Novel advancements in colposcopy: historical perspectives and a systematic review of future developments

Clinical application of the 2011 IFCPC colposcope terminology

BACKGROUND

Colposcopy offers an accurate way to the diagnose of cervical precancerous lesions. However, the diagnostic accuracy of colposcopy is unsatisfied. This study was to evaluate colposcopic accuracy according to the 2011 International Federation of Cervical Pathology and Colposcopy (IFCPC) terminology.

METHODS

A retrospective cohort study was performed in 1,838 patients who underwent colposcopy in Shandong Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University from October 2013 to April 2018. Using conization or cervical biopsy pathology as the gold standard, the agreement between colposcopic diagnosis and pathologic diagnosis was calculated, and correlations between variables were analyzed.

RESULTS

As an authoritative and widely used terminology for colposcopy diagnosis, the 2011 IFCPC terminology has certain clinical practicality and diagnostic accuracy. However, some signs such as mosaic, punctation, sharp border, inner border sign and ridge sign had high specificity but unsatisfactory sensitivity, which limited the diagnostic value. Therefore, we discussed the Lugol's staining, a very common sign in colposcopy, and analyzed the diagnostic significance of bright yellow staining in low-grade squamous intraepithelial lesion (LSIL) and mustard yellow staining in high-grade squamous intraepithelial lesion (HSIL). The results showed that mustard yellow may be a valuable indicator in the diagnosis of HSIL.

CONCLUSION

The 2011 IFCPC colposcope terminology has standardized interpretations of the colposcopic findings and improved the accuracy of colposcopy diagnosis. The aceto-white epithelium still has important diagnostic value; however, the value of a few signs is needed to be discussed and new signs are expected to be discovered. Although the significance of Lugol's staining was diminishing, mustard yellow might be a valuable indicator for the diagnosis of HSIL.

Real-time in-vivo microscopic imaging of the cervix using confocal laser endomicroscopy: preliminary observations and feasibility study

Confocal laser endomicroscopy (CLE) enables in-vivo, real-time, imaging of tissues with a micron-scale resolution through a fiber optic probe. CLE could be a valuable tool for the detection and characterization of suspicious (dysplastic) areas on the uterine cervix in a minimally invasive manner. This study evaluates the technical feasibility and safety of CLE on the cervix. The study also aims to create a preliminary iconography of normal and dysplastic squamous and columnar cervical epithelium. In-vivo CLE was performed on nine patients scheduled for a cervical loop electric excision procedure for high-grade superficial intraepithelial lesions. The CLE images were compared with standard hematoxylin and eosin analysis of loop electric excision procedure specimens. The histopathological diagnosis on the surgical specimen was established as per standard of care. CLE images were then reviewed by pathologists to point out specific histopathological features. pCLE of the exocervix and the transformation zone was performed successfully on seven out of nine patients. Uninterpretable images were obtained in two other cases: one using the AlveoFlex and one using the GastroFlex UHD after the application of acetic acid 2%. A total of 82.5% of the sequences recorded with the GastroFlex were suitable for interpretation. No adverse event or complications occurred. CLE enables proper in-vivo imaging of healthy and dysplastic cervical tissue. Images correlate well with the histopathological features established through traditional histology. Future blinded prospective analysis will determine the reliability of the real-time diagnosis and its potential use in the assessment and treatment of cervical lesions.

Alternative Colposcopy Techniques: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the diagnostic value of alternative (digital) colposcopy techniques for detection of cervical intraepithelial neoplasia (CIN) 2 or worse in a colposcopy population.

DATA SOURCES

MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Library were searched from inception up to January 11, 2016, for studies that evaluated the diagnostic value of alternative (digital) colposcopy techniques.

METHODS OF STUDY SELECTION

Inclusion criteria were: 1) an alternative (digital) colposcopy technique was used in a colposcopy population; 2) a histologic outcome was reported, classified as CIN, differentiating between mild dysplasia or less (CIN 1 or less), and moderate dysplasia or worse (CIN 2 or greater); 3) the entire cervix was scanned at once or a per-woman analysis was performed; 4) no other topical application than acetic acid and Lugol's solution was used; 5) at least three eligible studies had to be available within a single technique; and 6) studies obtained research ethics approval. Language was restricted to English.

