Is cervical punch biopsy enough for the management of low-grade cervical intraepithelial neoplasia?

Quantitative Proteomic Analysis of MCM3 in ThinPrep Samples of Patients with Cervical Preinvasive Cancer

Triage methods for cervical cancer detection show moderate accuracy and present considerable false-negative and false-positive result rates. A complementary diagnostic parameter could help improve the accuracy of identifying patients who need treatment. A pilot study was performed using a targeted proteomics approach with opportunistic ThinPrep samples obtained from women collected at the hospital's outpatient clinic to determine the concentration levels of minichromosome maintenance-3 (MCM3) and envoplakin (EVPL) proteins. Forty samples with 'negative for intraepithelial lesion or malignancy' (NILM), 21 samples with 'atypical squamous cells of undetermined significance' (ASC-US), and 33 samples with 'low-grade squamous intraepithelial lesion and worse' (≥LSIL) were analyzed, using cytology and the patients' histology reports. Highly accurate concordance was obtained for gold-standard-confirmed samples, demonstrating that the MCM3/EVPL ratio can discriminate between non-dysplastic and dysplastic samples. On that account, we propose that MCM3 and EVPL are promising candidate protein biomarkers for population-based cervical cancer screening.

The concordance between colposcopic biopsy and loop electrosurgical excision procedures in patients with known smear cytology and human papillomavirus results

Objective:

The objective of the study was to evaluate the concordance between colposcopic biopsy and loop electrosurgical excision procedure (LEEP) methods to diagnose cervical pre-invasive lesions and cervical cancer, and to calculate the low and high prediction rates of lesions for both methods.

Methods:

A total of 241 patients who underwent LEEP after colposcopic biopsy for different indications and also known cervical cytology and human papillomavirus test results were included in the study. Clinical variables such as age, gravida, parity, menopausal status, smoking, endocervical curettage results, and surgical margins were recorded.

Results:

The total concordance between colposcopic biopsy and LEEP was 41.9%. The rates of finding a more serious lesion than in colposcopic biopsy with LEEP (underestimation) for negative, Cervical Intraepithelial Neoplasia (CIN) 1, CIN 2, and CIN 3 were calculated as 100%, 12.8%, 14.8%, and 3.9%, respectively. Rates of finding a less serious lesion than detected in colposcopic biopsy with LEEP (overestimation) for CIN 1, CIN 2, and CIN 3, cervical carcinoma were calculated as 56.4%, 33.3%, 3.9%, and 0%, respectively. Underestimation was seen in a total of 28 patients, and overestimation was present in 113 patients. Parity was found to be the only associated factor that affected the final diagnosis for high-grade lesions in univariate logistic regression analysis (odds ratio=1.234, 95% confidence interval: 1.005–1.514).

Conclusion:

Discrepancies between colposcopically directed punch biopsy and subsequent histopathologic LEEP findings are common. New methods to reduce the inconsistency between colposcopic biopsy and LEEP are necessary to prevent patients from being under or over treated.

Optimizing the Detection of Occult Cervical Cancer: A Prospective Multicentre Study in China

Purpose

Early-stage cervical cancer is usually diagnosed by colposcopy-directed biopsy (CDB) and/or endocervical curettage (ECC), but some neglected lesions must be detected by conization because they are occult. This study aimed to explore the optimal method for detecting these "occult" cervical cancers.

Patients and Methods

A total of 1299 patients who were high-risk for early-stage cervical cancer from five centres in China were prospectively included. We evaluated the diagnostic performance of cytology, HPV testing, colposcopy and CDB&ECC for detecting "occult" cervical cancer and discussed the diagnostic importance of transformation zone (TZ) type, conization length and the proportion of cervical cone excision.

Results

The diagnostic agreement between colposcopy impression and conization was 64.5% and 72.4% between CDB&ECC and conization. Forty-two patients were finally diagnosed with pathologic cancer, and the sensitivities of cytology, colposcopy, CDB&ECC were 4.8%, 7.1%, and 47.4%, respectively. Twenty cases were neglected by CDB&ECC but further diagnosed as cancer by conization, considered to be occult cervical cancer, accounting for 1.6%. Cytologic high-grade squamous intraepithelial lesion (HSIL)+, positive HPV, biopsy HSIL+ and cervical TZ type 3 were considered risk factors for developing HSIL+, while colposcopy impression HSIL+ was not. There was a significant difference between cancerous and HSIL patients in the proportion of cervical cone excision (P<0.001), which was recognized as a risk factor (P<0.001) for detecting cancer, while the length of cervical cone excision was not. The average proportion was 0.62, and the minimal effective proportion was 0.56.

