Kappa statistics to measure interrater and intrarater agreement for 1790 cervical biopsy specimens among twelve pathologists: Qualitative histopathologic analysis and methodologic issues

Melasma in people with darker skin types: a scoping review protocol on prevalence, treatment options for melasma and impact on quality of life

BACKGROUND

Melasma is one of the most encountered dermatoses in dermatology and skin care clinics. It is a challenging chronic, recurrent condition associated with hyperpigmentation. Its aetiology is poorly understood. Melasma affects all races and gender but is more prevalent in women with darker skin types. Being a facial lesion, melasma has a severe impact on quality of life due to its disfigurement. While many modalities of treatment for melasma exists, unfortunately, effectiveness and safety remain a huge concern. Treatment modalities are variable and often unsatisfactory. The objective of this scoping review is to systemically map available evidence from literature regarding melasma on people with darker skin types, garner insight as to how melasma affects the quality of life and begin to investigate and gain understanding on effectiveness of different treatments used for melasma.

METHODS

A scoping review guided by Arksey and O'Malley's framework, the enhancements and recommendations of Levac, Colquhoun and O'Brien, Daudt and associates and the 2015 Johanna Briggs Institute's guidelines will be conducted. Systematic electronic searches of databases and search engines will include Scopus, PubMed, CINAHL Complete, Cochrane, Science Direct, and Web of Science which will be conducted to attain published peer-reviewed articles of all study designs excluding reviews and grey literature. All literature that meets the inclusion criteria, research question and sub-question will be included in this review. All the retrieved literature will be exported to an Endnote X20 library. Quality appraisal of the included articles will be conducted using the mixed methods appraisal tool (MMAT) 2018 version.

DISCUSSION

We anticipate mapping relevant literature on the melasma, investigating the effectiveness of treatment options of melasma as well as evaluating its association with quality of life in people with darker skin types. This study is likely to reveal research gaps, which could guide future implementation research on melasma treatment interventions.

SYSTEMATIC REVIEW REGISTRATION

This protocol has been registered a priori with OSF and is accessible on this link: https://osf.io/ru3jc/ .

Polymorphisms in the Nonhomologous End-joining DNA Repair Pathway are Associated with HPV Integration in Cervical Dysplasia

Previous evidence indicates that human papillomavirus (HPV) integration status may be associated with cervical cancer development and progression. However, host genetic variation within genes that may play important roles in the viral integration process is understudied. The aim of this study was to examine the association between HPV16 and HPV18 viral integration status and SNPs in nonhomologous-end-joining (NHEJ) DNA repair pathway genes on cervical dysplasia. Women enrolled in two large trials of optical technologies for cervical cancer detection and positive for HPV16 or HPV18 were selected for HPV integration analysis and genotyping. Associations between SNPs and cytology (normal, low-grade, or high-grade lesions) were evaluated. Among women with cervical dysplasia, polytomous logistic regression models were used to evaluate the effect of each SNP on viral integration status. Of the 710 women evaluated [149 high-grade squamous intraepithelial lesion (HSIL), 251; low-grade squamous intraepithelial lesion (LSIL, 310 normal)], 395 (55.6%) were positive for HPV16 and 192 (27%) were positive for HPV18. Tag-SNPs in 13 DNA repair genes, including RAD50, WRN, and XRCC4, were significantly associated with cervical dysplasia. HPV16 integration status was differential across cervical cytology, but overall, most participants had a mix of both episomal and integrated HPV16. Four tag-SNPs in the XRCC4 gene were found to be significantly associated with HPV16 integration status. Our findings indicate that host genetic variation in NHEJ DNA repair pathway genes, specifically XRCC4, are significantly associated with HPV integration, and that these genes may play an important role in determining cervical cancer development and progression.

PREVENTION RELEVANCE

HPV integration in premalignant lesions and is thought to be an important driver of carcinogenesis. However, it is unclear what factors promote integration. The use of targeted genotyping among women presenting with cervical dysplasia has the potential to be an effective tool in assessing the likelihood of progression to cancer.

Deep Learning-Based Recognition of Cervical Squamous Interepithelial Lesions

Cervical squamous intraepithelial lesions (SILs) are precursor lesions of cervical cancer, and their accurate diagnosis enables patients to be treated before malignancy manifests. However, the identification of SILs is usually laborious and has low diagnostic consistency due to the high similarity of pathological SIL images. Although artificial intelligence (AI), especially deep learning algorithms, has drawn a lot of attention for its good performance in cervical cytology tasks, the use of AI for cervical histology is still in its early stages. The feature extraction, representation capabilities, and use of p16 immunohistochemistry (IHC) among existing models are inadequate. Therefore, in this study, we first designed a squamous epithelium segmentation algorithm and assigned the corresponding labels. Second, p16-positive area of IHC slides were extracted with Whole Image Net (WI-Net), followed by mapping the p16-positive area back to the H&E slides and generating a p16-positive mask for training. Finally, the p16-positive areas were inputted into Swin-B and ResNet-50 to classify the SILs. The dataset comprised 6171 patches from 111 patients; patches from 80% of the 90 patients were used for the training set. The accuracy of the Swin-B method for high-grade squamous intraepithelial lesion (HSIL) that we propose was 0.914 [0.889-0.928]. The ResNet-50 model for HSIL achieved an area under the receiver operating characteristic curve (AUC) of 0.935 [0.921-0.946] at the patch level, and the accuracy, sensitivity, and specificity were 0.845, 0.922, and 0.829, respectively. Therefore, our model can accurately identify HSIL, assisting the pathologist in solving actual diagnostic issues and even directing the follow-up treatment of patients.

Multi-echo in steady-state acquisition improves MRI image quality and lumbosacral radiculopathy diagnosis efficacy compared with T2 fast spin-echo sequence

PURPOSE

This study compares the performance of a 4-min multi-echo in steady-state acquisition (MENSA) with a 6-min fast spin echo with variable flip angle (CUBE) protocol for the assessment of lumbosacral plexus nerve root lesions.

METHODS

Seventy-two subjects underwent MENSA and CUBE sequences on a 3.0-T MRI scanner. Two musculoskeletal radiologists independently assessed the images for quality and diagnostic capability. A qualitative assessment scoring system for image quality and quantitative nerve signal-to-noise ratio (SNR) and iliac vein and muscle contrast-to-noise ratios (CNR) was applied. Using surgical reports as the reference, sensitivity, specificity, accuracy, and area under the receiver operating characteristic curves (AUC) were evaluated. Intraclass correlation coefficients (ICC) and weighted kappa were used to calculate reliability.

RESULTS

MENSA image quality rating (3.679 ± 0.47) was higher than for CUBE images (3.038 ± 0.68), and MENSA showed higher mean nerve root SNR (36.935 ± 8.33 vs. 27.777 ± 7.41), iliac vein CNR (24.678 ± 6.63 vs. 5.210 ± 3.93), and muscle CNR (19.414 ± 6.07 vs. 13.531 ± 0.65) than CUBE (P < 0.05). Weighted kappa and ICC values indicated good reliability. Sensitivity, specificity, and accuracy of diagnosis based on MENSA images were 96.23%, 89.47%, and 94.44%, respectively, and AUC was 0.929, compared with 92.45%, 84.21%, 90.28%, and 0.883 for CUBE images. The two correlated ROC curves were not significantly different. Weighted kappa values for intraobserver (0.758) and interobserver (0.768-0.818) reliability were substantial to perfect.

CONCLUSION

A time-efficient 4-min MENSA protocol exhibits superior image quality and high vascular contrast with the potential to produce high-resolution lumbosacral nerve root images.

