Reliability of colposcopy and directed punch biopsy

Genome-integrated Human Papilloma Viruses Testing: A Complement to Colposcopy-guided Biopsy for Cervical Cancer Screening

OBJECTIVE

Our research aims to evaluate the diagnostic accuracy of colposcopy-guided biopsy (CGB) in detecting high-grade cervical lesions and explore how human papilloma virus (HPV) integration status and other factors affect its performance.

METHODS

A retrospective cohort analysis involving 550 patients was conducted to evaluate whether the HPV integration plays a role in identifying high-grade cervical lesions and cervical cancer. Logistic regression models and area under the curve (AUC) calculations were employed.

RESULTS

Our findings revealed that 53.5% of CGB/surgery pairs demonstrated congruent diagnoses, whereas 17.1% showed underestimation and 29.5% overestimation. Furthermore, multivariate logistic regression analysis identified several key predictors for cervical intraepithelial neoplasia (CIN)2+ and CIN3+ according to surgical pathology. Notably, a CGB confirming CIN2+ [odds ratio (OR)=6.0, 95% confidence interval (CI): 3.9-9.1, P<0.001], high-grade cytology (OR=2.6, 95% CI: 1.4-1.9, P=0.003), and HPV integration positivity (OR=2.2, 95% CI: 1.3-3.5, P<0.001) emerged as significant factors for CIN2+. Similarly, for CIN3+ identification, CGB confirming CIN2+ (OR=5.3, 95% CI: 3.4-8.3, P<0.001), high-grade cytology (OR=2.6, 95% CI: 1.5-4.7, P=0.001), and HPV integration positivity (OR=2.0, 95% CI: 1.3-3.1, P=0.003) were independent predictors.

CONCLUSION

Our study highlights the innovative role of HPV integration testing as a pivotal adjunct to CGB and cytology, offering a comprehensive approach that may enhance the diagnostic precision for high-grade cervical lesions, ultimately achieving more precise management strategies.

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.

Diagnostic accuracy of guided cervical biopsies: a prospective multicenter study comparing the histopathology of simultaneous biopsy and cone specimen

OBJECTIVE

We sought to determine the validity of colposcopically directed cervical biopsies as a diagnostic test to define the degree of cervical intraepithelial neoplasia (CIN).

STUDY DESIGN

In a prospective multicenter trial, patients undergoing excisional procedures of the transformation zone additionally had colposcopy and up to 3 guided cervical biopsies in a single procedure. Cervical biopsies were regarded as a diagnostic test to detect high-grade lesions (CIN 2,3), with the cone specimen as reference standard.

RESULTS

In all, 488 biopsies were performed in 244 cases, with 2 biopsies done in 192 cases. Cervical biopsies underestimated the severity of lesions in 46.7% of cases. Sensitivity, specificity, and positive and negative predictive values were 66.2% (95% confidence interval [CI], 59.4-72.3), 95.0% (95% CI, 83.5-98.6), 98.5% (95% CI, 94.8-99.6), and 35.5% (95% CI, 27.1-44.9), respectively.

CONCLUSION

Our data suggest that cytologically suspected high-grade lesions (CIN 2,3) can be confirmed by biopsy in many cases, but they cannot be excluded.

Screening history of women with cervical cancer: a 6-year study in Aarhus, Denmark

To identify possible weaknesses in cervical screening in Aarhus County, 10 years after the programme was introduced, screening histories were examined. A major problem for the screening programme was that 31% of women were never screened and 61% under-screened, the latter group being significantly dominated by older women and high-stage tumours.

Increased detection of high-grade cervical intraepithelial neoplasia utilizing an optical detection system as an adjunct to colposcopy

OBJECTIVE

To evaluate the impact of using a novel optical detection system (ODS) as an adjunct to colposcopy.

METHODS

A multicenter internally controlled trial designed to evaluate the performance of an ODS system (LUMA MediSpectra, Lexington, MA) used as an adjunct to colposcopy among women referred for the evaluation of an abnormal cervical cytology result was conducted at 7 colposcopy clinics in the United States and enrolled 227 women. After exclusions, 193 women remained in the analysis. The main study outcomes were incremental increases in true positives (CIN 2,3 and cancer, or CIN 2+) and false positives (women with additional cervical biopsies not found to be CIN 2+).

RESULTS

Initial colposcopy identified 41 cases of CIN 2+ for a true positive (TP) rate of 21.2%. Adjunctive use of ODS identified an additional 9 cases of CIN 2+ which corresponds to an incremental ODS TP rate of 4.7% (95% CI 2.2% to 8.7%). Adjunctive use of ODS therefore resulted in a 22.0% (95% CI 6.1% to 37.8%) relative gain in the number of women with CIN 2+ compared to colposcopy alone. The false positive (FP) rate for initial colposcopy was 51.8% (100 of 193 women). An additional 35 subjects had an ODS-directed biopsy that was not diagnosed as CIN 2+, yielding an incremental FP rate of 18.1% (95% CI 13.0% to 24.3%).

CONCLUSIONS

Adjunctive use of ODS with colposcopy provides a significant increase in the detection of CIN 2+ in women referred for the evaluation of abnormal cytology results.

Effective cervical neoplasia detection with a novel optical detection system: A randomized trial

OBJECTIVE

To assess whether the use of a novel optical detection system (ODS) as an adjunct to colposcopy increases the detection of biopsy-confirmed CIN 2,3.

