A Prospective Study to Evaluate the Correlation Between Reid Colposcopic Index Impression and Biopsy Histology

CIN2 + detection in high-risk HPV patients with no or minor cervical cytologic abnormalities: a clinical approach validated by machine learning

PURPOSE

To evaluate the feasibility and diagnostic value of the combination of colposcopy, cytology and hrHPV (high-risk human papilloma virus) PCR (polymerase chain reaction) testing in patients with no or minor cytologic abnormalities and HPV high risk infection and to find the best predictors for the presence of CIN2 + in this patient collective.

METHODS

Three hundred and thirty-four hrHPV patients with normal cytology or minor cytologic abnormalities who had a colposcopic examination at the center of colposcopy at the university hospital Aachen in 2021 were enrolled in this retrospective cohort analysis. Multivariate logistic regression and a machine-learning technique (random forests, leave-one-out analysis) were used.

RESULTS

The overall risk for CIN2 + in hrHPV-positive patients with normal cytology was 7.7% (N = 18) (5% for CIN3 +), 18% (N = 16) (10.1% for CIN3 +) in patients with PAP IIp (ASC-US) and 62.5% (N = 5) (25% for CIN3 +) in patients with PAP IIg (AGC). Variables that show a statistically significant influence for the CIN-status are 'major change' as the result of colposcopy, transformation zone type T1, PAP IIg upon referral (AGC) and hrHPV category 1a (HPV 16/18) detection. Using machine learning (random forests) techniques, the main influencing variables were confirmed. A monotonously decreasing risk for CIN2 + from hrHPV category 1a to 3 (in accordance to the IACR guidelines) was found.

CONCLUSION

In the collective of hrHPV patients with no or minor cytologic abnormalities, the result of colposcopy and HPV PCR status are key predictors for the detection of CIN2 + with a monotonously decreasing risk for CIN2 + from hrHPV category 1a to 3.

Concordance Rate of Colposcopy in Detecting Cervical Intraepithelial Lesions

Background: The purpose of this research is to estimate the rate of concordance, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of colposcopy for high-grade squamous lesions and carcinomas (HSIL+). Methods: We conducted a retrospective study of colposcopies performed in the certified Dysplasia Unit in Erlangen between January 2015 and May 2022 (7.5 years). The colposcopic findings were correlated with biopsies obtained during examinations or surgery. Cases without histology were excluded. The primary outcome was the rate of concordance between the colposcopic and histological findings in relation to the type of transformation zone (TZ), examiner’s level of experience and age of the patients. Results: A total of 4778 colposcopies in 4001 women were analyzed. The rates of concordance for CIN I/LSIL, CIN II/HSIL, CIN III/HSIL, and carcinoma were 43.4%, 59.5%, 78.5%, and 53.9%, respectively. The rate of concordance was lowest for TZ3 and highest for colposcopists with more than 10 years’ experience. Conclusions: Colposcopy is an important, feasible, and effective method. Careful work-up needs to be performed for women with TZ3 who are over 35 years old, as they are at the highest risk of being misdiagnosed. The highest concordance for detecting HSIL+ was seen for colposcopists with >10 years’ experience.

Analysis of the agreement between colposcopic impression and histopathological diagnosis of cervical biopsy in a single tertiary center of Chengdu

PURPOSE

The aim of this retrospective study was to analyze the agreement between colposcopic impression and histopathological diagnosis of cervical biopsy.

METHODS

The medical records of patients underwent a colposcopy-guided cervical biopsy at Chengdu Women's and Children's Central Hospital between January 2017 and January 2019 were collected, including age, menopausal status, cervical cytology and human papillomavirus (HPV) test results, type of transformation zone, colposcopic diagnosis and histopathological outcomes of cervical biopsy. Colposcopy was carried out using 2011 colposcopic terminology of International Federation for Cervical Pathology and Colposcopy (IFCPC). Related variables were analyzed.