Assessing Inter-Annotator Agreement for Medical Image Segmentation

Artificial Intelligence (AI)-based medical computer vision algorithm training and evaluations depend on annotations and labeling. However, variability between expert annotators introduces noise in training data that can adversely impact the performance of AI algorithms. This study aims to assess, illustrate and interpret the inter-annotator agreement among multiple expert annotators when segmenting the same lesion(s)/abnormalities on medical images. We propose the use of three metrics for the qualitative and quantitative assessment of inter-annotator agreement: 1) use of a common agreement heatmap and a ranking agreement heatmap; 2) use of the extended Cohen's kappa and Fleiss' kappa coefficients for a quantitative evaluation and interpretation of inter-annotator reliability; and 3) use of the Simultaneous Truth and Performance Level Estimation (STAPLE) algorithm, as a parallel step, to generate ground truth for training AI models and compute Intersection over Union (IoU), sensitivity, and specificity to assess the inter-annotator reliability and variability. Experiments are performed on two datasets, namely cervical colposcopy images from 30 patients and chest X-ray images from 336 tuberculosis (TB) patients, to demonstrate the consistency of inter-annotator reliability assessment and the importance of combining different metrics to avoid bias assessment.

IIB or not IIB, part 2: assessing inter-rater and intra-rater repeatability of the Kenney-Doig scale in equine endometrial biopsy evaluation

Inter- and intra-rater variability negatively affects the reliability of various histopathology grading scales used as prognostic aids in human and veterinary medicine. The Kenney-Doig categorization (grading) scale, which is used to associate equine endometrial histologic lesions with prognostic estimation of a broodmare's reproductive potential, has not been evaluated for inter- or intra-rater variability, to our knowledge. To assess whether the Kenney-Doig system produces reliable results among observers, 8 pathologists, all with American College of Veterinary Pathologists certification, were recruited to blindly categorize the same set of 63 digital equine endometrial biopsy slides as well as to re-evaluate anonymously 21 of 63 of these slides at a later time. Cohen kappa values for pairwise comparison of final Kenney-Doig categories were -0.05 to 0.46 (unweighted) and 0.08-0.64 (weighted), with an average Light kappa of 0.19 (unweighted) and 0.36 (weighted) across all 8 pathologists, 0.14 (unweighted) and 0.33 (weighted) for pathologists at different institutions, and 0.22 (unweighted) and 0.46 (weighted) for pathologists at the same institution. Intra-class correlations measuring intra-rater agreement were 0.12-0.77 with an average of 0.55 for all 8 pathologists. We found that only slight-to-moderate inter-rater agreement and poor-to-good intra-rater agreement was produced by 8 pathologists using the Kenney-Doig scale, suggesting that the system is subject to significant observer variability and care should be taken when communicating Kenney-Doig categories to submitting clinicians with emphasis on the quality of endometrial lesions present instead of the category and associated expected foaling rate.

HPV-mediated Cervical Cancer: A Systematic review on Immunological Basis, Molecular Biology and Immune evasion mechanisms

BACKGROUND

Human papillomavirus (HPV), one of the most frequently transmitted viruses globally, causing several malignancies including cervical cancer.

AIM

Owing to their unique pathogenicity HPV viruses can persist in the host organism for a longer duration than other virus types, to complete their lifecycle. During its association with the host, HPV causes various pathological conditions affecting the immune system by evading the host immune- mechanisms leading to the progression of various diseases, including cancer.

METHOD

To date, ~ 150 serotypes were identified, and certain high-risk HPV types are known to be associated with genital warts and cervical cancer. As of now, two prophylactic vaccines are in use for the treatment of HPV infection, however, no effective antiviral drug is available for HPV-associated disease/infections. Numerous clinical and laboratory studies are being investigated to formulate an effective and specific vaccine again HPV infections and associated diseases.

RESULT

As the immunological basis of HPV infection and associated disease progress persist indistinctly, deeper insights on immune evasion mechanism and molecular biology of disease would aid in developing an effective vaccine.

CONCLUSION

Thus this review focuses, aiming a systematic review on the immunological aspects of HPV-associated cervical cancer by uncovering immune evasion strategies adapted by HPV.

Rethinking Cervical Cancer Screening in Brazil Post COVID-19: A Global Opportunity to Adopt Higher Impact Strategies

The World Health Organization global call to eliminate cervical cancer encourages countries to consider introducing or improving cervical cancer screening programs. Brazil's Unified Health System (SUS) is among the world's largest public health systems offering free cytology testing, follow-up colposcopy, and treatment. Yet, health care networks across the country have unequal infrastructure, human resources, equipment, and supplies resulting in uneven program performance and large disparities in cervical cancer incidence and mortality. An effective screening program needs multiple strategies feasible for each community's reality, facilitating coverage and follow-up adherence. Prioritizing those at highest risk with tests that better stratify risk will limit inefficiencies, improving program impact across different resource settings. Highly sensitive human papillomavirus (HPV)-DNA testing performs better than cytology and, with self-collection closer to homes and workplaces, improves access, even in remote regions. Molecular triage strategies like HPV genotyping can identify from the same self-collected sample, those at highest risk requiring follow-up. If proven acceptable, affordable, cost-effective, and efficient in the Brazilian context, these strategies would increase coverage while removing the need for speculum exams for routine screening and reducing follow-up visits. SUS could implement a nationwide organized program that accommodates heterogenous settings across Brazil, informing a variety of screening programs worldwide.

Upconverting phosphor technology-based lateral flow assay for the rapid and sensitive detection of anti-Trichinella spiralis IgG antibodies in pig serum

Background

Trichinella spiralis is a zoonotic food-borne parasite. A disease caused by infection with T. spiralis is called trichinellosis in humans. It is important to investigate the epidemic situation and the surveillance of herds and then prevent infection in humans. Therefore, this study is to develop a rapid and sensitive diagnostic method for on-site test in domestic and wild animals.

Methods

Upconverting phosphor nanoparticles (UCNPs), an excellent optical label, were conjugated with the excretory-secretory (ES) antigens from T. spiralis muscle larvae (ML) or goat anti-rabbit IgG, and a lateral flow (LF) assay based on these probes (UCNPs-ES/goat anti-rabbit IgG) was developed for the rapid and sensitive detection of anti-T. spiralis IgG antibodies in pig serum. The assay is named the UPT-LF-ES assay. In addition, the probes were characterized, and the assay was optimized. A cut-off threshold of the assay was also identified by using 169 known negative pig samples. Performance of the assay to T. spiralis with different infective numbers, cross-reactivity with other parasitic infections, the single-blinded experiment, and coincidence were evaluated with the assay.

Results

The UPT-LF-ES assay was successfully constructed and optimized based on the probes of UCNPs-ES/goat anti-rabbit IgG. In the pigs infected with 100, 1000, and 10,000 ML, positive results were first presented at 35 days post-infection (dpi), 30 dpi, and 25 dpi, respectively. The assay had no cross-reaction with other parasitic infections. A single-blinded experiment indicated that the sensitivity and specificity of the UPT-LF-ES assay were 100% and 100%, respectively, the area under the receiver operating characteristic (ROC) curve was 1.000. In addition, the value detected by the UPT-LF-ES assay was significantly different between positive and negative samples. Moreover, compared with the “gold standard” magnetic stirrer method, the coincidence rate of the UPT-LF-ES assay was 87.27%, and the kappa (K) coefficient was 0.7454, showing a substantial agreement.

Conclusions

The UPT-LF-ES assay is a useful point-of-care test (POCT) with T. spiralis in the detection of pig, which contributes to preventing human trichinellosis.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04949-2.

The CERTAIN Study Results: Adjunctive p16 Immunohistochemistry Use in Cervical Biopsies According to LAST Criteria

The Lower Anogenital Squamous Terminology (LAST) Project recommends the use of p16 immunohistochemistry as an adjunct to morphologic assessment of cervical biopsies according to a specific set of criteria. We analyzed the effect of adjunctive p16 according to LAST criteria in a US-based diagnostic utility study involving 70 surgical pathologists providing a total of 38,500 reads on cervical biopsies. Compared with the results obtained using hematoxylin and eosin-stained slides only, including p16-stained slides per LAST criteria increased sensitivity and specificity for diagnosing histologic high-grade squamous intraepithelial lesions across all cases by 8.1% (95% confidence interval [95% CI], 6.5-9.7; P<0.0001) and 3.5% (95% CI, 2.8-4.2; P<0.0001), respectively, using expert consensus diagnoses on hematoxylin and eosin+p16 as reference. Within the subset of cases classified by the pathologists as fulfilling the LAST criteria, adding p16 significantly increased both sensitivity (+11.8%; 95% CI, 9.5-14.0; P<0.0001) and specificity (+9.7%; 95% CI, 7.8-11.5; P<0.0001). However, a comparable improvement in sensitivity (+11.0%; 95% CI, 7.8-14.1; P<0.0001) was found when p16 was used in cases for which p16 staining was not ordered per LAST by the pathologists, whereas specificity decreased by -0.8% (95% CI, -1.1 to -0.5; P<0.0001). The study demonstrates a clinically and statistically significant increase in sensitivity and specificity for high-grade squamous intraepithelial lesion when p16 is used according to LAST criteria. Expanding the use of p16 into non-LAST cases would lead to a comparable improvement in sensitivity within this subgroup of biopsies, at the cost of a minimal, but statistically significant difference in specificity.