METHODS

This is a multicenter two-arm randomized trial comparing colposcopy alone with colposcopy plus a pre-commercial ODS system that utilizes fluorescence, white light tissue reflectance, and cervical video imaging. Patients were recruited from 13 colposcopy clinics in a variety of practice settings. 2299 women referred for the evaluation of an abnormal cervical cytology were randomized with stratification by cytology; subsequently 113 women were excluded for a variety of reasons. The main study outcomes were differences in true-positive rates (CIN 2,3 and cancer identified) and false-positive rates between the study arms.

RESULTS

The true-positive (TP) rates were 14.4% vs. 11.4% (p=0.035, one-sided) for the combined colposcopy and ODS arm compared to colposcopy-only arm, respectively, in women with either an atypical squamous cell (ASC) or low-grade squamous intraepithelial lesion (LSIL) cytology result. TP rates were similar between the two arms among women referred for the evaluation of HSIL. The 26.5% gain in true-positives observed with the use of ODS and colposcopy among women referred for an ASC or LSIL cytology was achieved with only a fractional increase in number of biopsies obtained per patient (0.30) and a modest increase in false-positive rate (4%). In the combined colposcopy and ODS arm among women with ASC or LSIL, the PPV of biopsies indicated by ODS was 15.0% and the PPV of biopsies indicated by colposcopy was 15.2%. Joint hypothesis testing indicates that ODS and colposcopy provides benefit compared to colposcopy alone among women with ASC or LSIL.

CONCLUSIONS

Combining ODS with colposcopy provides a clinically meaningful increase in the detection of CIN 2,3 in women referred for the evaluation of mildly abnormal cytology results.

Colposcopic management of high-grade referral smears: a retrospective audit supporting 'see and treat'?

OBJECTIVE

The National Health Service Cervical Screening Programme monitors the quality of colposcopy services through the annual KC65 returns. The 2002 returns demonstrated that Standard 7c, which specifies a biopsy rate > or = 90% at first colposcopy visit for high-grade referrals, was not met in the assessed 3-month period. This was investigated along with the other standards.

METHODS

Retrospective colposcopy records were accessed for the 597 new referrals, excluding 10 pregnant patients, seen at the colposcopy clinic at the Royal Victoria Infirmary between 1 July 2001 and 31 December 2002, following an abnormal high-grade smear. Cytology and histopathology computer records were checked for confirmation. The results were assessed against the colposcopy standards applicable at that time and the revised standards (2004).

RESULTS

Biopsies were taken from 94.47% (Standard > or = 90%) of women at index colposcopy visit including wire loop excision biopsies from 66.16% (87.97% of high-grade colposcopic appearances). Cervical intraepithelial neoplasia (CIN) on histology was found in 91.79% in the study group (Standard > or = 85%) and in 96.71% of index visit biopsies (Standard > or = 90%), meeting the applicable colposcopy standards. The revised 2004 standards specify a biopsy in > or = 95% of high-grade referrals and excision biopsies in 95% if colposcopic appearances are also high-grade, if colposcopy is low grade but the smear is severely dyskaryotic, or when the lesion extends into the canal. The positive predictive value of high-grade cytology for this entire group was 75.54% with CIN present in 90.95%.

CONCLUSION

From this study it appears that high-grade cytology in this centre reliably indicates high-grade CIN. Therefore, in women referred for colposcopy following a high-grade smear, excision biopsies should be performed in a higher proportion at the first visit to comply with the revised standards.

Pre-invasive cervical disease and uterine cervical cancer in Brazilian adolescents: prevalence and related factors

The objective was to describe the prevalence and factors associated with uterine cervical cancer (CA) and high-grade squamous intraepithelial lesions (HSIL) in adolescents. A cross-sectional study was carried out with 702 sexually active adolescents treated at a general hospital in Rio de Janeiro, Brazil, from 1993 to 2002. Screening was performed by cytopathology and colposcopy and confirmation by biopsy. Exposure variables were socio-demographic characteristics and those related to reproductive health, habits, and sexual behavior. Adjusted odds ratios were estimated using multivariate logistic regression analysis. Based on histopathology, the prevalence of HSIL/CA was 3% (95%CI: 1.8-4.6). There was one case of invasive cancer. With each additional pregnancy, the odds of HSIL/CA increased by 2.2 (95%CI: 1.1-4.4). Age was also associated with this outcome, doubling the odds of acquiring this degree of disease with each year of age (OR = 2.0; 95%CI: 1.2-3.4). The prevalence of lesions suggests the importance of including sexually active adolescent females in cervical cancer screening programs aimed at early detection and treatment of these lesions.

Detection of cervical high-grade squamous intraepithelial lesions from cytologic samples using a novel immunocytochemical assay (ProEx™ C)

BACKGROUND

Routine liquid-based cytology (LBC) provides excellent sensitivity for the detection of cervical high-grade squamous intraepithelial lesion (HSIL); however, its specificity is low. Consequently, many women who have atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesion (LSIL) cytology undergo unnecessary colposcopy. The authors hypothesized that a novel immunocytochemical assay (ProEx C) that can be performed on LBC slides had a significantly higher positive predictive value (PPV) for biopsy-proven HSIL compared with routine LBC.