RESULTS

A total of 495 patients were collected in this study. The perfect agreement between colposcopic impression and histopathological diagnosis was 46.9%, and the strength of agreement with kappa value was 0.283 (P < 0.001), and the agreement within 1 grade was 93.5%. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, specificity, false-positive rate and false-negative rate of detecting HSIL or more (HSIL +) were 93.1%, 57.8%, 80.9%, 93.9%, 6.1% and 45.3%, respectively. Colposcopic diagnosis more often underestimated (43.2%) [especially in HSIL (59.3%) and carcinoma (70.7%) patients] than overestimated (9.9%) in cervical lesions. The results of cytology, HPV status, patients' age and different experiences of practitioners were the factors for under-diagnosis of HSIL + by colposcopy.

CONCLUSION

Colposcopy is an excellent tool to estimate cervical high-grade lesion but is imprecise. Many factors can bias the diagnosis of colposcopy, especially the known results of cervical cytology and HPV. Precise diagnosis of cervical lesion should rely on the colposcopy-directed biopsy.

The Diagnostic Efficacy of Swede Score for Prediction of Pre-invasive Cervical Lesions: A Prospective Hospital-Based Study

Context

The accuracy of colposcopy has recently been called into question particularly with regard to determining the site requiring biopsy. The technique of colposcopy is largely operator dependent, and the agreement between colposcopists is less reliable than once presumed. In an attempt to standardize colposcopy a new scoring system, the Swede score has been devised, which includes lesion size as a variable to be scored in addition to the 4 variables found in the modified Reids Colposcopic Index (RCI).

Aim

To assess the diagnostic accuracy of Swede score for pre-invasive cervical lesion.

Setting and Design

A cross-sectional study in a tertiary care centre.

Method

Swede score was calculated for assessment of pre-invasive cervical lesions on patients undergoing colposcopy who were suspected with pre-invasive cervical lesion. Cervical biopsy was taken if modified RCI ≥ 3 or Swede score ≥ 5. Histopathology report of the cervical biopsy was taken as gold standard.

Results

Swede scores of 5 or more had sensitivity, specificity, positive and negative predictive values of 94.9%, 88.4%, 75.5% and 92.9% respectively.

Conclusion

The Swede score by just incorporating one additional variable that is size of the lesion, showed better correlation with histopathology.

Replacing Iodine Staining with Size of Lesion: The Performance of Modified Reid Colposcopic Index

AIM

This study of diagnostic accuracy aimed to assess the performance of authors' proposing colposcopic index for detecting histological diagnosis of cervical intraepithelial neoplasia grade 2 or worse (CIN2 or worse).

METHODS

Retrospective analysis of data was carried out on medical records of women who underwent colposcopy in Rajavithi hospital from January 2007 to December 2014. The authors' proposed score included the first 3 criteria of RCI (margin, color, vascular pattern) and replacing the last RCI criterion (iodine staining) with the detail of size and location of a lesion which was retrospectively retrieved from medical records. Total score for detecting any lesion was ranged from 0-8, similar to the RCI. Performance of the score was assessed for sensitivity, specificity, and positive and negative predictive values at every cut-off level.

RESULTS

Among 207 eligible women, 87 (42%) had CIN2 or worse. Cut-off level of score ≥ 6 had a sensitivity, specificity, and positive and negative predictive values of 54.0%,97.5%,94.0%,74.5%, respectively while cut-off value ≥ 2 had sensitivity , specificity, positive and negative predictive values of 94.2% ,55.8% ,60.7%, and 93.0%, respectively, for histological diagnosis of CIN 2 or worse. The area under ROC curve was 0.88. In women with type 3 T-zone, the area under ROC curve was 0.94 which was excellent.

CONCLUSION

The performance of the colposcopic score that replaces iodine staining with the size and location of the lesion is good and practical. High cut-off level can be used in see and treat approach for high-grade squamous intraepithelial lesions. Low cut-off level may be used for omitting biopsy in case of low grade impression. This scoring system seems to have greater performance in womens with type 3 T- zone.

The efficacy of modified Swede Colposcopic Index in prediction of high-grade lesion and cancer of cervix

Objective

To evaluate the efficacy of modified Swede Colposcopic Index (MSCI) to predict high-grade lesion and cancer of cervix (CIN2+, cervical intraepithelial neoplasia grade 2 or worse) in women with abnormal cervical cytology who underwent a colposcopy.