The validity of the 'General Practice Physical Activity Questionnaire' against accelerometery in patients with chronic kidney disease

Background: The majority of patients with chronic kidney disease (CKD) are physically inactive. Simple yet accurate assessment of physical activity is important in identifying those in need of intervention. The 'General Practice Physical Activity Questionnaire' (GPPAQ) is a well-used clinical and research tool, but has not been validated.Methods: Forty individuals with CKD (age 62.5 (SD: 11.1) years, estimated glomerular filtration rate (eGFR) 33.2 (SD:19.1) ml/min/1.73 m²) completed the GPPAQ and objective physical activity was measured using a GENEActiv accelerometer for 7 days. Physical activity status was grouped as 'Active' (i.e. meeting current physical activity UK guidelines) or 'Inactive.' Sensitivity and specificity were calculated. Accuracy was defined as the probability the GPPAQ could correctly classify a patient as either 'Active' or 'Inactive' (based on accelerometery).Results: Using accelerometery, 18% of participants met the current UK guidelines, whereas 27% were classed as 'Active' according to GPPAQ. Sensitivity of the GPPAQ was 54.6% and specificity was 96.6%. The 'accuracy' of the GPPAQ was 85.0%. The accuracy of the GPPAQ was greater in males and those not in employment/retired, although these differences were not statistically significant.Conclusions: The GPPAQ may be a useful tool to identify CKD patients who would benefit most from a physical activity intervention. In particular, the GPPAQ can accurately identify those not sufficiently active.

Inter-rater reliability of the assessment of learning powered mobility use, version 2.0, when applied with children and adults engaged in Driving to Learn in a powered wheelchair

INTRODUCTION

The Assessment of Learning Powered mobility use (ALP) tool including the ALP instrument and facilitating strategies, was developed for Driving to Learn. This therapeutic intervention aims to provide children and adults who have profound cognitive disabilities with opportunities to learn tool use through powered mobility practise. To allow for longer intervention periods, a partnership was developed between professionals supervising Driving to Learn and persons accompanying children or adults to their practice sessions. Accompanying persons (relatives or assistants) gradually took on shared responsibility for applying the intervention and conducting assessments with the ALP-instrument. The aim of this study was to test the inter-rater reliability of the ALP-instrument version 2.0 as applied in this novel partnership in assessment and intervention.

METHOD

A psychometric analysis compared pair-wise assessments with the ALP-instrument version 2.0, made independently by professional supervisors and accompanying persons following each Driving to Learn session. Weighted kappa statistic was used to compare the matched pair ordinal data.

RESULTS

Eight professional supervisors and 22 accompanying persons independently completed assessments with the ALP-instrument after 55 sessions with six children and five adults, who each participated in five Driving to Learn sessions. When the scores from the 55 pairs of assessments were compared, a weighted kappa value of 0.85 was obtained, indicating very good inter-rater reliability between the two rater groups.

CONCLUSION

The resulting inter-rater reliability suggests that it is reliable to implement the ALP-instrument as part of partnership in intervention between supervisors and accompanying persons. Provision of longer periods of Driving to Learn is possible when those who accompany the child or adult are able to gradually assume responsibility for practice and assessment under the supervision of a professional. This partnership approach enables children and adults with multiple and complex disabilities to practise and learn in accordance with their conditions and needs.

Potential influence of p16 immunohistochemical staining on the diagnosis of squamous cell lesions in cervical biopsy specimens: observation from cytologic-histologic correlation

BACKGROUND

The p16 immunohistochemical (IHC) marker has been used increasingly as an adjunct to morphologic assessment of cervical biopsies in which the differential diagnoses include high-grade squamous intraepithelial lesion (HSIL) and its mimics. The objective of this study was to assess the potential influence of p16 IHC staining on the evaluation of cervical biopsy as observed through cytologic-histologic correlation (CHC).

METHODS

Cervical biopsy samples that had cytologic diagnoses of either low-grade squamous intraepithelial lesion (LSIL) or HSIL and also had histologic follow-up were retrieved from the department database. CHC and the use of p16 IHC from 2 periods (group 1, 2008; group 2, 2014-2016) were compared and analyzed.

RESULTS

Histology on 452 samples from patients who had prior LSIL cytology in group 1 yielded 126 benign (27.9%), 272 LSIL (60.2%), and 54 HSIL (11.9%) diagnoses. By comparison, 491 samples from the patients in group 2 yielded 106 benign (21.6%), 277 LSIL (56.4%), and 108 HSIL (22.0%) diagnoses. The difference in CHC discrepancies between the 2 groups was significant (P = .0001), mainly because of the increased diagnosis of HSIL in group 2. Although p16 IHC was not applied to any sample from group 1, it was performed on 141 of 491 samples (28.7%) from group 2. Further follow-up of patients who had histologic HSIL revealed that residual HSIL was identified significantly more often in those who did not have p16 IHC applied in the preceding cervical biopsy than in those did (P = .0004). A similar comparison was performed between 113 patients from group 1 and 152 patients from group 2 who had a prior diagnosis of HSIL cytology, and the difference was statistically insignificant.

CONCLUSIONS

The use of p16 IHC on cervical biopsies in patients who had a prior cytologic diagnosis of LSIL may lead to greater detection and upgrading of HSIL, thereby compounding the discrepancy in CHC.

Cytologic-Histologic Discrepancies in Pathology of the Uterine Cervix: Analysis of the Clinical and Pathologic Factors

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.

Proposed Terminology for Anal Squamous Lesions: Its Application and Interobserver Agreement Among Pathologists in Academic and Community Hospitals

OBJECTIVES

To analyze interobserver reproducibility and compare practice patterns between academic and community settings of Lower Anogenital Squamous Terminology (LAST).

METHODS

In total, 132 anal biopsy slides were revised as well as p16 immunostains.

RESULTS

LAST was used in 49% of cases (academic center, 68%; satellite hospitals [community practice setting], 32%). After pathology review and consensus interpretation, 23 (17%) case diagnoses were reclassified: eight (34.8%) cases (benign or low-grade squamous intraepithelial lesion [LSIL]) were upgraded to high-grade squamous intraepithelial lesion (HSIL) (p16 confirmed ordered during review); four (17.4%) cases originally classified as HSIL were downgraded to LSIL (p16 originally ordered in one case). There was no significant difference in discrepancies between original and consensus diagnosis in the community vs academic setting or by subspecialty (gynecological vs gastrointestinal). Overall interobserver agreement among reviewers was substantial (κ = 0.63) and improved with the use of p16 immunostain in challenging cases (κ = 0.71; P < .001).

CONCLUSIONS

This new terminology is not yet uniformly used by pathologists in anal/perianal biopsy specimens; this two-tier system has a good interobserver agreement and is further improved with p16 use in appropriate cases.