TABULATION, INTEGRATION, AND RESULTS

Two reviewers assessed the eligibility of the identified articles. Disagreements were resolved by a third reviewer. Thirteen studies met the inclusion criteria. We found six studies on fluorescence and reflectance spectroscopy, including 2,530 women, with a pooled sensitivity of 93% (95% confidence interval [CI] 89-95%) and specificity of 62% (95% CI 47-76%). Four studies on dynamic spectral imaging were found including 1,173 women with a pooled sensitivity of 69% (95% CI 48-85%) and specificity of 83% (95% CI 76-88%). We found three studies on optical coherence tomography including 693 women with a pooled sensitivity of 48% (95% CI 32-64%) and specificity of 77% (95% CI 52-91%). Previously published conventional colposcopy results showed a sensitivity of 61% (95% CI 58-63%) and a specificity of 85% (95% CI 83-86%).

CONCLUSION

Alternative (digital) colposcopy techniques may result in increased sensitivity and specificity, but no recommendation for introduction in clinical practice can be made yet.

The Use of the Colposcopically Directed Punch Biopsy in Clinical Practice: A Survey of British Society of Colposcopy and Cervical Pathology (BSCCP)-Accredited Colposcopists

OBJECTIVES

The colposcopically directed punch biopsy has been an integral component of colposcopic practice. In light of the changing landscape of the cervical screening programme, a study was conducted to investigate the current practice of British Society of Colposcopy and Cervical Pathology-accredited colposcopists on technique and rationale for performing a punch biopsy.

MATERIALS AND METHODS

A web-based questionnaire survey was e-mailed to all British Society of Colposcopy and Cervical Pathology-accredited colposcopists. Questions included selection criteria for performing a punch biopsy, number of biopsies, and technique. Results were analyzed by specialty, experience, and workload.

RESULTS

A total of 749 colposcopists responded, 50.2% of the 1,493 total. The respondents were obstetrician and gynecologists (42.9%), gynecologists/oncologists (33.6%), and nurse colposcopists (19.8%). Most colposcopists (78.3%) had more than 5-year colposcopy experience and saw in excess of 11 new cases (73.4%) of abnormal cervical cytology/month. Most colposcopists (56%) aimed to take 2 biopsies to diagnose cervical intraepithelial neoplasia, and very few (16.2%) reported routinely taking random biopsies from normal areas of cervix. Looking at the trends in management in the case scenarios, there was a lower threshold for performing punch biopsy before large loop excision of the transformation zone in younger (age, <25 years) or nulliparous women versus older women (age, >40 years; p < .05). Colposcopists were more likely to take biopsies in women with low-grade cytology/colposcopic findings (71.2%, always or most of the times) as compared with high-grade cytology/colposcopic findings (40.3%, never or rarely).

CONCLUSIONS

Colposcopically directed punch biopsy is routinely used by colposcopists; however, techniques, number of biopsies taken, and rationale for performing a biopsy vary greatly between colposcopists.

Quantification of confocal fluorescence microscopy for the detection of cervical intraepithelial neoplasia

BACKGROUND

Cervical cancer remains a major health problem, especially in developing countries. Colposcopic examination is used to detect high-grade lesions in patients with a history of abnormal pap smears. New technologies are needed to improve the sensitivity and specificity of this technique. We propose to test the potential of fluorescence confocal microscopy to identify high-grade lesions.

METHODS

We examined the quantification of ex vivo confocal fluorescence microscopy to differentiate among normal cervical tissue, low-grade Cervical Intraepithelial Neoplasia (CIN), and high-grade CIN. We sought to (1) quantify nuclear morphology and tissue architecture features by analyzing images of cervical biopsies; and (2) determine the accuracy of high-grade CIN detection via confocal microscopy relative to the accuracy of detection by colposcopic impression. Forty-six biopsies obtained from colposcopically normal and abnormal cervical sites were evaluated. Confocal images were acquired at different depths from the epithelial surface and histological images were analyzed using in-house software.

RESULTS

The features calculated from the confocal images compared well with those features obtained from the histological images and histopathological reviews of the specimens (obtained by a gynecologic pathologist). The correlations between two of these features (the nuclear-cytoplasmic ratio and the average of three nearest Delaunay-neighbors distance) and the grade of dysplasia were higher than that of colposcopic impression. The sensitivity of detecting high-grade dysplasia by analysing images collected at the surface of the epithelium, and at 15 and 30 μm below the epithelial surface were respectively 100, 100, and 92 %.

CONCLUSIONS

Quantitative analysis of confocal fluorescence images showed its capacity for discriminating high-grade CIN lesions vs. low-grade CIN lesions and normal tissues, at different depth of imaging. This approach could be used to help clinicians identify high-grade CIN in clinical settings.