Methods

We conducted a retrospective study and MSCI using 5 features of cervical lesions evidenced from colposcopy: acetouptake, margin and surface, vessels, lesion size, and location of lesion. Each feature was scored from cervicograhpic findings which transformation zone was completely seen. Odds ratio of each feature was obtained by logistic regression analysis. Receiver operating characteristic curve was used to assess the efficacy of summation score to predict CIN2+. An appropriate cut-off point score was assigned.

Results

Two hundred and twenty women were included in the study. The assigned score for each factor in level 1 to 3 was 1, 2 and 3 points with a total score of 15 points. The most appropriate cut-off points score for MSCI to predict CIN2+ was 11 points. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy using MSCI were 82.2%, 96.2%, 96.0%, 85.0%, and 90.0% respectively.

Conclusion

MSCI showed a high efficacy for predicting CIN2+ in satisfactory colposcopy.

Accuracy of colposcopy-directed biopsy in detecting early cervical neoplasia: a retrospective study

PURPOSE

Colposcopy-directed biopsy is a cornerstone method for diagnosing cervical intraepithelial neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with definitive surgery.

METHODS

The accuracy of colposcopy-directed biopsy was compared with the final histology in relation to different types of transformation zone (TZ), the patient's age, and the examiner's level of training.

RESULTS

The overall accuracy of biopsy in comparison with definitive surgery was 71.9% for all entities-benign lesions, low-grade squamous intraepithelial lesions, high-grade squamous intraepithelial lesions (HSILs), and cervical carcinoma-with an underdiagnosis rate of 11.8% and an overdiagnosis rate of 16.5%. The accuracy for detecting HSIL was 88% (401/455), with an underdiagnosis rate of 10.5% and overdiagnosis rate of 1.3%. The accuracy rates for detecting HSIL in women with TZ 1, TZ 2, or TZ 3 were 92.2, 90.5, and 76.5%, respectively. The accuracy rates for detecting HSIL in the different age groups were 93.1% (age 0-34), 83.6% (age 34-55), and 80% (age 55 or older).

CONCLUSIONS

A combination of the colposcopic findings, cytology, human papillomavirus testing, and colposcopy-directed biopsy is necessary for the correct diagnosis of HSIL. The accuracy rate depends on the TZ and the patient's age. The examiner's level of training does not have any substantial influence on the accuracy.

Diagnostic value of the 2011 International Federation for Cervical Pathology and Colposcopy Terminology in predicting cervical lesions

Objective

To evaluate the diagnostic accuracy of the 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) colposcopic terminology.

Methods

The clinicopathological data of 2262 patients who underwent colposcopy from September 2012 to September 2016 were reviewed. The colposcopic findings, colposcopic impression, and cervical histopathology of the patients were analyzed. Correlations between variables were evaluated using cervical histopathology as the gold standard.

Results

Colposcopic diagnosis matched biopsy histopathology in 1482 patients (65.5%), and the weighted kappa strength of agreement was 0.480 (P<0.01). Colposcopic diagnoses more often underestimated (22.1%) than overestimated (12.3%) cervical pathology. There was no significant difference between the colposcopic diagnosis and cervical pathology agreement among the various grades of lesions (P=0.282). The sensitivity, specificity for detecting high-grade lesions/carcinoma was 71.6% and 98.0%, respectively. Multivariate analysis showed that major changes were independent factors in predicting high-grade lesion/carcinoma, whereas transformation zone, lesion size, and non-stained were not statistically related to high-grade lesion/carcinoma.

Conclusions

The 2011 IFCPC terminology can improve the diagnostic accuracy for all lesion severities. The categorization of major changes and minor changes is appropriate. However, colposcopic diagnosis remains unsatisfactory. Poor reproducibility of type 2 transformation zone and the significance of leukoplakia require further study.