Detection of cervical intraepithelial neoplasia by using optical coherence tomography in combination with microscopy

Optical coherence tomography (OCT) is a noninvasive high-resolution imaging technique that permits the detection of cancerous and precancerous lesions of the uterine cervix. The purpose of this study was to evaluate a new system that integrates an OCT device into a microscope. OCT images were taken from loop electrosurgical excision procedure (LEEP) specimens under microscopic guidance. The images were blinded with respect to their origin within the microscopic image and analyzed independently by two investigators using initially defined criteria and later compared to the corresponding histology. Sensitivity and specificity were calculated with respect to the correct identification of high-grade squamous intraepithelial lesions (HSIL). The interinvestigator agreement was assessed by using Cohen’s kappa statistics. About 160 OCT images were obtained from 20 LEEP specimens. Sixty randomly chosen images were used to define reproducible criteria for evaluation. The assessment of the remaining 100 images showed a sensitivity of 88% (second investigator 84%) and a specificity of 69% (65%) in detecting HSIL. Surgical microscopy-guided OCT appears to be a promising technique for immediate assessment of microanatomical changes. In the gynecological setting, the combination of OCT with a colposcope may improve the detection of high-grade squamous intraepithelial lesions.

Predictive Value of Cytokeratin 7 Immunohistochemistry in Cervical Low-grade Squamous Intraepithelial Lesion as a Marker for Risk of Progression to a High-grade Lesion

The squamocolumnar junction (SCJ) cell population of the uterine cervix is a discrete epithelial area and the putative source of the majority of high-grade squamous intraepithelial lesions (HSIL). The SCJ cells can be identified by immunohistochemical (IHC) stains including cytokeratin 7 (CK7). Others have theorized that an SCJ marker-positive low-grade squamous intraepithelial lesion (LSIL) has a higher risk for future HSIL compared with an SCJ marker-negative LSIL. This study has 2 aims: first, to refine the definition of a positive CK7 immunostaining pattern in cervical lesions, and, second, to test the hypothesis that CK7 positivity in LSIL indicates higher risk for future HSIL, with both questions addressed using a data set with consensus diagnoses. One hundred cases each of LSIL, moderate HSIL (CIN2), and severe HSIL (CIN3) were stained for CK7, with positivity defined as a diffuse cytoplasmic staining pattern (>5 to 6 contiguous cells); all others were considered negative. Using this model, 34% of CIN1, 45% of CIN2, and 60% of CIN3 were CK7 positive. With follow-up, CK7-positive LSILs were more likely to progress to HSIL compared with CK7-negative LSIL (32% vs. 11%, P=0.05), in concordance with the results of other researchers. This study simplifies cervical CK7 IHC grading into a reproducible system and supports the thesis that CK7 positivity in LSIL is associated with increased risk for future HSIL. Larger cohorts using consensus-diagnosed LSIL are needed to confirm these results before CK7 may be considered for clinical validation.

High reproducibility of histological diagnosis of human papillomavirus-related intraepithelial lesions of the anal canal

In a natural history study of anal human papillomavirus (HPV) infection and HPV-related lesions, we examined the reproducibility of histological high-grade squamous intraepithelial lesion (HSIL). Three expert anogenital pathologists share the reporting of histological specimens from the Study of the Prevention of Anal Cancer (SPANC), utilising Lower Anogenital Squamous Terminology (LAST) criteria. In total, 194 previously reported biopsies were randomly chosen within diagnostic strata [50 HSIL-anal intraepithelial neoplasia (AIN) 3; 45 HSIL-AIN 2; 49 'flat' low-grade squamous intraepithelial lesion (LSIL); 50 'exophytic' LSIL; and 50 negative for squamous intraepithelial lesion] and reviewed by each of these three pathologists. Consensus was defined as agreement between at least two review diagnoses, using a binary classification of HSIL and non-HSIL, or if consensus was not obtained in this way, it was achieved through a multiheader microscope session by the three pathologists. We found very high agreement between original and consensus diagnoses (Kappa = 0.886) and between each pathologist's review and consensus (Kappas = 0.926, 0.917 and 0.905). Intra-observer agreement for the three pathologists was 0.705, 1.000 and 0.854. This high level of diagnostic reproducibility indicates that the findings of SPANC should be robust and provide reliable information about HPV-related anal canal disease.

Reliability of diagnosis from Mohs slides: interpersonal and intrapersonal agreement on basal cell carcinoma presence and histological subtype

BACKGROUND

The success of Mohs micrographic surgery (MMS) depends partly on the correct diagnosis of slides.

OBJECTIVES

To determine reliability of diagnosis from Mohs slides.

METHODS

This was a prospective study evaluating the reliability of diagnosis from Mohs slides of basal cell carcinoma (BCC) presence, BCC location on the slide and BCC subtype among six raters who independently assessed 50 Mohs slides twice with a 2-month interval. Slides were randomly selected whereby difficult-to-diagnose slides were oversampled. For each slide, a reference diagnosis was established by an expert panel. Cohen's kappa (κ) was calculated to determine levels of agreement interpersonally (rater vs. reference diagnosis) and intrapersonally (rater at T1 vs. T2). Multivariable logistic regression was used to determine independent risk factors for slides with interpersonal discordant diagnosis. The variables studied were BCC presence, whether a slide was scored as easy or difficult to diagnose, review duration of the 50 slides, profession and years of experience in diagnosis from Mohs slides.

RESULTS

Interpersonal and intrapersonal agreement were substantial on BCC presence (κ = 0·66 and 0·68) and moderate on BCC subtype (κ = 0·45 and 0·55). Slides that were scored as difficult to diagnose were an independent risk factor for interpersonal discordant diagnosis on BCC presence (odds ratio 3·54, 95% confidence interval 1·81-6·84).

CONCLUSIONS

Reliability of diagnosis from Mohs slides was substantial on BCC presence and moderate on BCC subtype. For slides that are scored difficult to diagnose, a second opinion is recommended to prevent misinterpretation and thereby recurrence of skin cancer.

Preliminary study of optical coherence tomography imaging to identify microscopic extrathyroidal extension in patients with papillary thyroid carcinoma

BACKGROUND AND OBJECTIVES

We evaluated the feasibility of using optical coherence tomography (OCT), to identify microscopic extrathyroidal extension (mETE) in ex vivo thyroidectomy specimens of patients who underwent thyroidectomy for the treatment of papillary thyroid carcinoma (PTC).

METHODS

A total of 170 ex vivo OCT images of the tumor, were acquired just after completion of thyroidectomy in 17 patients. The OCT images of each patient were separately evaluated by two blinded investigators, and the outcomes were compared with the histopathology reports.

RESULTS

The sensitivity and specificity of mETE identification from the OCT images were 81.4% and 86.0%, respectively, for the first investigator, and 82.9% and 87.0%, respectively, for the second investigator. Substantial agreement between the investigators was verified by Cohen's κ (Cohen's κ = 0.772).

CONCLUSION

In this preliminary study of a limited series of ex vivo thyroidectomy specimens, we verified the feasibility of OCT as a method of identifying mETE in patients with PTC.

[Optical coherence tomography for differentiation of parathyroid gland tissue]

BACKGROUND

Optical coherence tomography (OCT) is a high-resolution imaging technique that allows the identification of microarchitectural features in real-time.

OBJECTIVE

Can OCT be used to differentiate parathyroid tissue from other cervical tissue entities?

MATERIAL AND METHODS

All investigations were carried out during cervical operations. Initially, ex vivo images were analyzed to define morphological imaging criteria for each tissue entity. These criteria were used to evaluate a first series of ex vivo images. In a second phase the practicability of the technique was investigated in vivo and in the third phase backscattering intensity measurements were analyzed employing linear discriminant analysis (LDA).

RESULTS

In the ex vivo series parathyroid tissue could be differentiated from other tissue entities with a sensitivity and specificity of 84  % and 94  %, respectively. Parathyroid tissue was correctly identified in the in vivo series in only 69.2 %. The analysis of backscattering intensity profiles employing LDA reliably distinguished between the different tissue types.

CONCLUSION

The OCT images displayed typical characteristics for each tissue entity. Due to technical problems in handling the probe the in vivo OCT images were of much poorer quality. Backscattering intensity measurements illustrated that OCT images provide an individual profile for each tissue entity independent of the defined morphological assessment criteria. The results show that OCT is fundamentally suitable for intraoperative differentiation of tissues.