METHODS

The ProEx C immunocytochemical assay utilizes a cocktail of monoclonal antibodies directed against proteins associated with aberrant S-phase cell cycle induction (topoisomerase IIA, minichromosome maintenance protein 2). The ProEx C reagents were validated in the authors' laboratory for staining and scoring reproducibility, open-vial stability, and accuracy before a retrospective analysis using these reagents was performed on 317 residual cytology samples. Sensitivity, specificity, PPV, and negative predictive value (NPV) for the detection of biopsy-proven HSIL were determined.

RESULTS

The ProEx C assay was validated successfully in the authors' cytology laboratory. Using biopsy-proven HSIL as an endpoint, the ProEx C assay yielded a sensitivity of 85.3%, specificity of 71.7%, PPV of 44.6%, and NPV of 94.8%. Compared with the routine LBC results in the same cohort, the ProEx C sensitivity for biopsy-proven HSIL was 70.6% greater than HSIL+ cytology (50% vs. 85.3%). ProEx C also showed a 114% increase in PPV relative to ASC-US cytology (21.1% vs. 44.6%).

CONCLUSIONS

The ProEx C immunocytochemical assay can be integrated into a clinical cytology laboratory and may increase the PPV of LBC for biopsy-proven HSIL.

Use of loop electrosurgical excision procedure specimens to provide tissue fractions for immunologic analyses

OBJECTIVE

To determine if dividing loop electrosurgical excision procedure (LEEP) specimens to provide tissue for research increases rates of LEEP specimen misdiagnosis and recurrent cervical intraepithelial neoplasia.

MATERIALS AND METHODS

In this chart review, 42 women with biopsy-confirmed cervical intraepithelial neoplasia (CIN) 2,3 had up to 20% of their LEEP specimens sectioned and used for immunologic analysis. The remainder of each specimen was assessed routinely. Follow-up cytologic analyses and cervical biopsies also were assessed. This cohort was compared with a control cohort of 80 patients with biopsy confirmed CIN 2,3 whose LEEP specimens were not divided. Statistical significance was defined as a p value of < .05.

RESULTS

There were no statistically significant differences between the groups with regard to histologic assessment of LEEP specimens or follow-up outcomes.

CONCLUSIONS

Use of up to 20% of LEEP specimens for research purposes neither adversely affects histologic evaluation of LEEP specimens nor leads to poorer follow-up outcomes.

Colposcopy at a crossroads

New cervical cancer prevention strategies are arising from rapidly improving insight into human papillomavirus (HPV) natural history and cervical carcinogenesis, challenging the conventional roles of cytology and colposcopically directed biopsy as the reference standards of screening and diagnosis, respectively. HPV testing has high sensitivity but mediocre specificity and positive predictive value, making the role of colposcopy for the accurate identification of patients requiring treatment even more important. We believe that deficiencies of the colposcopically guided biopsy must be addressed, in particular, the inaccuracy of biopsy placement leading to low sensitivity for detection of CIN3. This opinion outlines our concerns and summarizes new data, suggesting possible steps that may lead to improvement in colposcopic accuracy.

Should punch biopsies be used when high-grade disease is suspected at initial colposcopic assessment? A prospective study

The reliability and applicability of colposcopically directed cervical punch biopsy was assessed in a sample of 170 paired punch and large loop excision of cervical transformation zone (LLETZ) specimens obtained from previously untreated women who had been selected for treatment on the basis of cytology and/or colposcopic findings and in whom the entire cervical transformation zone was visible. A single punch biopsy was taken immediately before the LLETZ, and all the specimens were reviewed by a single pathologist. Nine (5.3%) punch biopsies were inadequate. In terms of whether or not there was cervical intraepithelial neoplasia (CIN), the chance-corrected kappa analysis rated overall agreement as poor (kappa = 0.21, 95% confidence limits 0.02-0.39), whereas in terms of histologic grade, it was fair to moderate (kappa = 0.32, 95% confidence limits 0.23-0.42). Punch biopsy tended to underestimate the disease. The sensitivity and specificity of colposcopically directed punch biopsy for the detection of high-grade CIN was 74% and 91%, respectively, with positive- and negative predictive values of 97% and 48%, respectively. Two microinvasive and two intraepithelial glandular lesions were missed on punch biopsy. Punch biopsy should be avoided when high-grade disease is suspected.

Using the cone biopsy to compare colposcopy clinics in new york and london

OBJECTIVE

To assess whether there were significant differences in cytologic and colposcopic assessments associated with conization specimens at a colposcopy clinic in New York compared with a colposcopy clinic in London.

MATERIALS AND METHODS

A retrospective histopathologic survey of patients evaluated at the Mt. Sinai Hospital Colposcopy Clinic (MSH) in New York City and the Royal Free Hospital Colposcopy Clinic (RFH) in London between January 1, 1997, and December 31, 1998, was reviewed. Study groups included all patients who underwent conization at either clinic. Referral cytologic results, colposcopic findings, and conization histologic results were compared.