Correlation of Two Colposcopic Indices for Predicting Premalignant Lesions of Cervix

Cervical cancer is the second most common malignancy among women in India, mainly affecting the females of Peri-Menopausal age group. Colposcopy has been very useful for diagnosing cervical cancer to guide the biopsy. Reids and Scalzi proposed the Reids Colposcopic Index (RCI) to make colposcopic diagnosis less subjective, which is currently the most accepted scoring system. Recognizing the correlation of size of the lesion with likelihood of harbouring high grade disease, a new scoring system, the Swede score, has been devised by Strander et al in 2005. In present study we compared the Reids colposcopic index with Swede score. From the present study it is evident that Swede score of 8 or more has 100% specificity and can be used for performing direct excisional procedure as a "see-and-treat" method at this cut-off. This may be the preferred method for the treatment of high-grade CIN because it reduces the number of visits to the clinic and failure to receive treatment.

Optimization of Classification Strategies of Acetowhite Temporal Patterns towards Improving Diagnostic Performance of Colposcopy

Efforts have been being made to improve the diagnostic performance of colposcopy, trying to help better diagnose cervical cancer, particularly in developing countries. However, improvements in a number of areas are still necessary, such as the time it takes to process the full digital image of the cervix, the performance of the computing systems used to identify different kinds of tissues, and biopsy sampling. In this paper, we explore three different, well-known automatic classification methods (k-Nearest Neighbors, Naïve Bayes, and C4.5), in addition to different data models that take full advantage of this information and improve the diagnostic performance of colposcopy based on acetowhite temporal patterns. Based on the ROC and PRC area scores, the k-Nearest Neighbors and discrete PLA representation performed better than other methods. The values of sensitivity, specificity, and accuracy reached using this method were 60% (95% CI 50–70), 79% (95% CI 71–86), and 70% (95% CI 60–80), respectively. The acetowhitening phenomenon is not exclusive to high-grade lesions, and we have found acetowhite temporal patterns of epithelial changes that are not precancerous lesions but that are similar to positive ones. These findings need to be considered when developing more robust computing systems in the future.

Closer to a Uniform Language in Colposcopy: Study on the Potential Application of 2011 International Federation for Cervical Pathology and Colposcopy Terminology in Clinical Practice

As the newest colposcopic terminology, the 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) classification provides standardized interpretation of colposcopic findings. In this study, we analyzed the colposcopic accuracy and the significance of individual findings according to the 2011 IFCPC classification in 525 patients, reviewed by 13 trained colposcopists. Results show that colposcopic diagnoses are in 64.95% perfect agreement with cervical pathology, with 63.64% sensitivity and 96.01% specificity for high-grade squamous intraepithelial lesion (HSIL+). And the accuracy is reproducible across different experienced examiners. Many individual findings, especially the two new signs, inner border sign and ridge sign, are proved to have good predictive accuracy, while iodine negativity demonstrates an inferior performance. However, the distribution of three cervical transformation zone (TZ) types is heterogeneous in examiners. A comparison was also made of the findings of another two colposcopists without nomenclature training according to the Reid Colposcopic Index (RCI), modified RCI, and Swede Score. Results show that colposcopic accuracies in them are lower than in those nomenclature trained colposcopists. The 2011 IFCPC nomenclature improves colposcopic accuracy in trained colposcopists, like speaking the same language. However, the reproducibility of TZ and the predictive value of a few signs remain to be discussed.

Clinical Practice Guidelines on the Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention in Saudi Arabia

BACKGROUND

Cervical cancer is the third most common gynecological malignancy in Saudi women with an estimated incidence rate of 1.9 cases per 100 000 women-years. More than 40% of cervical cancer cases are diagnosed at advanced stages due to lack of a routine screening program in Saudi Arabia. Thus, national guidelines for routine screening and treatment of precancerous cervical lesions are needed.

METHODS

The Saudi Centre for Evidence-Based Healthcare invited a panel of local experts and partnered them with a team from McMaster University in Canada for methodological support, to develop national clinical practice guidelines on the screening and treatment of precancerous lesions for cervical cancer. After the panel identified key clinical questions, the McMaster University working group updated existing systematic reviews that had been used for the 2013 WHO Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Recommendations were based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. Those recommendations took into account the available evidence, patient values and preferences, and resource use in the Saudi context. The panel provided recommendations on two major issues: screening for precancerous lesions (cervical intraepithelial neoplasia 2 & 3) and treatment of those lesions to prevent cervical cancer in women who tested positive after screening.