A prospective randomized study on limits of colposcopy and histology: the skill of colposcopist and colposcopy-guided biopsy in diagnosis of cervical intraepithelial lesions

BACKGROUND

The main objective of our study was to evaluate the colposcopist ability to correctly identify the worst area of a cervical lesion where biopsy should be performed; the secondary objective was to investigate the influence of the colposcopist skill in grading cervical preneoplastic lesions.

METHODS

296 patients referred for colposcopy were enrolled in a prospective study. All patients were randomized in two groups: in the first group, "senior group", the colposcopy was performed by an experienced colposcopist; in the second group, "junior group", the colposcopy was performed by a less experienced colposcopist. A detailed colposcopic description, including a grading of the lesion, was completed for each case. During the colposcopic exam patients underwent two direct biopsies; each biopsy was labeled with letter A (suspicious area with most severe grade) or B (suspicious area with less severe grade) according to the judgment of the colposcopist. An experienced pathologist reanalyzed the histological slides, after routine diagnosis.

RESULTS

The senior group identify the worst area of the cervical lesion in statistical significant higher rates than junior group. Specimen A resulted representative of the higher-grade lesion (A > B) in 73.7 % (N = 28) in senior group and in 48.4 % (N = 15) in junior group; while in 26.3 % (N = 10) the higher-grade lesion corresponded to specimen B (A < B) in senior group and in 51.6 % (N = 16) in junior group (p < .05).

CONCLUSION

The ability of a colposcopist in grading cervical lesion depends on his experience.

Prediction using hierarchical data: Applications for automated detection of cervical cancer

Although the Papanicolaou smear has been successful in decreasing cervical cancer incidence in the developed world, there exist many challenges for implementation in the developing world. Quantitative cytology, a semi-automated method that quantifies cellular image features, is a promising screening test candidate. The nested structure of its data (measurements of multiple cells within a patient) provides challenges to the usual classification problem. Here we perform a comparative study of three main approaches for problems with this general data structure: a) extract patient-level features from the cell-level data; b) use a statistical model that accounts for the hierarchical data structure; and c) classify at the cellular level and use an ad hoc approach to classify at the patient level. We apply these methods to a dataset of 1,728 patients, with an average of 2,600 cells collected per patient and 133 features measured per cell, predicting whether a patient had a positive biopsy result. The best approach we found was to classify at the cellular level and count the number of cells that had a posterior probability greater than a threshold value, with estimated 61% sensitivity and 89% specificity on independent data. Recent statistical learning developments allowed us to achieve high accuracy.

Intraoperative optical coherence tomography imaging to identify parathyroid glands

OBJECTIVE

Optical coherence tomography (OCT) is a non-invasive high-resolution imaging technique that permits characterization of microarchitectural features in real time. Previous ex vivo studies have shown that the technique is capable of distinguishing between parathyroid tissue, thyroid tissue, lymph nodes, and adipose tissue. The purpose of this study was to evaluate the practicality of OCT during open and minimally invasive parathyroid and thyroid surgery.

METHODS

During parathyroid and thyroid surgery, OCT images were generated from parathyroid glands, thyroid tissue, lymph nodes, and adipose tissue. The images were immediately assessed by the operating team using the previously defined criteria. Second, the OCT images were blinded with respect to their origin and analyzed by two investigators. Whenever possible the OCT findings were matched to the corresponding histology.

RESULTS

A total of 227 OCT images from 27 patients undergoing open or minimally invasive thyroid or parathyroid surgery were analyzed. Parathyroid glands were correctly identified in 69.2%, thyroid tissue in 74.5%, lymph nodes in 37.5%, and adipose tissue in 69.2%. 43 OCT images (18.9%) could not be allocated to one of the tissue types (Table 2). Sensitivity and specificity in distinguishing parathyroid tissue from the other entities were 69% (63 true positive, 13 false negative findings, 15 images where an allocation was not possible) and 66%, respectively (71 true negative, 9 false positive, 28 images where an assessment was not possible).

CONCLUSION

OCT is capable of distinguishing between parathyroid, thyroid, and adipose tissue. An accurate differentiation between parathyroid tissue and lymph nodes was not possible. The disappointing results compared to the previous ex vivo study are related to problems handling the endoscopic probe intraoperatively. However, further refinement of this new technology may lead to OCT systems with higher resolution and intraoperative probes that are easier to handle.

Evaluation of HPV infection and smoking status impacts on cell proliferation in epithelial layers of cervical neoplasia

Accurate cervical intra-epithelial neoplasia (CIN) lesion grading is needed for effective patient management. We applied computer-assisted scanning and analytic approaches to immuno-stained CIN lesion sections to more accurately delineate disease states and decipher cell proliferation impacts from HPV and smoking within individual epithelial layers. A patient cohort undergoing cervical screening was identified (n = 196) and biopsies of varying disease grades and with intact basement membranes and epithelial layers were obtained (n = 261). Specimens were sectioned, stained (Mib1), and scanned using a high-resolution imaging system. We achieved semi-automated delineation of proliferation status and epithelial cell layers using Otsu segmentation, manual image review, Voronoi tessellation, and immuno-staining. Data were interrogated against known status for HPV infection, smoking, and disease grade. We observed increased cell proliferation and decreased epithelial thickness with increased disease grade (when analyzing the epithelium at full thickness). Analysis within individual cell layers showed a ≥50% increase in cell proliferation for CIN2 vs. CIN1 lesions in higher epithelial layers (with minimal differences seen in basal/parabasal layers). Higher rates of proliferation for HPV-positive vs. -negative cases were seen in epithelial layers beyond the basal/parabasal layers in normal and CIN1 tissues. Comparing smokers vs. non-smokers, we observed increased cell proliferation in parabasal (low and high grade lesions) and basal layers (high grade only). In sum, we report CIN grade-specific differences in cell proliferation within individual epithelial layers. We also show HPV and smoking impacts on cell layer-specific proliferation. Our findings yield insight into CIN progression biology and demonstrate that rigorous, semi-automated imaging of histopathological specimens may be applied to improve disease grading accuracy.

Impact of p16(INK4a) immunohistochemistry staining on interobserver agreement on the diagnosis of cervical intraepithelial neoplasia

OBJECTIVES

This study aimed to compare the interobserver Cohen κ on H&E staining and on H&E plus p16(INK4a) staining of all cervical biopsy specimens in a population-based screening program.

METHODS

All the colposcopy-guided biopsies generated by the routine screening of 23,258 women aged 25 to 64 years were stained with H&E and H&E plus p16. Biopsy specimens were reviewed by six external experts.

RESULTS

The four diagnoses were available in 441 cases. The interobserver κ values were 0.52 (95% confidence interval [CI], 0.45-0.58) and 0.48 (95% CI, 0.42-0.56) with H&E and H&E + p16, respectively, when using a five-group classification (normal, CIN 1, CIN 2, CIN 3, and cancer); adopting a two-group classification (≤CIN 1 and ≥CIN 2), the values were 0.75 (95% CI, 0.66-0.82) and 0.70 (95% CI, 0.61-0.79), respectively.

CONCLUSIONS

The use of p16 on all cervical biopsy specimens in a screening program showed virtually no effect on reproducibility of the histologic diagnosis.

Optical coherence tomography as a method to identify parathyroid glands

BACKGROUND AND OBJECTIVE

The identification of parathyroid glands can be a major problem in parathyroid surgery. The purpose of this study was to evaluate the feasibility of optical coherence tomography (OCT) in distinguishing between parathyroid tissue, thyroid tissue, lymph nodes, and adipose tissue.

METHODS

Ex vivo OCT images as well as histological sections were generated from parathyroid glands, thyroid tissue, lymph nodes and fat in order to define significant morphologic differences between these entities. As a second step all OCT images were separately evaluated by two blinded investigators and later compared to the corresponding histology. Sensitivity and specificity of OCT in distinguishing between the different tissues were determined. To assess the interobserver agreement, κ coefficients were calculated from the ratings of each investigator for each OCT image seen.

RESULTS

A total of 320 OCT images from 32 patients undergoing thyroid surgery, parathyroidectomy or lymphadenectomy were compared with the corresponding histology. The sensitivity and specificity in distinguishing parathyroid tissue from the other entities was 84% (second investigator: 82%) and 94% (93%) respectively. Unweighted κ using four diagnostic categories was 0.97 (95% CI, 0.94-0.99) showing substantial agreement between both investigators.