RESULTS

Two hundred three cases from MSH and 457 cases from RFH were reviewed. Most patients undergoing conization in either clinic were referred with Pap smears suggesting high-grade squamous intraepithelial lesions (MSH, 77%; RFH, 77%). Colposcopic biopsy was performed on all patients at MSH. At RFH, colposcopic-directed punch biopsy was not performed on 35% of the patients who would have been treated regardless of biopsy results. There is a significant difference in the distribution of cone histologic diagnosis between the two clinics (p = .02); there are proportionally more women diagnosed with high-grade disease in RFH than in MSH, where there are more normal and low-grade cone histologic results. According to the kappa coefficients, there is only slight agreement between the Pap smear cytologic results and punch biopsy with the conization histologic results for either clinic (MSH, kappa = 0.13; RFH, kappa = 0.19), with the RFH performing slightly better.

CONCLUSIONS

This study shows exact agreement between cytologic and final conization diagnosis and colposcopic biopsy and final conization as 47% to 64%. Treatment decisions and outcomes are different between the two clinics, with the RFH clinic performing fewer biopsies and having more procedures yielding high-grade disease. Recommendations regarding changing colposcopic practices could best be made after a prospective study.

Independent determinants of inaccuracy of colposcopically directed punch biopsy of the cervix

OBJECTIVE

The goal of this study was to determine the clinical factors independently associated with inaccuracy of colposcopically directed punch biopsy in defining extent and severity of epithelial lesions of the cervix.

METHODS

The study was conducted in a colposcopy clinic devoted to the management of patients with abnormal Pap smear and/or histology diagnosis of cervical intraepithelial neoplasia (CIN) on punch biopsy or endocervical curettage. Seven hundred and thirty-nine patients (median age, 33 years; range, 18-83 years) referred with a punch biopsy diagnosis of CIN2-3 and treated with electrosurgical conization were evaluated. Cone histology diagnosis was assumed to supply the correct diagnosis. Two types of deviation of biopsy diagnosis were considered: (1). unconfirmed high-grade CIN diagnosis, defined as a cone diagnosis of CIN1 and reactive/reparative changes, and (2). nondiagnosis of carcinoma, defined as a cone diagnosis of microinvasive and invasive squamous carcinoma. Multinomial logistic regression analysis was used to assess the determinants of the probability of each type of deviation.

RESULTS

The probability of unconfirmed high-grade CIN diagnosis (n = 190, 25.7%) was inversely related to number of quadrants involved, severity of referral Pap smear, and grade of biopsy. The probability of nondiagnosis of carcinoma (n = 43, 5.8%) was positively related to patient age, invisibility of the squamocolumnar junction, number of quadrants involved, and cone width. Endo-ectocervical location, cone depth, and time period had no effect whatsoever.

CONCLUSIONS

The study confirmed previous observations regarding the positive association of patient age and invisibility of squamocolumnar junction with the probability of nondiagnosis of carcinoma. The concomitant positive effects of number of quadrants involved and cone width were suggested to mirror the effect of circumferential development and, respectively, surface area of CIN. Severity of referral Pap smear and grade of biopsy were shown to be inversely related to the probability of a cone diagnosis of CIN1 and benign changes.

Human papillomavirus testing for triage of women referred because of abnormal smears. a decision analysis considering outcomes and costs

The objective of this article was to evaluate the utility of high-risk human papillomavirus (HR-HPV) testing for triage of women referred for colposcopy because of abnormal smears. We considered women with persistent mild or moderate dyskaryosis and women with severe dyskaryosis who were referred for colposcopy. For both patient groups we evaluated three alternative management policies: (1) conventional management based on histological assessment; (2) HR-HPV-triage with direct treatment without prior histologic assessment for HR-HPV-positive women and conventional management for HR-HPV-negative women; and (3) direct treatment without histologic assessment for all referred women. For each policy the average number of medical procedures, doctor visits, and the costs per referred woman were calculated. Based on a literature review, the results were tested and translated to other patient groups. Per woman with persistent mild or moderate dyskaryosis and compared with conventional policy, HR-HPV-triage will avoid 0.51 colposcopically directed biopsies, but adds 0.05 local treatments of the cervix (i.e., loop excision of the transformation zone) and 0.09 outpatient visits, and will cost $134 US dollars extra. HPV triage is less efficient in women with borderline or mildly dyskaryotic cytology. In women with severe dyskaryosis, direct treatment is more efficient as conventional management or HPV triage. The decision to introduce HPV testing or direct treatment in women with persistent mild or moderate dyskaryosis strongly depends on the relative burden attributed to a colposcopically directed biopsy and an outpatient visit compared to loop excision of the transformation zone treatment of the cervix. For women with severe dyskaryosis, direct treatment should be seriously considered.

Identification of cervical intraepithelial neoplasia (CIN) using UV-excited fluorescence and diffuse-reflectance tissue spectroscopy

BACKGROUND AND OBJECTIVE

The diagnostic potentials of ultraviolet-excitation fluorescence spectroscopy and diffuse-reflectance spectroscopy of tissue are assessed in a study to identify cervical intraepithelial neoplasia (CIN) in vivo. A multivariate algorithm is used to classify tissue into normal tissues, CIN I, and CIN II/III categories, based on spectral characteristics of biopsied tissue sites.

STUDY DESIGN/MATERIALS AND METHODS

An optical instrument with the capability of measuring fluorescence and diffuse-reflectance spectra from 120 locations uniformly distributed over the surface of the cervix is described. Using this device, these optical spectra of the cervix were measured on women referred for colposcopy due to an abnormal Pap smear.