CONCLUSIONS

The Saudi expert panel recommends using the HPV DNA test followed by colposcopy or cytology (Pap test) followed by colposcopy to screen for CIN2+ in women at risk of cervical cancer. The panel recommends cryotherapy or loop excision electrosurgery procedure (LEEP) over cold knife cone biopsy to treat women at risk of cervical cancer that tests positive for CIN2+. Universal screening for precancerous cervical dysplasia in women in Saudi Arabia is recommended using HPV testing and or cytology. Either cryotherapy or LEEP are preferred for treatment.

LIMITATIONS

National studies on cervical cancer screening modalities and treatment of precancerous cervical lesions, including HPV prevalence and its association with cervical cancer, are scarce.

Performance of the abbreviated Reid colposcopic index in prediction of high-grade lesions

OBJECTIVE

To assess the diagnostic performance of the Reid colposcopic index (RCI) and establish the optimal cutoff value to predict a histology of cervical intraepithelial neoplasia grade 2 or worse (CIN2+).

METHODS

A retrospective analysis was undertaken of the medical records of women who underwent colposcopy with RCI scoring at a center in Bangkok, Thailand, between 2003 and 2014. Only patients for whom histology reports were available were included. Cases had been scored according to three criteria: margin, color, and vascular pattern. The performance of this three-criterion score (abbreviated RCI) was assessed for sensitivity, specificity, and positive and negative predictive values at every cutoff level. Receiver operation characteristics (ROC) curve analysis was performed to determine the optimal cutoff value to distinguish between women with CIN2+ and others.

RESULTS

Among 349 included patients, 158 (45.3%) had CIN2+. The most appropriate cutoff score was 3, which had a sensitivity of 72.7%, a specificity of 86.9%, and positive and negative predictive values of 82.1% and 79.4%, respectively. The area under ROC curve was 0.857 (95% confidence interval 0.815-0.898).

CONCLUSION

The performance of the abbreviated RCI seems satisfactory. The optimal cutoff value was 3.

Study of accuracy of colposcopy in VIA and HPV detection-based cervical cancer screening program

OBJECTIVE

This population-based study was conducted to evaluate the performance of colposcopy to assess women with positive visual inspection with acetic acid (VIA) and/or human papillomavirus (HPV) tests.

MATERIALS AND METHODS

A total of 30,773 women were screened by VIA and oncogenic HPV test. Hybrid capture 2 was used for oncogenic HPV detection. All VIA- and/or HPV-positive women and 8.7% test-negative women had the colposcopy. International Federation of Cervical Pathology & Colposcopy (IFCPC) 2011 nomenclature was used for colposcopic classification of abnormalities. All women with grade 1 or worse lesions had punch biopsies. Biopsies were also obtained from HPV-positive women with normal colposcopy.

RESULTS

Colposcopy and satisfactory biopsy reports were available for total 2466 women. The overall strength of agreement between colposcopy and histologic classification of cervical neoplasias was poor (kappa = 0.17). Agreement was better when colposcopy was performed on HPV-positive women compared to VIA-positive women. Sensitivity of colposcopy to detect high-grade squamous intraepithelial lesions (HSIL) at referral threshold of grade 1 abnormality was 84.8% after correction of verification bias. Colposcopy was most inaccurate in identifying non-neoplastic conditions often encountered in VIA- and/or HPV-positive women. In 68.8% women with normal histology, colposcopic impression was grade 1 and above. Overestimation of disease severity on colposcopy was more common in VIA-positive women. Colposcopy also underestimated severity of disease in 52.6% of women with HSIL diagnosis on biopsy.

CONCLUSIONS

Colposcopy performed well in the overall detection of cervical neoplasias, though its capability for accurate categorisation of degree of abnormality was poor.