CONCLUSION

OCT is highly sensitive in distinguishing between parathyroid tissue, thyroid tissue, lymph nodes and adipose tissue. These ex vivo results should be confirmed by using OCT imaging intraoperatively.

A comparison of cervical histopathology variability using whole slide digitized images versus glass slides: experience with a statewide registry

Whole slide imaging is increasingly used for primary and consultative diagnoses, teaching, telepathology, slide sharing, and archiving. We compared pathologist evaluations of glass slides and corresponding digitized images within the context of a statewide surveillance effort. Cervical specimens collected by the New Mexico HPV Pap Registry research program targeted cases diagnosed between 2006 and 2010. Two samples of 250 slides each were digitized with the ScanScope XT (Aperio, Vista, CA) microscope and reviewed with Aperio ImageScope reader. (1) A "random set" had a distribution of community diagnoses: 70% from cases of cervical intraepithelial neoplasia grade 2 or higher, 20% from cases of cervical intraepithelial neoplasia grade 1 and 10% from negative cases. (2) A "discrepant set" was represented by difficult cases where 2 study pathologists initially disagreed. Within the regular workflow of the New Mexico HPV Pap Registry, 3 pathologists read the slides 2 to 3 times each without knowledge of clinical history, previous readings or sampling scheme. Pathologists also read each corresponding image twice. For within- and between-reader comparisons we calculated unweighted κ statistics and asymmetry χ(2) tests. Across all comparisons, slides and images yielded similar results. For the random set, almost all within-reader and between-reader Kappa values ranged between 0.7 and 0.8 and 0.6 and 0.7, respectively. For the discrepant set, most within- and between-reader κ values were 0.4 to 0.6. As cervical intraepithelial neoplasia diagnostic terminology changes, pathologists may need to re-read histopathology slides to compare disease trends over time, eg, before/after introduction of human papillomavirus vaccination. Diagnosis of cervical intraepithelial neoplasia differed little between slides and corresponding digitized images.

Adjunctive HPV in-situ hybridization (ISH) assay as an aid in the diagnosis of cervical intraepithelial neoplasia in cervical tissue specimens: an analytical and functional characterization

The purpose of this study was to develop and analytically and functionally validate a new human papillomavirus (HPV) in-situ hybridization (ISH) assay and to determine whether the use of this assay combined with hemotoxylin and eosin (H&E) staining could potentially improve the diagnostic accuracy of interpreting cervical intraepithelial neoplasia (CIN) in human cervical tissue specimens. An automated HPV ISH assay was developed using probes that targeted the broad spectrum of HPV genotypes most commonly associated with CIN. In an exploratory study, tissue sections (n=118) were stained with H&E alone and H&E with HPV ISH and evaluated by 6 general surgical pathologists. Results were compared with diagnoses established by expert pathologists on H&E alone. The change in specificity (diagnosis of no-CIN) and sensitivity (diagnosis of CIN) using H&E plus HPV versus H&E alone was determined. The HPV ISH assay detected 21 HPV genotypes and demonstrated no cross-reactivity to Epstein-Barr virus, cytomegalovirus, herpes simplex virus (HSV)-1, HSV-2, or human placental DNA. The assay detected HPV in a range of 1 to 600 copies on CaSki, HeLa, and SiHa xenografts. Use of this assay with H&E staining improved the average diagnostic specificity of the surgical pathologists from 68.5% to 89.9% (P<0.001), with fewer false-positive CIN 1 results (122 vs. 39). The diagnostic sensitivity was similar for assessments made with H&E alone and those made with HPV plus H&E (93.1% vs. 93.6%). In conclusion, a new automated broad-spectrum HPV ISH assay combined with H&E-stained slides contributed to better ascertainment of CIN than H&E staining alone.

Cervical histopathology variability among laboratories: a population-based statewide investigation

To inform the proposed systematic adjudicative staining of cervical intraepithelial neoplasia grade 2 (CIN2) and equivocal diagnoses, we characterized diagnostic heterogeneity across 15 laboratories. Laboratory-specific distributions of 37,486 biopsy specimen diagnoses were compared after adjusting for preceding cytology. In a subset of preceding cytology specimens, HPV16 genotyping was considered an indicator of lesion severity. Distributions of normal and CIN1 diagnoses varied widely, with laboratories favoring either normal (5.5%-57.7%) or CIN1 diagnoses (23.3%-86.7%; P < .001 for normal:CIN1 variability). Excluding extreme values, 6.2% to 14.4% of diagnoses were CIN2 (P < .001). For CIN2 diagnoses, HPV16 positivity in the preceding cytology varied between 39.0% in the largest laboratory and 57.4% in others (P < .001), suggesting differential interpretation, not population differences, as a cause of variability. In conclusion, the frequency of diagnoses requiring special staining (p16(INK4a) immunostaining) to adjudicate equivocal CIN2 will be sizable and vary between laboratories, especially if extended to a fraction of CIN1 lesions.

Has fluorescence spectroscopy come of age? A case series of oral precancers and cancers using white light, fluorescent light at 405 nm, and reflected light at 545 nm using the Trimira Identafi 3000

BACKGROUND

Optical spectroscopy devices are being developed and tested for the screening and diagnosis of cancer and precancer in multiple organ sites. The studies reported here used a prototype of a device that uses white light, green-amber light at 545 nm, and violet light at 405 nm. Given that oral neoplasia is rare, the need for a device that increases the sensitivity of comprehensive white light oral screening is evident. Such a device, in the hands of dentists, family practitioners, otorhinolaryngologists, general surgeons, obstetrician gynecologists, and internists, could greatly increase the number of patients who have lesions detected in the precancerous phase.

OBJECTIVES

The objective of this study was to present a case series of oral precancers and cancers that have been photographed during larger ongoing clinical trials.

METHODS

Over 300 patients were measured at 2 clinical sites that are comprehensive cancer centers and a faculty practice associated with a major dental school. Each site is conducting independent research on the sensitivity and specificity of several optical technologies for the diagnosis of oral neoplasia. The cases presented in this case series were taken from the larger database of images from the clinical trials using the aforementioned device. Optical spectroscopy was performed and biopsies obtained from all sites measured, representing abnormal and normal areas on comprehensive white light examination and after use of the fluorescence and reflectance spectroscopy device. The gold standard of test accuracy was the histologic report of biopsies read by the study histopathologists at each of the 3 study sites.

RESULTS

Comprehensive white light examination showed some lesions; however, the addition of a fluorescence image and a selected reflectance wavelength was helpful in identifying other characteristics of the lesions. The addition of the violet light-induced fluorescence excited at 405 nm provided an additional view of both the stromal neovasculature of the lesions and the stromal changes associated with lesion growth that were biologically indicative of stromal breakdown. The addition of 545 nm green-amber light reflectance increased the view of the keratinized image and allowed the abnormal surface vasculature to be more prominent.

CONCLUSIONS

Optical spectroscopy is a promising technology for the diagnosis of oral neoplasia. The conclusion of several ongoing clinical trials and an eventual randomized Phase III clinical trial will provide definitive findings that sensitivity is or is not increased over comprehensive white light examination.

Epidemiologic differentiation of diagnostic and screening populations for the assessment of cervical dysplasia using optical technologies

BACKGROUND

We report here the logistic modeling of the epidemiologic differences between a diagnostic population and a screening population recruited for the study of optical technologies for cervical cancer detection.

OBJECTIVES

The goal of this analysis was to determine if there were differences in the sociodemographic or clinical factors between subjects recruited to our diagnostic and screening trials.

METHODS

Epidemiologic data were obtained from a risk factor interview as a component of a multicenter Phase II clinical trial that used fluorescence and reflectance point spectroscopy to diagnose cervical disease. Participants with recent or past abnormal findings on a Papanicolaou smear were grouped into the diagnostic (high-risk) population, whereas those with a history of normal findings on Papanicolaou smears and no cervical treatments were grouped into the screening (low-risk) population.

