Accuracy of colposcopy-directed biopsy vs dynamic spectral imaging directed biopsy in correctly identifying the grade of cervical dysplasia in women undergoing conization: A methodological study

The Incidence of Cervical Intraepithelial Neoplasia or Cervical Cancer in Women Referred With Postcoital Bleeding

OBJECTIVES

The incidence of cervical cancer among patients with postcoital bleeding (PCB) was the primary objective of this study. Furthermore, the proportion of cervical intraepithelial neoplasia requiring treatment and the correlation between PCB and the presence of high-risk human papillomavirus (HPV) was determined. Lastly, the study aimed to identify risk factors among the referred women.

METHODS

A retrospective cohort study was conducted at a university hospital in Denmark between January 1, 2017 and December 31, 2019. Women referred with PCB were identified with the ICD diagnosis codes "DN930 Postcoital and contact bleeding" and "DN930B Contact bleeding." Demographic and paraclinical data were extracted from the journals and the supportive systems: Patoweb and the Danish Microbiology Database.

RESULTS

A total of 789 women were included in this study, with only 0.25% ( n = 2) diagnosed with cervical cancer and 2.5% ( n = 20) diagnosed with cervical intraepithelial neoplasia II-III and adenocarcinoma in situ. Human papillomavirus testing was only conducted in a minority of cases, and a low incidence of high-risk human papilloma virus was detected in the 22 cases, n = 5.

CONCLUSIONS

A very low incidence of cervical cancer and high-grade cervical intraepithelial neoplasia reported among women referred with PCB. Prognostic factors as body mass index, smoking, and HPV vaccination status may predict the risk of cervical cancer. Selection criteria like primary testing for hrHPV and cytology as cotests before referral to colposcopy may reduce the number of unnecessary colposcopies.

Agreement on Lesion Presence and Location at Colposcopy

OBJECTIVES/PURPOSE

The reproducibility and sensitivity of image-based colposcopy is low, but agreement on lesion presence and location remains to be explored. Here, we investigate the interobserver agreement on lesions on colposcopic images by evaluating and comparing marked lesions on digitized colposcopic images between colposcopists.

METHODS

Five colposcopists reviewed images from 268 colposcopic examinations. Cases were selected based on histologic diagnosis, i.e., normal/cervical intraepithelial neoplasia (CIN)1 ( n = 50), CIN2 ( n = 50), CIN3 ( n = 100), adenocarcinoma in situ ( n = 53), and cancer ( n = 15). We obtained digitized time-series images every 7-10 seconds from before acetic acid application to 2 minutes after application. Colposcopists were instructed to digitally annotate all areas with acetowhitening or suspect of lesions. To estimate the agreement on lesion presence and location, we assessed the proportion of images with annotations and the proportion of images with overlapping annotated area by at least 4 (4+) colposcopists, respectively.

RESULTS

We included images from 241 examinations (1 image from each) with adequate annotations. The proportion with a least 1 lesion annotated by 4+ colposcopists increased by severity of histologic diagnosis. Among the CIN3 cases, 84% had at least 1 lesion annotated by 4+ colposcopists, whereas 54% of normal/CIN1 cases had a lesion annotated. Notably, the proportion was 70% for adenocarcinoma in situ and 71% for cancer. Regarding lesion location, there was no linear association with severity of histologic diagnosis.

CONCLUSION

Despite that 80% of the CIN2 and CIN3 cases were annotated by 4+ colposcopists, we did not find increasing agreement on lesion location with histology severity. This underlines the subjective nature of colposcopy.

Untreated cervical intraepithelial neoplasia grade 2 and subsequent risk of cervical cancer: population based cohort study

OBJECTIVE

To describe the long term risk of cervical cancer in women with untreated (that is, undergoing active surveillance) or immediately treated cervical intraepithelial neoplasia grade 2 (CIN2).

DESIGN

Nationwide population based historical cohort study.

SETTING

Danish healthcare registries.

PARTICIPANTS

Women with CIN2 diagnosed in 1998-2020 and aged 18-40 years at diagnosis, who had either active surveillance or immediate treatment with large loop excision of the transformation zone (LLETZ). Women with a previous record of CIN2 or worse or LLETZ were excluded.

MAIN OUTCOME MEASURE

A Weibull survival model for interval censored time-to-event data was used to estimate the cumulative risk of cervical cancer. Inverse probability treatment weighting was used to adjust estimates for age, index cytology, calendar year, and region of residence.