Reid Colposcopic Index Evaluation: Comparison of General and Oncologic Gynecologists

The Reid colposcopic index (RCI) helps physicians for interpret the results of colposcopic examination. To compare the accuracy of RCI in colposcopic evaluation between general and oncologic gynecologists, this prospective trial was conducted by invited women over 20 years of age who were scheduled for a colposcopy at Chiang Mai University Hospital between August, 2008 and May, 2014 to participate. Pregnant patients or those having a history of hysterectomy or conization were excluded. During the colposcopy, all patients were simultaneously evaluated by general and oncologic gynecologists utilizing the RCI. Further management with either a biopsy or LEEP in each patient was dependent on the decision of the attending oncologic gynecologist. The accuracy of the RCI in diagnosing HSIL or more was calculated by the comparison with the final histology. Finally, 135 patients were recruited into this study. The sensitivity, specificity, PPV, NPV, and accuracy of RCI in diagnosing HSIL or more in general gynecologists were 45.2%, 80.7%, 41.1%, 83.2% and 72.6% while in the oncologic gynecologists were 51.6%, 85.6%, 51.6%, 85.6% and 77.8%, respectively. The difference in accuracy between evaluator groups was not significant (p-value=0.28). Of 3 patients with invasive cervical cancer, all were undetected by the general gynecologists using RCI while only 1 invasive cervical cancer was missed via RCI by the oncologic gynecologists. We conclude that RCI could be used by general gynecologists in provincial hospitals with major concerns about missing invasive cervical cancer. A short training period regarding colposcopy might help to resolve this problem.

Colposcopy: a global perspective: introduction of the new IFCPC colposcopy terminology

This article describes the current nomenclature of colposcopic findings in the lower genital tract as defined by the International Federation for Cervical Pathology and Colposcopy (IFCPC) and agreed at their Triennial General Meeting in July 2012 in Rio de Janeiro. It builds on previous nomenclature published by the IFCPC over the last two decades and introduces for the first time the concept of transformation zone excision types. Vulval and vaginal colposcopic terminology is described.

Prospective evaluation of E6/E7 mRNA detection by the NucliSENS Easy Q HPV assay in a stepwise protocol

The objective of the study was to evaluate prospectively the added value of E6/E7 mRNA detection in a stepwise protocol. A total of 1,422 samples were collected over a period of 17 months. The samples were referred for human papillomavirus (HPV) genotyping if they showed cytological evidence of atypical squamous cells of undetermined significance, low- or high-grade squamous intraepithelial lesion. If one or more of HPV types 16, 18, 31, 33, or 45 were present, mRNA was analyzed by the NucliSENS EasyQ HPV assay. The genotypical distribution of high-risk HPV was very heterogeneous; HPV 16, 18, 31, 33, and 45 represented 20.2%, 3.4%, 10.8%, 3.4%, and 3.8% of HPV-positive samples, respectively. Follow-up data were available for 35 patients. Although over the half (51.4%) of follow-up samples showing HPV DNA/mRNA consensus evolved to cervical intraepithelial neoplastic lesions, 25.7% showed no progression to neoplasia despite mRNA positivity. However, the major concern was the group (14.3%) that showed progression to cervical intraepithelial neoplasia despite mRNA negativity: all but one of these cases had a high-risk HPV genotype other than the five included in the NucliSENS EasyQ HPV assay. Markedly, 66.7% of the discordant samples between colposcopy and histology that underestimated the degree of cervical dysplasia were found in this group. Close monitoring of high-risk HPV DNA-positive/mRNA-negative cases remains necessary, which leads to questions about the added value of the evaluated protocol.

Colposcopy to evaluate abnormal cervical cytology in 2008

The rates of cervical cancer in the United States are low in comparison with developing nations. Whereas the Papanicolaou smear has performed well in terms of detecting both precursors of squamous cell carcinoma and squamous cell carcinoma of the cervix, this test has been less successful at identifying those women with the highest-risk premalignant disease. The use of human papillomavirus testing has also contributed to the improved sensitivity of screening for cervical cancer. In light of this, the colposcopy clinic retains high referral rates yet has poor diagnostic accuracy. Unfortunately, patients are triaged to follow-up for abnormal Papanicolaou smears based on algorithms that rely on the less evidence-based techniques of colposcopy. Therefore, the need to improve the specificity of colposcopic-guided biopsy remains. The colposcopic procedure is highlighted in this review and evaluated in terms of current literature on technique, the colposcopic impression, cervical biopsy, and methods proposed to enhance appreciation of the highest-risk lesions. By outlining certain flaws in technique and discussing the proposal of new tests to supplement the current standard of care, this review aimed to highlight the need for future research to maintain sensitivity but improve the specificity of colposcopy.