The accuracy of colposcopically directed biopsy in diagnosis of CIN

Hysterectomy for Treatment of CIN

The objective of this investigation was to determine the percentage of microinvasive and invasive cancers found when CIN 3 was treated by hysterectomy. The postoperative histologic findings of all patients with CIN 3 treated by conization or hysterectomy were analyzed. In 295 patients treated by conization, 14 (4.75%) microinvasive and 11 (3.73%) invasive cancers were found. Histologic analysis of 106 hysterectomy specimens revealed microinvasive carcinoma in 11 (10.38%) and invasive carcinoma in 17 (16.04%) cases. The finding of unexpected invasive cervical cancer in hysterectomy specimens seems significantly higher compared with conization. One must be cautious to avoid hysterectomy as the primary mode of treatment for women with coincident uterine pathology, postmenopausal women, or those who do not desire further reproduction. Hysterectomy as a mode of treatment for CIN 3 should be performed only if the existence of invasive cancer was excluded with certainty.

Direct oral microscopy and its value in diagnosing mucosal lesions: a pilot study

OBJECTIVE

Clinical examination of the oral mucosa often leads to an uncertain diagnosis, and a supplementary biopsy with a histopathologic examination of the lesion is necessary to establish a definite diagnosis. However, the site for the biopsy is a subjective choice that sometimes raises doubts about its representativeness. So far, no simple and reliable method is available for selecting the most appropriate area for biopsy.

STUDY DESIGN

In a prospective study, we performed direct oral microscopy (oral application of the colposcopy technique used in gynecology) in 35 patients with various clinical diagnoses, such as leukoplakia, oral lichenoid lesions, or suspected malignancy. First, the oral mucosa was examined with direct microscopy, and the most representative site, according to colposcopic criteria, was selected. Then, the mucosa was clinically inspected by an independent examiner. The best site for biopsy according to clinical criteria was noted, and any difference in biopsy sites was recorded. Biopsy specimens were taken from 2 of these sites.

RESULTS

Twenty-nine patients (83%) showed changes in the vascular picture on microscopy, according to the colposcopy criteria. In 14 patients (40%), the biopsy sites identified by direct oral microscopy showed more advanced histologic signs than those selected by routine clinical examination (0.01 < P </=.05). Four patients (11%) had more advanced histologic signs in the biopsy samples, as identified during routine clinical examination. In 17 patients (49%), we found no differences between the biopsy specimens.

CONCLUSION

Direct oral microscopy of mucosal lesions seems to offer advantages in selecting more representative sites for biopsy than routine clinical examination alone.

Image analysis for discrimination of cervical neoplasia

Colposcopy involves visual imaging of the cervix for patients who have exhibited some prior indication of abnormality, and the major goals are to visually inspect for any malignancies and to guide biopsy sampling. Currently colposcopy equipment is being upgraded in many health care centers to incorporate digital image acquisition and archiving. These permanent images can be analyzed for characteristic features and color patterns which may enhance the specificity and objectivity of the routine exam. In this study a series of images from patients with biopsy confirmed cervical intraepithelia neoplasia stage 2/3 are compared with images from patients with biopsy confirmed immature squamous metaplasia, with the goal of determining optimal criteria for automated discrimination between them. All images were separated into their red, green, and blue channels, and comparisons were made between relative intensity, intensity variation, spatial frequencies, fractal dimension, and Euler number. This study indicates that computer-based processing of cervical images can provide some discrimination of the type of tissue features which are important for clinical evaluation, with the Euler number being the most clinically useful feature to discriminate metaplasia from neoplasia. Also there was a strong indication that morphology observed in the blue channel of the image provided more information about epithelial cell changes. Further research in this field can lead to advances in computer-aided diagnosis as well as the potential for online image enhancement in digital colposcopy.

Relation of human papillomavirus status to cervical lesions and consequences for cervical-cancer screening: a prospective study

BACKGROUND

A relation has been established between infection with high-risk types of human papillomavirus and development of cervical cancer. We investigated a role for testing for human papillomavirus as part of cervical-cancer screening.

METHODS

We monitored by cytology, colposcopy, and testing for high-risk human papillomavirus 353 women referred to gynaecologists with mild to moderate and severe dyskaryosis. The median follow-up time was 33 months. At the last visit we took biopsy samples. Our primary endpoint was clinical progression, defined as cervical intraepithelial neoplasia (CIN) 3, covering three or more cervical quadrants on colposcopy, or a cervical-smear result of suspected cervical cancer.

FINDINGS

33 women reached clinical progression. All had persistent infection with high-risk human papillomavirus. The cumulative 6-year incidence of clinical progression among these women was 40% (95% CI 21-59). In women with end histology CIN 3, 98 (95%) of 103 had persistent infection with high-risk human papillomavirus from baseline. Among women with mild to moderate dyskaryosis at baseline, a second test for human papillomavirus at 6 months predicted end histology CIN 3 better than a second cervical smear.