RESULTS

The cohort included 27 524 women with CIN2, of whom 12 483 (45%) had active surveillance and 15 041 (55%) had immediate LLETZ. During follow-up, 104 cases of cervical cancer were identified-56 (54%) in the active surveillance group and 48 (46%) in the LLETZ group. The cumulative risk of cervical cancer was comparable across the two groups during the active surveillance period of two years. Thereafter, the risk increased in the active surveillance group, reaching 2.65% (95% confidence interval 2.07% to 3.23%) after 20 years, whereas it remained stable in the LLETZ group at 0.76% (0.58% to 0.95%).

CONCLUSIONS

Undergoing active surveillance for CIN2, thereby leaving the lesion untreated, was associated with increased long term risk of cervical cancer compared with immediate LLETZ. These findings show the importance of continued follow-up of women having active surveillance.

European consensus statement on expert colposcopy

BACKGROUND

Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease.

AIMS

To provide expert guidance on complex colposcopy cases through published evidence and expert consensus.

MATERIAL & METHODS

Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics.

RESULTS & DISCUSSION

The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

Added value of electrical impedance spectroscopy in adjunction of colposcopy: a prospective cohort study

OBJECTIVE

To assess whether electrical impedance spectroscopy (EIS) as an adjunctive technology enhances the performance of colposcopy.

DESIGN

Prospective cohort study.

SETTING

University Hospital colposcopy clinic.

PARTICIPANTS

Colposcopy with EIS for 647 women and conventional colposcopy for 962 women.

INTERVENTIONS

Comparison of the performance of colposcopy by referral cervical cytology in two cohorts, with and without EIS as an adjunctive technology.

OUTCOME MEASURES

Prevalence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+), diagnostic testing accuracy to detect CIN2+ with and without EIS and their relative differences between cohorts.

RESULTS

The prevalence of CIN2+ varied between the cohorts according to referral cytology: 17.0% after abnormal squamous cells of unknown significance referral cytology in EIS cohort and 9.1% in the reference cohort, 16.5% and 18.9% after low-grade squamous intraepithelial lesion (LSIL), 44.3% and 58.2% after atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (HSIL) (atypical squamous cells that cannot exclude HSIL), and 81.9% and 77.0% after HSIL cytology, respectively. Sensitivity to detect CIN2+ was higher in the EIS cohort, varying from 1.79 (95% CI 1.30 to 2.45) after LSIL referral cytology to 1.16 (95% CI 1.09 to 1.23) after HSIL referral cytology, with correspondingly lower specificity after any referral cytology.

CONCLUSIONS

Colposcopy with EIS had overall higher sensitivity but lower specificity to detect CIN2+ than conventional colposcopy. CIN2+ prevalence rates were, however, not consistently higher in the EIS cohort, suggesting innate differences between the cohorts or truly lower detection rates of CIN2+ for EIS, highlighting the need for randomised controlled trials on the effectiveness of EIS.

Cervical intraepithelial neoplasia in women with transformation zone type 3: cervical biopsy versus large loop excision

OBJECTIVE

To compare the proportion of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in cervical biopsies with that in large loop excision of the transformation zone (LLETZ) specimens in women aged ≥45 years with transformation zone type 3 (TZ3).

DESIGN

Multicentre cross-sectional study.

SETTING

Three colposcopy clinics in the Central Denmark Region.

POPULATION

Women aged ≥45 years referred to colposcopy as a result of a positive human papillomavirus (HPV) test and/or abnormal cytology and with TZ3 at colposcopy.

METHODS

Women had multiple biopsies taken and an LLETZ was performed.

MAIN OUTCOME MEASURES

Histologically confirmed CIN2+ in biopsies compared with that in LLETZ specimens.

RESULTS

Of 166 eligible women at colposcopy, 102 women with paired data from biopsies and LLETZ specimens were included for final analysis. The median age was 67.7 years (IQR 62.6-70.4 years), and most were postmenopausal (94.1%) and had undergone HPV-based screening (81.3%). The CIN2+ detection rate was significantly higher in LLETZ specimens than in biopsies (32.4% vs 14.7%, difference 17.7%, 95% CI 6.3-29.0%), resulting in more than half of CIN2+ cases being missed in biopsies (54.5%, 95% CI 36.4-71.9%). The overall agreement between biopsies and LLETZ was 82.4% (95% CI 73.6-89.2%).