Conclusion

Since the incidence of occult cervical cancer neglected by CDB&ECC, colposcopy and cytology was far beyond expectations, conization is necessary, especially in patients with TZ type 3, high-grade cytology and biopsy results. As the cervical length varies in patients, the proportion of cervical cone excision might be a better indicator for detecting occult cervical cancer.

Loop Electrosurgical Excision Procedure in Managing Persistent Low-Grade Abnormality or Human Papillomavirus Positivity

OBJECTIVES

The aims of the study were to estimate the rate and to identify predictors of high-grade abnormalities among women with persistent low-grade abnormalities or high-risk human papillomavirus (hrHPV) positivity for at least 2 years stratified by presence (high risk) or absence (low risk) of previous high-grade results or HPV 16/18.

MATERIALS AND METHODS

A retrospective cohort study of patients who underwent a loop electrosurgical excision procedure (LEEP) for persistent low-grade or hrHPV positivity was performed. Patients were stratified based on whether they had a history of high-grade and/or HPV 16/18 positivity. Rates of high-grade or worse abnormalities on LEEP were compared using Fisher exact tests. Logistic regression was used to evaluate the associations between patient characteristics and high-grade results on the LEEP.

RESULTS

Three hundred eleven LEEPs were performed for persistent low-grade or hrHPV positivity. The rates of occult high grade were 12% and 22% among the low- and high-risk groups, respectively. Compared with those 45 years and older, the adjusted odds of high grade was 3.79 (95% CI = 1.19-12.1) for women aged 25-29 years. The odds of high grade was higher among current versus never smokers (6.40; 95% CI = 2.01-20.4) and those with a history of high-grade abnormality (2.23; 95% CI = 1.12-4.43). At 2 years, approximately half had an abnormal cytology and/or hrHPV positivity result independent of whether high grade was identified on their LEEP specimen.

CONCLUSIONS

Patients with persistent low-grade abnormalities or persistent hrHPV should be counseled on the risks and benefits of a LEEP given that 12%-22% have a risk of occult high grade, especially if they have a history of high-grade dysplasia.

Factors Correlated with the Accuracy of Colposcopy-Directed Biopsy: A Systematic Review and Meta-Analysis

PURPOSE/AIM OF THE STUDY

Colposcopy-directed cervical biopsy has played a major role in diagnosing cervical lesions. The precision of colposcopy-guided biopsy has been questioned. We analyzed several factors that may be correlated with the accuracy of biopsy.

METHODS

PubMed, EMBASE were searched from January 1, 1998 to March 1, 2020. Odds ratio with 95% confidence intervals (CIs) were calculated.

SELECTION CRITERIA

Included studies evaluated factors correlated with the accuracy of biopsy and patients' final diagnosis was established by histological examination of the specimen obtained by conization, loop electrosurgical excision procedure (LEEP), or colpohysterectomy.

RESULTS

A total of 10 studies were selected for the systematic review and meta-analysis. The pooled analysis indicated that the diagnostic inaccuracies of colposcopy-directed cervical biopsy were magnified in women who were 50 years of age or older. Postmenopausal status and transformation zone 3 type were also associated with the diagnostic inaccuracies of colposcopy-directed biopsy. High-grade squamous intraepithelial lesions had better concordance rates than low-grade squamous intraepithelial lesions. The number of vaginal deliveries, number of biopsies, and HPV type were associated with biopsy underdiagnosis and biopsy overestimation.

CONCLUSIONS

This meta-analysis found that the correlation between the histological findings at biopsy and after surgical treatment was influenced by women's age, menopausal status, and the transformation zone type. The diagnostic efficacy was also better for high-grade squamous intraepithelial lesions than for low-grade squamous intraepithelial lesions. Further large-scale randomized clinical trials are required to analyze the factors correlated with biopsy underdiagnosis and biopsy overestimation.

Pathologic discrepancies between colposcopy-directed biopsy and loop electrosurgical excision procedure of the uterine cervix in women with cytologic high-grade squamous intraepithelial lesions

Objective

To investigate pathologic discrepancies between colposcopy-directed biopsy (CDB) of the cervix and loop electrosurgical excision procedure (LEEP) in women with cytologic high-grade squamous intraepithelial lesions (HSILs).

Methods

We retrospectively identified 297 patients who underwent both CDB and LEEP for HSILs in cervical cytology between 2015 and 2018, and compared their pathologic results. Considering the LEEP to be the gold standard, we evaluated the diagnostic performance of CDB for identifying cervical intraepithelial neoplasia (CIN) grades 2 and 3, adenocarcinoma in situ, and cancer (HSIL+). We also performed age subgroup analyses.