INTERPRETATION

Persistent infection with high-risk human papillomavirus is necessary for development and maintenance of CIN 3. All women with severe dyskaryosis should be referred to gynaecologists, whereas women with mild to moderate dyskaryosis should be referred only after a second positive test for high-risk human papillomavirus at 6 months.

Positive predictive rate of colposcopic examination of the cervix uteri: an overview of literature

Study of literature revealed that the positive predictive rate of the colposcopic impression is better as the cervical lesion is more severe. When directed biopsies are taken, the positive predictive rate of colposcopy increases considerably. For microinvasive disease, the positive predictive rate is quite poor, probably because of the absence of characteristic features. Large loop biopsies diagnosed all cases of microinvasive disease missed by directed biopsies, but this technique has the disadvantage of considerable "overtreatment" when integrated in the management of all patients with abnormal cytology. The restrictions of colposcopy are the invisibility of the squamocolumnar junction and observer variability in the assessment of the impression. The levels of agreement among experienced colposcopists are in the same range as those in cytological and histopathological diagnosis. It is concluded that colposcopy is an indispensable tool in the management of premalignant cervical disease, as long as the restrictions of the technique are kept in mind by the colposcopist.

The presence of persistent high-risk HPV genotypes in dysplastic cervical lesions is associated with progressive disease: natural history up to 36 months

To evaluate the clinical significance of HPV genotyping for the prediction of progressive cervical intraepithelial neoplasia (CIN) in women with cytomorphologically abnormal smears, a prospective, blind, non-intervention study was performed. A total of 342 patients screened with cytomorphologically abnormal cervical smears were monitored every 3-4 months by cervical cytology, colposcopy and HPV testing using PCR. Women with progressive CIN disease were defined as patients developing lesions with a colposcopic impression of CIN III over more than 2 quadrants or resulting in a cytological smear equivalent to Pap 5. These patients were subsequently treated according to standard procedures. If any doubt arose about the true status of the patients (n = 75) these patients were censored and biopsied. The mean follow-up time was 16.5 months (range 3-36 months). Nineteen women showed progressive CIN disease and all appeared to be continuously HPV-positive from the start of the study. At biopsy, all these patients were histologically classified as CIN III. Seventeen of these women were positive for high-risk HPV types. Two cases were classified as still unidentified HPV. No progression was seen in the absence of HPV DNA or in the presence of low-risk HPV types. In life-table analysis the cumulative rate of progressive, histologically verified CIN disease was 17% after 36 months. Further analyses showed that other risk factors such as age, sexarche, number of sexual partners or smoking hardly influenced the effect of HPV on progression. The results show that the continuous presence of high-risk HPV types in women with cytomorphologically abnormal smears is a strong marker for progressive CIN disease.

Conization for CIN associated with human papillomavirus infection

We report results of follow-up by PAP smears and colposcopy in 116 women treated since 1981 by conization for cervical intraepithelial neoplasia with human papillomavirus infection (HPV-CIN). The mean follow-up time was 31.9 (SD 19) months. Preoperative diagnosis was HPV-CIN II (with extension into the endocervix) in 11 cases and HPV-CIN III in 103 cases; two diagnostic conizations were performed. The histological examination of the cone biopsies showed complete excision of CIN in 109 cases (94%). Three patients underwent hysterectomy after conization; one had microinvasion in the cone biopsy, one had suspicion of microinvasion and one had non-radical conization. Three patients (2.6%) were lost to follow-up. After excluding these six patients the primary cure rate of HPV lesions (normal cytological and colposcopical finding after conization) was 82.7%. Four patients (4.6%) had residual CIN after conization. During the follow-up 15 patients had recurrence of HPV infection, only one had HPV-CIN I. HPV 16 was the most common HPV type (56/116, 48.2%) in the conization group and also in the recurrent cases (9/15, 60%). The results support the role of HPV 16 in cervical carcinogenesis.

Endocervical curettage by Vabra aspiration as part of colposcopic evaluation

Endocervical curettage as routine part of colposcopic examination in patients with abnormal cervical cytology is recommended by many experts. Endocervical curettage (ECC) by Vabra aspiration has never been reported in literature. The results of Vabra ECC in 103 patients are analyzed and compared to the results of a second endocervical specimen, obtained by conventional curettage, cone biopsy, or hysterectomy. An accordance of over 98% is demonstrated and the difference is discussed. In 88% and 71% adequate Vabra ECC specimens were available for cytological and histological examination, respectively. In any patient at least one result was present. Both cytological and histological specimens are of reliable quality. No cases of invasive (adeno)carcinoma were missed. In addition, the results are compared to literature data concerning Vabra aspiration for endometrial disease and ECC by other techniques. Vabra ECC is considered an efficient, safe, and well-tolerated diagnostic outpatient method and recommended as a standard part of colposcopic evaluation.