RESULTS

UV fluorescence differentiates CIN II/III lesions from normal squamous tissue with a sensitivity and specificity of 91 and 93%, respectively. CIN I is distinguished from normal tissue with a sensitivity of 86% and a specificity of 87%.

CONCLUSION

Optical spectroscopy shows promise for the detection of pre-cancerous cervical lesions in vivo. The fluorescence and reflectance methods are complementary in their ability to differentiate different tissue types, making the use of the two techniques together more diagnostic than the use of either method separately.

Analysis of acetic acid-induced whitening of high-grade squamous intraepithelial lesions

Immature and dysplastic cervical squamous epithelium whitens after the application of acetic acid during a colposcopic examination. The whitening process occurs visually over several minutes and subjectively discriminates between dysplastic and normal tissue. In this work, examples of the acetowhitening process are detailed in three ways: the color-imaged colposcopic appearance of the acetowhitening of high-grade cervical intraepithelial neoplasia (CIN 2/3), the kinetics of these reflectance patterns transformed to reduce noise in the signal, and a self-normalized green to red ratio measurement of the kinetics of these reflectance patterns. A total of six patients with biopsy confirmed CIN 2/3 were examined to obtain a set of timed images tracking the acetowhitening and the whitening-decay process over the course of 5-10 min. Regions of normal mature squamous epithelium within the same patients were also followed as an internal control. We determined that the temporal change over a 10 min time period in the ratio of green to red light intensities, taken from the respective color channels of the CCD, provides a reliable measure to clearly distinguish CIN 2/3 from normal cervical epithelium. This imaging and data normalization procedure may be applied to cervical lesions of different grades, to determine if a quantitative estimate provides predictive value during the colposcopic diagnosis.

How can the incidence of negative specimens resulting from large loop excision of the cervical transformation zone (LLETZ) be reduced? An analysis of negative LLETZ specimens and development of a predictive model

OBJECTIVE

To analyse biopsies of large loop excision of the transformation zone of the cervix; to identify factors associated with negative histology; and to develop predictive models in order to reduce the number of negative loop excisions.

DESIGN

Retrospective analysis of patient notes and audit database.

SETTING

Colposcopy clinic of a large district general hospital in North Staffordshire.

POPULATION

Four hundred and fifty-two women who underwent a large loop excision of the transformation zone (LLETZ) procedure for suspected cervical intraepithelial neoplasia.

METHODS

Women who underwent a LLETZ procedure were placed in two different groups, one positive for cervical intra epithelial neoplasia and the other negative for cervical intra epithelial neoplasia. Information was obtained on a number of clinical and colposcopic variables. Analysis was undertaken to determine if there were any differences between the two groups. These factors were then identified and three predictive models generated. Receiver-operator characteristic curves were used to assess and test these models.

MAIN OUTCOMES MEASURES

To identify factors associated with negative histology on a LLETZ specimen. To predict how to reduce the number of negative LLETZ specimens.

RESULTS

Four hundred and fifty-two women underwent a LLETZ procedure, 88 were negative (19%) and 364 were positive (81%). In women who were treated at their first visit, 56/316 (18%) had negative histology. There were significant associations between negative histology in the LLETZ and negative or low grade cytological atypia, negative colposcopic findings and years of age > 50 in both bivariate analysis and stepwise logistic regression. In the predictive models, the sensitivity ranged between 72% and 80%, the specificity 59%-72%, and the area under the receiver-operator characteristic was 0.75-0.77. If we had used the predictor models and managed women with negative or low grade cervical atypia and negative colposcopy findings conservatively, we would have reduced the negative biopsy rate from 19% to 14%, but five cases of high grade disease and 25 cases of low grade disease would have been missed. If we had also included women aged > 50 years in this model, the negative biopsy rate would have dropped from 19% to 15%, with only one case of high grade disease and 11 cases of low grade disease missed. All these women would require continued cytological and colposcopic surveillance. Importantly, no cases of invasion would have been missed.

CONCLUSION

Using a predictive model can reduce the number of negative LLETZ specimens, but at the expense of continued cytological and colposcopic surveillance and cannot be recommended in normal practice. This raises the question whether current standards for negative histology in LLETZ specimens are set unrealistically high.

Combined colposcopy, loop conization, and laser vaporization reduces recurrent abnormal cytology and residual disease in cervical dysplasia

OBJECTIVES

Loop electrosurgical excision of the transformation zone (LEETZ) was recently associated with relatively high failure rates. We evaluated whether the combination of LEETZ with laser vaporization is superior to LEETZ alone in reducing the rates of recurrent abnormal cytology and residual disease.

METHODS

The study population included 426 women with histologic diagnosis of cervical intraepithelial neoplasia (CIN) 2-3, of whom 289 (study group) were treated by LEETZ followed by laser vaporization of the crater base and walls and 137 (control group) were treated by LEETZ alone. All women were followed scrupulously at regular intervals for recurrent abnormal cytology and residual disease. The mean follow-up periods were 43 and 59 months for the study and control groups, respectively.

RESULTS

Both groups were derived from the same community and were similar in epidemiologic characteristics and disease severity. Although the incidence of positive surgical margins was similar in both groups (10.4 and 9.5% for the study and control groups, respectively), recurrent abnormal cytology (10.2% vs 5.5%, P = 0.07) and histologic residual disease (21.4% vs 0%, P = 0.05) were more frequent among women in the control group. This applied to women with both negative and positive surgical margins. Both study and control women with positive surgical margins, especially at the endocervix, were at higher risk for recurrence.