Results

Among the study population, 90.9% (270/297) had pathologic HSIL+ using the LEEP. The diagnostic performance of CDB for identifying HSIL+ was as follows: sensitivity, 87.8%; specificity, 59.3%; balanced accuracy, 73.6%; positive predictive value, 95.6%; and negative predictive value, 32.7%. Thirty-three false negative cases of CDB included CIN2,3 (n=29) and cervical cancer (n=4). The pathologic HSIL+ rate in patients with HSIL− by CDB was 67.3% (33/49). CDB exhibited a significant difference in the diagnosis of HSIL+ compared to LEEP in all patients (p<0.001). In age subgroup analyses, age groups <35 years and 35–50 years showed good agreement with the entire data set (p=0.496 and p=0.406, respectively), while age group ≥50 years did not (p=0.036).

Conclusion

A significant pathologic discrepancy was observed between CDB and LEEP results in women with cytologic HSILs. The diagnostic inaccuracy of CDB increased in those ≥50 years of age.

Clinical factors that affect diagnostic discrepancy between colposcopically directed biopsies and loop electrosurgical excision procedure conization of the uterine cervix

Objective

This study aimed to determine the factors affecting pathologic discrepancy and final diagnosis between colposcopic biopsy and pathology by loop electrosurgical excision procedure (LEEP).

Methods

Between 2004 and 2016, 1,200 patients who underwent LEEP were enrolled for this study. 667 underwent cervical cytology, human papillomavirus (HPV) test, colposcopic biopsy, and LEEP. We analyzed patient's age, menopausal status, number of delivery, abortion times, cervical cytology, number of punch biopsies, HPV type, LEEP, and interval between colposcopic biopsy and LEEP.

Results

Logistic regression analysis of the final diagnosis showed that age 30-39 years and other high HPV group types were associated with cancer diagnosis, whereas atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H), high-grade squamous intraepithelial lesion (HSIL), and HPV type 16 affected the diagnosis of cervical intraepithelial neoplasia (CIN) 2. The overall concordance rate of histopathology between punch biopsy and LEEP was 43.3%. The rates of detecting a more severe lesion by LEEP than those by biopsy were 23.1%. The rates of a less severe lesion detected by LEEP than those by biopsy were 33.6%. Factors related with biopsy underestimation were as follows: <1 vaginal delivery, HSIL, number of punch biopsies and HPV type. Punch biopsy number is a unique factor of biopsy overestimation.

Conclusion

Patients with ASC-H, HSIL, and HPV type 16 may undergo conization immediately without colposcopic biopsy. We suggest that colposcopically directed 3 to 5 punch biopsies may be used to determine the need for conization.

Influence of knowledge of human immunodeficiency virus serostatus on accuracy of cervical cytologic diagnosis

BACKGROUND

Women who are infected with the human immunodeficiency virus (HIV) are at high risk of human papillomavirus-persistent infections. Invasive cervical cancer is listed among the illnesses associated with the acquired immunodeficiency syndrome. The objective of the current study was to investigate whether, in South Africa, the accuracy of abnormal cytology confirmed by a histological diagnosis using loop electrosurgical excision procedure (LEEP) is affected by knowledge of the woman's HIV serostatus.

METHODS

Of 7648 biopsy specimens, 941 were LEEPs indicated by a cytology report of low-grade squamous intraepithelial lesion or high-grade squamous intraepithelial lesion. A total of 618 specimens (65.7%) were from HIV-uninfected women and 323 specimens (34.3%) were from HIV-infected women. Those women with an unknown pre-LEEP cytological diagnosis were excluded from the study.

RESULTS

The total prevalence of HIV infection among the 7648 patients was 18.6%, reflecting its prevalence in the general population of women aged 15 to 49 years. The rate of HIV infection among 3462 women with invasive cervical cancer was 10.7%. The overall prevalence of preinvasive lesions was 73.9% in HIV-infected women compared with 50.3% in women not infected with HIV (P<.0001). The concordance and discordance rates between cytology and histology were similar in uninfected and infected women (P =.93 and P =.18, respectively). Among HIV-infected women, 79.1% of discordant results were due to cytological overdiagnosis; among HIV-negative women, 86.5% of discordant results were due to underdiagnosis (P<.0001).

CONCLUSIONS

It appears that the finding of a higher prevalence of preinvasive lesions combined with the knowledge of a patient's HIV-positive serostatus prompts more cytological overdiagnosis, thereby resulting in avoidable LEEP interventions.