildly dyskaryotic cervical smear be referred for colposcopy or should the smear be repeated? One way to answer this question is to use decision analysis and compare the expected mortality and cost of each policy. Data for each component of the question were obtained from published work worldwide and were supplemented with an audit of mildly dyskaryotic smears in West Yorkshire, UK. 2 out of 1000 women with an initial mildly dyskaryotic smear will develop cancer if a conservative repeat smear policy is adopted in association with five-yearly cervical screening. This number can be reduced to 1.6 per 1000 if cervical screening is offered every three years. A policy of immediate referral for colposcopy is also associated with a subsequent cancer rate of 1.6 per 1000. Therefore, repeating the smear is almost as effective as an immediate referral to a colposcopy unit. Even if a five-yearly cervical screening programme is adopted, 2500 women with a mildly dyskaryotic smear will need to be referred for immediate colposcopy to save 1 additional cancer. A conservative policy is not financially cheaper: an average of six additional smears is required to save each colposcopy referral. Sensitivity analysis shows that the excess cost of the conservative policy increases exponentially as the risk of a subsequent cytological abnormality exceeds 60%. Local cytopathology laboratories should audit their recurrent dyskaryosis rate associated with borderline, mild, and moderate dyskaryosis before accepting the U-turn in the national recommendations.

Progressive potential of mild cervical atypia: prospective cytological, colposcopic, and virological study

A prospective study of 100 women with cytological and colposcopic evidence of mild cervical atypia consistent with cervical intraepithelial neoplasia (CIN) grade I was started in October, 1983. 26% of early preinvasive cervical lesions progressed to histologically proven CIN III. Spontaneous regression of mild cervical atypia occurred in only 11 cases, and in 4 of these CIN recurred. The overall prevalence of human papillomavirus type 16 (HPV 16) in the study group, detected by filter DNA-DNA hybridisation of a cervical cytological specimen, was 39%. However, 22 of the 26 (85%) cases of progressive disease were positive for HPV 16. Detection of HPV 16 may be a non-invasive way of identifying women at high risk of rapid progression of mild cervical atypia to CIN III.

Intraepithelial neoplasia of the uterine cervix in the teenager

One hundred and seventeen teenagers with abnormal cervical cytology were evaluated using colposcopy and directed biopsies. Eighty-eight cases of cervical intraepithelial neoplasia were discovered including 24 cases of severe dysplasia or carcinoma in situ. Erradication of these lesions is essential as a preventative measure. The importance of routine cytologic screening and early evaluation of abnormal Papanicolaou smears in the teenager is emphasized.

Microinvasive carcinoma of the uterine cervix

There has been remarkable improvement in the early diagnosis of cervical carcinoma in recent years. There is, however, disagreement regarding the definition and treatment of microinvasive carcinoma of the uterine cervix. This review analyzes a large number of reports representing current opinion about the definition, diagnosis and appropriate management of early cervical carcinoma.

Abnormal cervical cytology in the teen-ager: a continuing problem

Abnormal cervical cytology is being discovered in an alarming number of sexually active teen-agers. Over an 18 month period, cytology consistent with mild dysplasia or worse was noted in 188 of 2,655 teen-agers screened. This represents a rate of 70.8 per thousand. Colposcopically directed biopsies in 65 patients revealed 15 cases of severe dysplasia-carcinoma in situ. Cryosurgery was the principle method of treatment and, combined with colposcopy, is a safe and effective means of managing these patients.

Dysplasia and carcinoma in situ of the uterine cervix: prevalence in very young women (under age 22). A one-year study in a health plan population

An increased number of cervical epithelial abnormalities has been observed in women up to and including 21 years of age. The prevalence and incidence of dysplasia in adolescents and young women is increasing at a time when the incidence of cervical carcinoma is decreasing. We studied 247 women under age 22 with "other than negative" cytologic diagnoses identified during a one-year period (1973) in which approximately 27,500 women in this age group were screened. The prevalence rates of "other than negative" cytology and "other than negative" cytology with confirmed histopathologic abnormalities were 9/1,000 and 2.7/1,000, respectively. Repeat smears and/or tissue speciments were obtained in over 70 per cent of these cases. The majority of abnormalities identified were mild or moderate dysplasia; however eight severe dysplasias and three carcinomas in situ were identified. Fifty-nine percent of these women had a history of one or more pregnancies. Our findings emphasize the presence of dysplasia and carcinoma in situ in young women and suggest the need for re-evaluation of the age at which initiation of the Papanicolaou smear should be considered.

Intraepithelial carcinoma of the cervix uteri in women aged under 35 years

The number of cases of intraepithelial carcinoma of the cervix among women of different age groups has been related to the number of cervical smears from women of the same age groups. Among women aged 25 to 34 years the incidence of intraepithelial carcinoma was 0.67% and among those aged 35 to 44 years it was 0.75%. The overall rate of intraepithelial carcinoma in women under 35 years was 0.55% compared with an overall rate of 0.59% in women over 35 years.If screening of women for cervical cancer is to play any part in preventive medicine it is suggested that the national campaign for the early detection of cervical cancer should be expanded to encourage practitioners to take cervical smears from younger women, particularly from those under 35 years.