RESULTS

Our model revealed that nonwhite race, higher than a high school education, and peri- and postmenopausal status were associated with the screening population. A history of genital infections, current oral contraceptive use, human papillomavirus positivity (by Hybrid Capture II and consensus polymerase chain reaction), and worst histological diagnosis at clinic visit were important predictors of being in the diagnostic group.

CONCLUSIONS

We were successful in recruiting 2 distinctive populations and anticipate being able to use these results to more correctly classify women at higher risk for cervical lesions in our future studies of optical spectroscopy.

Accuracy of optical spectroscopy for the detection of cervical intraepithelial neoplasia without colposcopic tissue information; a step toward automation for low resource settings

Optical spectroscopy has been proposed as an accurate and low-cost alternative for detection of cervical intraepithelial neoplasia. We previously published an algorithm using optical spectroscopy as an adjunct to colposcopy and found good accuracy (sensitivity=1.00 [95% confidence interval (CI)=0.92 to 1.00], specificity=0.71 [95% CI=0.62 to 0.79]). Those results used measurements taken by expert colposcopists as well as the colposcopy diagnosis. In this study, we trained and tested an algorithm for the detection of cervical intraepithelial neoplasia (i.e., identifying those patients who had histology reading CIN 2 or worse) that did not include the colposcopic diagnosis. Furthermore, we explored the interaction between spectroscopy and colposcopy, examining the importance of probe placement expertise. The colposcopic diagnosis-independent spectroscopy algorithm had a sensitivity of 0.98 (95% CI=0.89 to 1.00) and a specificity of 0.62 (95% CI=0.52 to 0.71). The difference in the partial area under the ROC curves between spectroscopy with and without the colposcopic diagnosis was statistically significant at the patient level (p=0.05) but not the site level (p=0.13). The results suggest that the device has high accuracy over a wide range of provider accuracy and hence could plausibly be implemented by providers with limited training.

Can Acceptance & Commitment Therapy be delivered with fidelity as a brief telephone-intervention?

This study examined therapist adherence and competence of the first telephone-based Acceptance & Commitment Therapy (ACT) intervention for smoking cessation. An independent rater assessed 100% (n=54 sessions) of the recorded phone sessions for adherence and competence on a 1 (never addressed) to 5 (addressed extensively) scale. A separate 20% random sample was rated by both the same independent rater and a second independent rater. The two coders were in perfect agreement (kappa of 1.0). Overall adherence (x=4.61, SD=0.63) and competence (x=4.81, SD=0.39) was high. Except self-as-context, benchmark ratings (i.e., 4 or more) were between 93% and 100%. Results suggest ACT therapy can be delivered competently over the telephone, opening many options for future research on the potential uses of telephone-based ACT for smoking and other behaviors.

Variabilidade interobservadores no diagnóstico de lesões precursoras do câncer anal: estudo do cenário habitual

OBJETIVO: Analisar a variabilidade interobservadores no diagnóstico de lesões precursoras do câncer anal no cenário mais comum de um serviço constituído por patologistas sem experiência prévia no diagnóstico destas lesões. MÉTODOS: Quinhentas e duas lâminas histopatológicas com espécimes anais retirados de 372 pacientes HIV-positivos e HIV-negativos foram analisadas no Departamento de Patologia da Fundação de Medicina Tropical do Amazonas por três patologistas com ampla experiência no diagnóstico de doenças tropicais e infecciosas, mas sem experiência prévia importante no diagnóstico de lesões precursoras do câncer anal. As leituras individuais de cada patologista foram comparadas com a que se seguiu a diagnóstico de consenso em microscópio de ótica compartilhada. Os diagnósticos individuais foram confrontados com os de consenso mediante análise da estatística kappa. RESULTADOS: A concordância absoluta entre cada diagnóstico individual e o de consenso correspondente foi ruim (kappa=-0,002). Considerando os resultados apenas positivos ou negativos para lesões intraepiteliais escamosas anais, obteve-se concordância regular entre os observadores (kappa=0,35), enquanto que a concordância foi moderada quando os resultados histopatológicos foram considerados positivos ou negativos para lesão intraepitelial de alto grau ou câncer (kappa=0,52). CONCLUSÃO: A variabilidade interobservadores no diagnóstico histopatológico do câncer anal e de suas lesões precursoras entre patologistas sem grande experiência na área, apesar de experts em outras, é tal que os diagnósticos neste campo e neste cenário comum devem sempre ser de consenso.

Optical technologies and molecular imaging for cervical neoplasia: a program project update

There is an urgent global need for effective and affordable approaches to cervical cancer screening and diagnosis. In developing nations, cervical malignancies remain the leading cause of cancer-related deaths in women. This reality may be difficult to accept given that these deaths are largely preventable; where cervical screening programs have been implemented, cervical cancer-related deaths have decreased dramatically. In developed countries, the challenges of cervical disease stem from high costs and overtreatment. The National Cancer Institute-funded Program Project is evaluating the applicability of optical technologies in cervical cancer. The mandate of the project is to create tools for disease detection and diagnosis that are inexpensive, require minimal expertise, are more accurate than existing modalities, and can be feasibly implemented in a variety of clinical settings. This article presents the status and long-term goals of the project.

Reproducibility of endocervical curettage diagnoses

OBJECTIVE

To estimate overall interobserver variability of histopathology diagnoses on endocervical curettage (ECC) specimens.

METHODS

Five study pathologists, blinded to the original diagnosis, reviewed archived ECC specimens initially interpreted as normal, low-grade dysplasia, and high-grade dysplasia. We assessed interobserver agreement and agreement between pathologists using the κ statistic and analyzed the effect of reducing diagnostic choices to two categories (one method using "normal and dysplasia" and another method using "normal and low-grade" and "high-grade or worse").

RESULTS

A total of 90 specimens were reviewed. The overall observer agreement was moderate (κ = 0.52). For specific diagnoses, cases interpreted as normal or high-grade dysplasia demonstrated greater agreement than those interpreted as low-grade dysplasia. Individual pathologists' comparison κ values ranged from 0.31 to 0.80. Changing diagnostic options to a two-tiered system resulted in significant improvement in κ values for only 1 of 36 pathologist comparisons. Using the gynecologist pathologist consensus interpretation, study pathologists downgraded 44% of cases originally interpreted as high-grade.

CONCLUSION

Interobserver agreement in the interpretation of ECC specimens is at best moderate, even between those with additional experience and training in gynecologic pathology. Furthermore, reducing diagnostic options to two categories did not improve agreement. It is concerning that important clinical decisions may be made based on an ECC diagnosis that is moderately or poorly reproducible.

LEVEL OF EVIDENCE

II.

The accuracy of colposcopic biopsy: analyses from the placebo arm of the Gardasil clinical trials

We evaluated the overall agreement between colposcopically directed biopsies and the definitive excisional specimens within the context of three clinical trials. A total of 737 women aged 16-45 who had a cervical biopsy taken within 6 months before their definitive therapy were included. Per-protocol, colposcopists were to also obtain a representative cervical biopsy immediately before definitive therapy. Using adjudicated histological diagnoses, the initial biopsies and the same day biopsies were correlated with the surgically excised specimens. The overall agreement between the biopsies taken within 6 months of definitive therapy, and the definitive therapy diagnoses was 42% (weighted kappa = 0.34) (95% CI: 0.29-0.39). The overall underestimation of cervical intraepithelial neoplasia grade 2/3 or adenocarcinoma in situ (CIN2-3/AIS) and CIN3/AIS was 26 and 42%, respectively. When allowing for one degree of variance in the correlation, the overall agreement was 92% for CIN2-3/AIS. The overall agreement between the same day biopsy and definitive therapy specimen was 56% (weighted kappa = 0.41) (95% CI: 0.36-0.47), and the underestimation of CIN2-3/AIS was 57%. There were significant associations in the agreement between biopsies and excisional specimen diagnoses when patients were stratified by age, number of biopsies, lesion size, presence of human papillomavirus (HPV)16/18 and region. Of 178 diagnostic endocervical curettages performed, 14 (7.9%) found any HPV disease. Colposcopic accuracy improved when CIN2 and CIN3/AIS were grouped as a single predictive measure of high-grade disease. Colposcopy functioned well when allowed a one-degree difference between the biopsy and the surgical histologic interpretations, as done in clinical practice. Taking more than one biopsy improved colposcopic accuracy and could improve patient management.