CONCLUSIONS

CIN2+ detection is underestimated in women aged ≥45 years with TZ3 if detection relies on the results of biopsies alone. To reduce the risk of underdiagnosis and overtreatment, future studies should explore the use of new biomarkers for risk stratification to improve discrimination between women at increased risk of CIN2+ who need to undergo LLETZ and women who may undergo follow-up.

Value of colposcopy with dynamic spectral imaging in the detection and evolution of high-grade cervical lesions

OBJECTIVE

To analyze the performance of colposcopy assisted with dynamic spectral imaging (CC-DSI) compared to conventional colposcopy (CC) in diagnosing cervical intraepithelial neoplasia 2+ (CIN2+).

METHODS

: 973 consecutive women were referred for colposcopy between 2012 and 2016 and were examined simultaneously by CC and CC-DSI; 877 were eligible. Comparisons between CC and CC-DSI were performed against the histological diagnosis performed by either punch biopsy or loop electrosurgical excision procedure (LEEP).

RESULTS

: In final histology, 494 women had no CIN, 250 had CIN1 and 133 had CIN2+. The sensitivity to identify women with CIN2+ was significantly higher for CC-DSI compared to CC for the entire group and in the subgroup of 675 women referred with ASCUS or LSIL. In women with HPV16/18 infections, the sensitivity of CC increased with the addition of DSI from 53% to 79% (p<0.001). Using a multivariant Cox regression model, CC-DSI was an independent factor for progression of the cervical lesions (HR: 2.29, 95%CI 1.07-4.90). Other predictive factors were the number of sexual partners (HR: 1.05, 95%CI: 1.01-1.09) and anal intercourse (HR: 2.45, 95%CI 1.23-5.02).

CONCLUSION

CC-DSI improves the ability to detect cervical lesions compared to CC and could help predict their potential to progress.

When is There no Benefit in Performing a Biopsy in the Suspicion of Intraepithelial Lesions of the Cervix?

OBJECTIVE

 To evaluate whether colposcopy-directed biopsy is necessary to increase the accuracy of diagnosing cervical intraepithelial lesions in relation to colposcopy.

METHODS

 We performed a retrospective, observational study by analyzing medical records obtained from Hospital de Clínicas do Paraná from February 2008 to February 2018. Patients with results of Pap tests, colposcopy, colposcopy-directed biopsy, and surgical procedures (high-frequency surgery or cold conization) were included. Data such as quadrants involved during colposcopy and age differences were also analyzed.

RESULTS

 A total of 299 women were included. Colposcopy was found to have an accuracy rate of 76.25% (95% confidence interval [CI], 71.4-81.1). Among the highest-grade lesions, the accuracy rate was 80.5% (95% CI, 75.7-85.3). The accuracy rates for biopsy were 79.6% (95% CI, 75-84.2) and 84.6% (95% CI, 80-89.1) for the highest-grade lesions. High-grade lesions were accurately confirmed in 76.9% and 85% of patients with 1 and 2 or more affected quadrants, respectively. For women younger than 40 years, the accuracy rates were 77.6% and 80.8% for colposcopy and biopsy, respectively. For women 40 years or older, the accuracy rates were 72.5% and 76.3% for colposcopy and biopsy, respectively.

CONCLUSION

 There is no difference between the accuracy of colposcopy and that of biopsy in diagnosing cervical intraepithelial lesions in relation with the result of conization. The patients who received the greatest benefit when biopsy was not performed were those with high-grade lesions at colposcopy, a lesion involving 2 or more quadrants, and those younger than 40 years.

Can biopsies be omitted after normal colposcopy in women referred with low-grade cervical cytology? A prospective cohort study

Background

Controversy surrounds whether women with low-risk cytology screening results but a normal colposcopic assessment should have random biopsies taken. The aim of this study was to determine the yield of CIN2+ from one to four cervical biopsies in women with cytology of LSIL or ASCUS and a normal colposcopic impression.

Methods

Between January 2017 and September 2020, women over 18 years old referred for colposcopic examination due to either an abnormal smear (ASCUS+) or follow-up after previous cervical intraepithelial neoplasia (CIN) were invited to participate in the study. All study participants underwent colposcopic examination and had four biopsies taken. The biopsies were analyzed separately.