CONCLUSION

The addition of laser vaporization to LEETZ may improve outcome of both women with positive margins and women with negative margins. Our results support conservative management for all treated women, regardless of cone margin status.

Management of pre-invasive disease of the cervix

The management of pre-invasive disease of the cervix is based on local control and prevention of progression to invasive malignancy. Screening continues to be an effective tool for detecting cervical neoplasia in a pre-invasive state due to the long natural history of progression from low-grade dysplasia to invasion. When abnormal cells are detected with a Papanicolaou (Pap) smear, a thorough evaluation should consist of colposcopy, directed biopsy, and cone biopsy, where appropriate. In the absence of invasion, local control may be achieved by excisional or ablative techniques including traditional cold-knife cone, laser cone, loop electrosurgical excision, cryotherapy, laser or electrocoagulation diathermy. The benefit of excisional therapy is the ability for histologic specimen assessment. Ablative therapies are associated with lower complication rates (<2%). Success rates for these modalities are comparable, exceeding 90%. Eradication of human papilloma virus (HPV) from the genitourinary tract [associated with over 90% of condylomas, cervical intraepithelial neoplasia (CIN) and invasive malignancies] is not possible with currently available techniques.

The correlation between the grade of dyskaryosis on cervical smear, grade of cervical intraepithelial neoplasia (CIN) on punch biopsy and the final histological diagnosis on cone biopsies of the cervix

This study was carried out to assess how reliably a punch biopsy of the cervix predicts the maximum grade of CIN present and whether a colposcopically directed punch biopsy is more reliable than cytology in predicting the grade of intraepithelial neoplasia present in the cervix. The grade of CIN in 107 cone biopsy specimens was compared with the grade of CIN and dyskaryosis in punch biopsies and smears from the same patients. Exact correlations were identified between the highest grade lesions on cone biopsy and those in 63% of punch biopsies and 49% of cervical smears. We conclude that punch biopsy provides a more reliable estimate of the highest grade of CIN present in a subsequent cone biopsy than cervical cytology, but nonetheless fails to give a consistent estimate of the final grade of CIN in a significant percentage of cases.

Indications for cone biopsy: pathologic correlation

OBJECTIVE

Our purpose was to determine the ability of different indications for cone biopsy to predict the presence of disease in the cone specimen and the utility of conization for low-grade disease.

STUDY DESIGN

The records were reviewed of all patients who had an excisional cone biopsy at Queens Hospital Center between 1984 and 1995. Data were gathered regarding cytologic studies, visualization of the transformation zone, colposcopically directed biopsy, and endocervical curettage. The indications for the cone procedure were grouped as being for treatment (biopsy-proved disease) (indication A), discrepancy between cytologic and histologic diagnoses (indication B), positive endocervical curettage results (indication C), and transformation zone not fully visualized (indication D), and combinations of the above.

RESULTS

Two thousand nine hundred sixty-nine records were reviewed. Of these, 604 had cone biopsies. Three hundred twenty-three of 355 (91%) cone biopsies done for indication A alone had disease on the cone specimen (defined as any grade of dysplasia or condyloma). Forty of 47 (85.1%) cone biopsies done for indication B alone had disease of the cone specimen. Forty-three of 46 (93.5%) cone biopsies done for indication C alone had disease on the cone specimen. Ninety-one cone procedures were done for a combination of indications A and D, with 87 (95.6%) showing disease on the cone specimen. Thirty-one procedures were done for a combination of indications B and D, with 25 (80.6%) showing disease on the cone specimen. Cone procedures were done on 32 women for a combination of indications C and D, and 30 (93.8%) had disease on the cone specimen. Two cone procedures were done because of the colposcopic appearance alone; one had high-grade disease on the cone specimen. Age did not help to predict the likelihood that disease would be found on the cone specimen. The data were then reanalyzed to determine the likelihood of finding high-grade disease (cervical intraepithelial neoplasia grades 2 or 3 or invasive cancer) on the cone specimen. Overall, those with preoperative high-grade cytologic or histologic characteristics (cervical intraepithelial neoplasia grades 2 or 3) were much more likely to have high-grade disease (277/371 [74.7%]) than were those with preoperative low-grade cytologic or histologic characteristics (condyloma or cervical intraepithelial neoplasia grade 1) (49/233 [21.0%]) (p < 0.001).

CONCLUSION

Neither age nor the preoperative grade of disease are good discriminators of the likelihood that disease will be found on a conization specimen. However, patients who have high-grade disease on the preoperative evaluation are much more likely than those with only low-grade disease to have high-grade dysplasia or cancer on a subsequent conization.

Observer variability among colposcopists from the West Midlands region

OBJECTIVE

To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy.

DESIGN

A two-part video questionnaire study.

PARTICIPANTS

Colposcopists from West Midlands Region.

METHODS

Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart.

RESULTS

Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (chi 2 = 19.45, P < 0.0001) but not where the histology was CIN 1 or less (chi 2 = 2.64, P = 0.10). Overall interobserver agreement improved slightly from kappa = 0.169 to kappa = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been overtreated.

CONCLUSION

There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy.