Accuracy of optical spectroscopy for the detection of cervical intraepithelial neoplasia: Testing a device as an adjunct to colposcopy

Testing emerging technologies involves the evaluation of biologic plausibility, technical efficacy, clinical effectiveness, patient satisfaction, and cost-effectiveness. The objective of this study was to select an effective classification algorithm for optical spectroscopy as an adjunct to colposcopy and obtain preliminary estimates of its accuracy for the detection of CIN 2 or worse. We recruited 1,000 patients from screening and prevention clinics and 850 patients from colposcopy clinics at two comprehensive cancer centers and a community hospital. Optical spectroscopy was performed, and 4,864 biopsies were obtained from the sites measured, including abnormal and normal colposcopic areas. The gold standard was the histologic report of biopsies, read 2 to 3 times by histopathologists blinded to the cytologic, histopathologic, and spectroscopic results. We calculated sensitivities, specificities, receiver operating characteristic (ROC) curves, and areas under the ROC curves. We identified a cutpoint for an algorithm based on optical spectroscopy that yielded an estimated sensitivity of 1.00 [95% confidence interval (CI) = 0.92-1.00] and an estimated specificity of 0.71 [95% CI = 0.62-0.79] in a combined screening and diagnostic population. The positive and negative predictive values were 0.58 and 1.00, respectively. The area under the ROC curve was 0.85 (95% CI = 0.81-0.89). The per-patient and per-site performance were similar in the diagnostic and poorer in the screening settings. Like colposcopy, the device performs best in a diagnostic population. Alternative statistical approaches demonstrate that the analysis is robust and that spectroscopy works as well as or slightly better than colposcopy for the detection of CIN 2 to cancer.

Colposcopy prediction of progression in human papillomavirus infections with minor cervical lesions

OBJECTIVES

To evaluate the risk of progression to cervical intraepithelial neoplasia (CIN) grade 2 or 3 in women with positive human papillomavirus (HPV) testing and low-grade (low-grade squamous intraepithelial lesions), borderline (atypical squamous cells of undetermined significance), or no cervical lesions, and to determine the accuracy of initial colposcopy to predict progression.

METHODS

Women with HPV infection and low-grade squamous intraepithelial lesions, atypical squamous cells, or normal cytology were recruited and grouped according to cytologic or histologic diagnosis. Exclusion criteria were histologic CIN 2 or 3, previous cervical cancer and HPV infection, cervical disease, or treatment for CIN 2 or 3 in the past 3 years. Four-hundred sixty-five women were included and monitored by cytology, Hybrid Capture-2 test, and colposcopy every 6 months. Colposcopy results were described as normal, with minor or major changes, and lesion size was recorded in quadrants.

RESULTS

Forty-three women (9.3%) had progression to CIN 2 or 3. No significant differences were found in rate of progression between women with low-grade squamous intraepithelial lesions, atypical squamous cells, or negative results (8.2%, 13.4%, and 9.8%, respectively; P=.679). Neither colposcopy pattern (P=.284) nor lesion size (P=.170) at recruitment provided any information on the risk of progression. History of cervical lesion and worsening of the colposcopy pattern during follow-up were associated with progression (P<.001).

CONCLUSION

Initial colposcopy findings do not provide relevant information on the risk of progression in HPV-positive women with minor or no cervical lesions. These women have a similar risk of progression and should benefit from the same follow-up strategies.

Optical coherence tomography as a non-invasive imaging technique for preinvasive and invasive neoplasia of the uterine cervix

OBJECTIVE

Optical coherence tomography (OCT) is a non-invasive high-resolution imaging technique that permits characterization of microarchitectural features of tissue up to 2 mm in depth in real time. The purpose of this study was to evaluate the feasibility of OCT for the identification of precancerous (cervical intraepithelial neoplasia (CIN)) and cancerous lesions of the uterine cervix.

METHODS

We conducted a prospective study on the use of OCT in women with suspected CIN. OCT images were obtained on colposcopy from non-suspicious and suspicious areas, and were evaluated independently by two investigators and later compared with the corresponding histology. The sensitivity, specificity, negative and positive predictive values and accuracy of the new technique in identifying CIN or carcinoma were calculated.

RESULTS

Of a total of 610 OCT images, 97 from suspicious areas in 60 women were compared with the corresponding histology. Sixty-three of 67 CIN lesions and four invasive carcinomas were diagnosed correctly on evaluation of the OCT images by the first observer. There were 69 true-positive, 11 true-negative, 13 false-positive and four false-negative results, giving a sensitivity of 95% and a specificity of 46%.

CONCLUSION

OCT is a rapid, easy-to-use modality that provides real-time, microarchitectural information of the cervical epithelium. Further refinement of this technology will lead to OCT systems with a significantly higher resolution and may result in better differentiation of cancerous and precancerous lesions.

Detection of TERC amplification in cervical epithelial cells for the diagnosis of high-grade cervical lesions and invasive cancer: a multicenter study in China

Because the activation of telomerase is a relatively early event in the progression of cervical carcinogenesis, the expression of the human telomerase RNA gene, TERC, has the potential to serve as a biomarker for both the diagnosis and prognosis of cervical neoplasias. In total, 83 research centers participated in the study, and 7786 patients were enrolled. TERC amplification was detected using a dual-color fluorescence in situ hybridization (FISH) probe set, and these results were compared with cytological and histological results, testing for high-risk human papillomavirus (HPV) DNA (n = 2316 for the HPV DNA test), as well as patient age. TERC amplification was found to be increased in more advanced cases of cervical carcinogenesis. Moreover, a Youden's index value and the area under the receiver operating characteristic (ROC) curve were also calculated for samples with TERC amplification and found to be higher than the same values calculated for both cytology and high-risk HPV analyses of the same samples. With regard to cytological ASCUS and LSIL findings, the combination of HPV + TERC testing showed the potential to provide effective triaging to detect CIN2(+). Therefore, TERC amplification represents a valuable genetic biomarker, which in combination with an evaluation of cytology or HPV testing, can achieve higher sensitivity and specificity in distinguishing high-grade cervical lesions and invasive cancers from low-grade lesions compared with conventional methods.

Automatic measurement of epithelium differentiation and classification of cervical intraneoplasia by computerized image analysis

BACKGROUND

The feasibility of evaluating an objective grading of cervical intraneoplasia lesions (CIN) is attempted using an automatic computerized system able to measure several valuable parameters with special reference to epithelium differentiation.

METHODS

4 groups of 10 images each were selected at random from 68 consensus images coming from 80 archival cervical biopsies, normal (n = 10), CIN 1 (n = 10), CIN 2 (n = 10), CIN 3 (n = 10). Representative images of lesions were captured from the microscopic slides and were analyzed using mathematical morphology, with special reference toVoronoï tessellation and Delaunay triangulation. Epithelium surface, nuclear and cytoplasm area, triangle edge and area, total and upper nuclear index were precisely measured in each lesion, and discriminant coefficients were calculated therewith. A dilation/erosion coefficient was automatically defined using triangle edge length and nuclear radius in order to measure the epithelium ratio of differentiation. A histogram ratio was also automatically established between total nuclei and upper nuclei on top of differentiated epithelium. With the latter two ratios added to the nucleo-cytoplasmic ratio, a cervical score able to classify CIN is proposed.

RESULTS

There is a quasi-linear increase of mean cervical score values between normal epithelium and CIN 3: (27) for normal epithelium, (51) for CIN 1, (78) for CIN 2 and (100) for CIN 3, with significant differences (P < 0.05).

CONCLUSION

Our results highlight the possibility of applying a cervical score for the automatic grading of CIN lesions and thereby assisting the pathologist for improvement of grading. The automatic measure of epithelium differentiation ratio appears to be a new interesting parameter in computerized image analysis of cervical lesions.