Results

In total, 1327 women with abnormal cervical cancer screening results or attending follow-up after a previous CIN diagnosis were enrolled in the study and examined by colposcopy. Of these, 173 were newly referred with cytology of LSIL or ASCUS and had a normal colposcopic impression and four adequate biopsies. Of these, 22.0% were diagnosed with CIN2+. When combining the results of the four biopsies, we found a 100% relative increase in CIN2+ cases compared to using only one biopsy (from 11.0% to 22.0%, P = 0.006).

Conclusion

As we found CIN2+ from random cervical biopsies in 22.0% of women with cytology of LSIL or ASCUS who had a normal colposcopic impression, we advocate performing four random cervical biopsies at the squamocolumnar junction in such women.

Trial registration NCT04249856, January 31 2020 (retrospectively registered).

Dynamic Spectral Imaging Colposcopy Versus Regular Colposcopy in Women Referred With High-Grade Cytology: A Nonrandomized Prospective Study

OBJECTIVE

The aim of the study was to evaluate the sensitivity of dynamic spectral imaging (DSI) colposcopy compared with regular colposcopy for women referred with high-grade cervical cytology.

METHODS

In a prospective, nonrandomized, multicenter study, we included women referred for colposcopy at hospital gynecology clinics with high-grade cytology. Women were examined using either a regular or DSI colposcope. In both groups, colposcopists located 1 area viewed as most suspicious. In the DSI group, this was done before viewing the DSI map. Subsequently, an area was chosen based on the worst color of the DSI map, and further additional biopsies were taken. All women had 4 cervical biopsies taken, all analyzed separately. The main outcome was sensitivity to find cervical intraepithelial neoplasia grade 2 or worse (CIN2+).

RESULTS

A total of 261 women were examined using DSI colposcopy, and 156 women were examined using regular colposcopy. The sensitivity for finding CIN2+ when using the DSI technology as an adjunctive technology was found to be 82.2% (95% CI = 75.9-87.4), based on an average of 1.4 biopsies. This was corresponding in sensitivity to 2 biopsies taken using regular colposcopy (80.3%; 95% CI = 72.3-86.8). There was no difference in sensitivity for CIN+ between the groups when 3 or more biopsies were taken.

CONCLUSIONS

We found that the DSI colposcope may help direct biopsy placement; however, the improvement is based on small differences in needed biopsies and the clinical significance of this may be small. Multiple biopsies were still superior.

Can the dynamic spectral imaging (DSI) color map improve colposcopy examination for precancerous cervical lesions? A prospective evaluation of the DSI color map in a multi-biopsy clinical setting

Background

Colposcopy serves as a subjective examination of the cervix with low sensitivity to detect cervical intraepithelial dysplasia (CIN) grade 2 or worse (CIN2 +). Dynamic spectral imaging (DSI) colposcopy has been developed to provide an objective element to cervix examinations and has been proven to increase sensitivity of detecting CIN2 + . We aimed to assess the performance of the DSI color map and compared it to histological diagnoses of cervical biopsies in determining the CIN grade present.

Methods

Women were included in a consecutive, prospective manner at Randers Regional Hospital, Denmark. Women were eligible to participate if they were referred for colposcopy due to abnormal cervical smear (threshold:  ≥ ASCUS) or follow-up after previously diagnosed CIN. All women had four biopsies taken, one directed by colposcopists alone prior to viewing the DSI color map, one directed by the worst color on the respective DSI color map, and two additional biopsies. All biopsies were analyzed separately. We calculated sensitivity, specificity, positive predictive values, and negative predictive values (NPVs) with 95% confidence intervals (CIs).

Results

A total of 800 women were recruited. Of these, 529 (66.1%) were eligible for inclusion. The sensitivity of the DSI color map was found to be 48.1% (95% CI 41.1–55.1) in finding CIN grade 2 or worse (CIN2 +) when compared to the histological diagnosis of the DSI directed biopsy. This was 42.5% (95% CI 36.7–48.5) when compared to the final histological diagnosis of all four cervical biopsies and with an NPV of 53.5% (95% CI 50.5–56.5).

Conclusion

The worst color indicated by the DSI map might not consistently reflect the true grade of cervical dysplasia present. Thus, even though the DSI color map indicates low-grade changes, colposcopists should still consider taking biopsies from the area as high-grade changes might be present.

Trial registration: NCT04249856, January 31 2020 (retrospectively registered).