Human papillomavirus deoxyribonucleic acid detection in mildly or moderately dysplastic smears: a possible method for selecting patients for colposcopy

OBJECTIVE

Current screening protocols for cervical cancer dictate that patients with smears read as mild or moderate dysplasia of the uterine cervix undergo colposcopy, although approximately half these women do not prove to have high-grade squamous intraepithelial lesions. The aim of this study was to determine whether human papillomavirus testing is capable of discriminating between high- and low-grade squamous intraepithelial lesions so as to be useful in reducing the number of colposcopic examinations.

STUDY DESIGN

We tested 190 consecutive patients with smears read as mild or moderate dysplasia for the presence of human papillomavirus deoxyribonucleic acid by use of two different polymerase chain reactions with the consensus primer pairs CPI/IIG and MY09/11. Typing was carried out by direct sequence analysis of the CPI/IIG amplimers. The MY09/11 amplimers were detected in enzyme-linked immunosorbent assay format with the SHARP (Solution Hybridization Assay for PCR Products) Signal System with two probe mixtures (A and B) to detect nononcogenic and oncogenic human papillomavirus types. The human papillomavirus test results were compared with the histologic diagnosis, which was regarded as the reference standard.

RESULTS

Fifty-six of the 190 patients had high-grade squamous intraepithelial lesions. The sensitivity was 96% for the CPI/IIG test and 95% for the MY09/11 polymerase chain reaction plus SHARP Signal System when probe B only was used. The specificity was 33% for the CPI/IIG test and 40% for the MY09/11 polymerase chain reaction plus SHARP Signal System when probe B was used.

CONCLUSION

A negative CPI/IIG or SHARP Signal System probe B test can select, respectively, 44 or 54 of the 134 patients without high-grade squamous intraepithelial lesions. The use of these human papillomavirus tests as a secondary triage in patients with smears that were read as mild or moderate dysplasia could prevent those patients from undergoing unnecessary colposcopy. However, respectively, 2 or 3 of the 56 patients who have high-grade squamous intraepithelial lesions would be missed by human papillomavirus testing.

The use of large loop excision of the transformation zone (LLETZ) in an outpatient setting

An audit of the results of 129 patients treated in the first 12 months of operation of an outpatient large loop excision of the transformation zone (LLETZ) clinic was performed. It confirmed the efficacy of the procedure in treatment of cervical intraepithelial neoplasia (CIN) with a cure rate of 93.8%. Major deficiencies identified were the lack of compliance with recommended follow-up, a major discrepancy between predicted diagnosis on colposcopically directed punch biopsy and LLETZ specimen histology, and a large proportion of LLETZ specimens which had negative histology and may be regarded as overtreatment. Suggested strategies to address these include observation of low-grade lesions and treatment with LLETZ at the first clinic appointment.

The effect of directed biopsy on the atypical cervical transformation zone: assessed by digital imaging colposcopy

OBJECTIVE

To determine the effect of directed punch biopsy trauma on the natural history of atypical cervical transformation zones.

DESIGN

A prospective randomised clinical trial.

SETTING

Academic Unit colposcopy clinics in Birmingham.

PARTICIPANTS

One hundred and eighty women attending the colposcopy clinics were recruited over an 18 month period, of which 161 were eligible for analysis.

METHODS

Three-way randomisation of patients into 1. no biopsy, 2. central biopsy and 3. peripheral biopsy groups. Quantitative assessment of the change in surface area and severity of cervical intra-epithelial neoplasia (CIN) lesions in each group measured six weeks apart using digital imaging colposcopy.

RESULTS

No significant difference in change in lesion size (P = 0.40) was noted in the three treatment groups. Results suggest that the severity of the lesion was underestimated by the peripheral biopsy.

CONCLUSIONS

The results of this study suggest that directed punch biopsy trauma does not have a significant effect on the immediate natural history of CIN. No statistically significant differences were found in lesion size whether biopsy was employed or not. In addition, the site of biopsy had no influence on the outcome. It appears, therefore, that tissue trauma from punch biopsy and the subsequent inflammatory and wound healing processes do not modify the course of CIN. The regressive changes observed after punch biopsy in previous natural history studies are probably not a result of the initial inflammatory response to biopsy trauma and subsequent re-epithelialisation with normal cells, but may result from processes that continue long after tissue repair is completed.

Does colposcopically directed punch biopsy reduce the incidence of negative LLETZ?

OBJECTIVE

To evaluate the role of punch biopsy in reducing the occurrence of negative histology provided by large loop excision of the transformation zone in the management of cervical intraepithelial neoplasia.

DESIGN

Retrospective review of computerised data base and clinic files.

SETTING

Colposcopy Clinic, Groote Schuur Hospital, Cape Town, South Africa.

SUBJECTS

Two hundred and ninety-eight women considered suitable for the local outpatient management of cervical intraepithelial neoplasia.

METHODS

Two groups of patients were identified: group A consisted of women who had cervical intraepithelial neoplasia confirmed colposcopically and who underwent directed punch biopsy; group B consisted of women who had cervical intraepithelial neoplasia confirmed colposcopically and were referred for large loop excision of the transformation zone without confirmatory punch biopsy.

RESULTS

In Group A (n = 184) 123 women had cervical intraepithelial neoplasia diagnosed on punch biopsy. Large loop excision of the transformation zone was performed on 116 women and 7 were lost to follow up. The procedure confirmed cervical intraepithelial neoplasia in 95 cases (82%), but there was no cervical intraepithelial neoplasia in 21 cases (18%). Sixty-one women had negative punch biopsies. Of these, 13 underwent large loop excision of the transformation zone, 31 had persistently negative follow up cytology, and 9 had positive cervical smears of which 7 were treated with large loop excision of the transformation zone, and 8 were lost to follow up. Overall, 25% of all negative punch biopsies were falsely negative. In group B 114 were treated with large loop excision of the transformation zone and cervical intraepithelial neoplasia was confirmed in 97 cases (85%); one woman had unsuspected microinvasion (1%) and 16 women (14%) had no cervical intraepithelial neoplasia. Negative histology after large loop excision of the transformation zone was not statistically different in groups A and B.

CONCLUSION

Punch biopsy does not reduce the occurrence of negative histology after large loop excision of the transformation zone.

Retrospective analysis of non-correlating cervical smears and colposcopically directed biopsies

The purpose of this study is to evaluate the cause of discrepancies between non-correlating cytologic and histologic cervical samples. The biopsy results of 433 women examined colposcopically were compared to their referral cervical smears (RS). There was a discrepancy between the RS and the subsequent biopsy in 120 women (28%). One hundred of these 120 RS were available for review; and in each case, a reason for the discrepancy was established and classified as RS overcall, RS undercall, RS sampling error, or biopsy sampling error. Fifty-one discrepant RS were overcalled. They were reported initially as condyloma (19), mild dysplasia (22), and moderate dysplasia (10). One RS was undercalled. Nine RS were not diagnostic of the biopsy-proven lesion due to smear sampling error. The discrepancies in the remaining 39 cases were due to biopsy sampling error. Twenty-one of these 39 cases had additional biopsies or smears that confirmed the presence of condyloma/dysplasia, and 18 had negative follow-up. In summary, discrepancies were a result of pathologists' interpretative error, predominantly overcalls, in 52% of non-correlating cases, and smear or biopsy sampling error in the remaining 48%.

Cervical cytologic abnormalities and negative colposcopy: histologic assessment

Colposcopic assessment may be normal in the presence of severe or persistent minor cytologic abnormality. To assess the significance of negative satisfactory colposcopy in patients with abnormal cervical smears, a retrospective review was carried out on 1170 patients who had undergone out-patient loop diathermy excision for abnormal cervical cytology. Of these, 69 patients were treated for abnormal cervical cytology, despite normal colposcopic findings. Cytologic abnormalities ranged from persistent borderline changes to severe dyskariosis. Histologic assessment of the excision specimens revealed cervical intraepithalial neoplasia (CIN) in 43 (62.3%) cases, of which high-grade CIN accounted for 24 (34.8%) cases. There was good correlation between cytologic and histologic diagnosis. Simple regression analysis showed r = 0.46, P < 0.0001. The cytologic abnormality was highly predictive of the corresponding histologic diagnosis. This analysis has shown that significant intraepithelial lesions may exist despite negative colposcopic examination and highlights the need for histologic evaluation in such cases. In these circumstances, loop cone biopsy permits accurate definition of lesion severity, avoids potential undertreatment of significant lesions and causes less morbidity than conventional cone biopsy.

A prospective study of the treatment of cervical intraepithelial neoplasia by loop electrosurgical excision procedure (LEEP) in Hong Kong population

From May to December 1990, 72 patients suffering from cervical intraepithelial neoplasia confirmed with guided biopsy were treated with loop electrosurgical excision procedure (LEEP) as outpatients under local anaesthesia. Overall success rate of a single treatment at 6 weeks follow-up was 88.9%. All the specimens obtained from the procedure were of good quality for histological examination. The overall significant complication rate of the procedure was 4.2% during treatment and 8.4% after treatment. The results suggested that LEEP is an effective and safe outpatient treatment for CIN lesions. It is easy to use and readily acceptable to patients. It also has the advantage of providing histological confirmation and more economical than the use of laser.

Outpatient excisional management of cervical intraepithelial neoplasia. A prospective, randomized comparison between loop diathermy excision and laser excisional conization

OBJECTIVE

The purpose of our study was to compare loop diathermy excision and laser excisional conization with respect to treatment time, reliability, effectiveness, and safety.

STUDY DESIGN

Three hundred women with cervical intraepithelial neoplasia attending our colposcopy clinic were randomized to treatment with either loop diathermy excision (group 1, n = 150) or carbon dioxide laser excisional conization (group 2, n = 150), both performed with local anesthesia on an outpatient basis. Student's t or Mann-Whitney test were used to compare continuous data; the chi 2 test was used for categoric data.

RESULTS

The mean age, parity, histologic features, depth of excision, and occurrence of residual or recurrent disease were similar; however, the mean time required to complete treatment and hemostasis (2.5 +/- 3.6 vs 24.2 +/- 11.8 min), patient discomfort, blood loss (2.77 +/- 3.76 vs 27.15 +/- 17.51 ml; p < 0.001), and considerable thermal artifact affecting histologic interpretation of excision margins (5 cases vs 25 cases; p < 0.01) were significantly less in group 1 than in group 2.

CONCLUSION

In our experience outpatient loop diathermy excision is an equally effective, quicker, safer, and more reliable excisional technique than laser excisional conization.