2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia

The Relationship Between Cervicovaginal Infection, Human Papillomavirus Infection and Cervical Intraepithelial Neoplasia in Romanian Women

Cervical intraepithelial neoplasia (CIN) is a premalignant cervical condition closely linked to persistent high-risk HPV infection, a major risk factor for cervical cancer. This study aims to investigate the relationship between cervicovaginal infections, HPV infection, and CIN development in 94 Romanian women with cervical lesions. Comprehensive assessments included HPV genotyping, cytology, colposcopy, and histopathology. In 53.20% of cases, vaginal infections were identified, with Candida albicans most frequently associated with HPV. Histopathology revealed 48.94% low-grade CIN, 42.55% high-grade CIN, and 8.51% invasive carcinoma. There was a strong correlation between high-risk HPV types (especially HPV 16 and 18), colposcopic findings, histopathology, and age. This study emphasizes the mutual effect of cervicovaginal infections and HPV infection in increasing the risk of developing CIN and cervical cancer among Romanian women. Persistent infection with high-risk HPV types, particularly HPV 16 and 18, has been confirmed as a primary driver of CIN and cervical cancer progression.

The value of endocervical curettage for diagnosis of cervical precancers or worse at colposcopy of women with atypical glandular cells cytology

Objective

This study evaluates the effectiveness of endocervical curettage (ECC) in identifying additional cervical cancer and its precursors in women with atypical glandular cells (AGC) cytology.

Methods

We conducted a retrospective analysis of medical records for women referred to colposcopy with AGC cytology between January 2019 and December 2023. The study included 433 women with AGC cytology who underwent both biopsy and ECC. Clinical characteristics such as demographics, clinical history, cytology, HPV status, colposcopic findings, and pathology were analyzed. Chi-square and Fisher's exact tests were applied to compare the characteristics of ECC-diagnosed cervical precancers or worse (HSIL+) and normal/low-grade squamous intraepithelial lesions (LSIL).

Results

The overall detection rate of HSIL+ in this population was 19.4% (86/443), with ECC alone identifying HSIL+ in 1.3% (6/443) of cases. However, ECC showed greater utility in certain subgroups. The highest additional HSIL+ detection from ECC was observed in women with HPV 16/18 infection (7.2%) and those with AGC-FN cytology (4.4%). ECC's additional yield of HSIL+ was higher in those with normal or LSIL colposcopic impressions compared to those with HSIL+ impressions. Conversely, no additional HSIL+ cases were identified by ECC alone in women under 30 years old, those with negative high-risk HPV results, or those with type 1/2 transformation zones.

Conclusion

For women with AGC cytology, ECC should be performed in patients with AGC-FN cytology, HPV 16/18 infections, type 3 transformation zones, and normal or low-grade colposcopic impressions. This approach enhances the identification of HSIL+ cases by reducing false negatives. However, for women younger than 30 years old and those with type 1/2 transformation zones, ECC offers limited benefit.

History of cervical excisional treatment is associated with changes in the cervical microbiota in women with preterm prelabor rupture of membranes

BACKGROUND

This study aimed to determine the differences in the cervical load and prevalence of Lactobacillus crispatus DNA, Lactobacillus iners DNA, Gardnerella vaginalis DNA, Sneathia sanguinegens DNA, and Ureaplasma species DNA between pregnant women with preterm prelabor rupture of membranes (PPROM) with and without a history of cervical excisional treatment. We also assessed the changes in the cervical load and prevalence of L. crispatus DNA, L. iners DNA, G. vaginalis DNA, S. sanguinegens DNA, and U. spp DNA. according to the cone length.

METHODS

This retrospective study included 132 women with singleton pregnancies complicated by PPROM. For all women, information about the cervical loads of bacterial DNA corresponding to L. crispatus, L. iners, G. vaginalis, S. sanguinegens, and U. spp., which was assessed using PCR, was available.

RESULTS

Women with a history of cervical excisional treatment had a higher cervical load of L. iners DNA (4.4 × 106 copies DNA/mL vs. 3.5 × 105 copies DNA/mL, p = .04) and a higher load and prevalence of U. spp. DNA (1.1 × 105 copies DNA/mL vs. 9.6 × 104 copies DNA/mL, p = .03; 2.7% vs. 0.5%, p = .04) than those without a history of cervical excisional treatment. In the subset of women with a history of cervical excisional treatment, those with a cone length 18 mm and more had a lower relative abundance of L. crispatus DNA (6% vs. 89%, p = .02), a higher load and relative abundance of L. iners DNA (1.1 × 107 copies DNA/mL vs. 8.2 × 105 copies DNA/mL, p = .04; 91% vs. 35%, p = .04), and higher loads of G. vaginalis DNA (7.6 × 104 copies DNA/mL vs. 3.2 × 102 copies DNA/mL, p = .02) than those with cone length < 18 mm.

CONCLUSIONS

A history of cervical excisional treatment was associated with alterations in the cervical microbiota composition in pregnant women with PPROM.

Development of a clinical prediction model for pathological upgrading in low-grade squamous intraepithelial lesions following cervical conization

Objective

This study aimed to identify key factors influencing post-operative pathologic escalation in Chinese women with histologic cervical low-grade squamous intraepithelial lesions (LSILs) undergoing cervical conization and construct a predictive nomogram model.

Material and Methods

A retrospective analysis was conducted on 107 patients with LSIL from Bengbu City, Anhui Province, China, who underwent cervical conization at the First Affiliated Hospital of Bengbu Medical College from January 2019 to January 2023. Patients were categorized into groups based on post-operative pathological upgrade. Univariate and multivariate logistic regression analyses identified independent risk factors. A nomogram model was developed and evaluated for clinical predictive ability using calibration curves, the Hosmer-Lemeshow test, and decision curve analysis (DCA).

Results

Post-operative pathological upgrades were experienced by 39.3% of patients with LSIL. Independent risk factors for escalation included positive human papillomavirus (HPV)16/18/52/53/58 high-risk types (P < 0.05, OR = 4.95, 95% CI = 1.32-18.46), ThinPrep Cytology Test (TCT) results indicating high-grade squamous intraepithelial lesion (HSIL)/atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H)/atypical glandular cells ( AGC) (P < 0.01, OR = 13.12, 95% CI = 3.10-55.50), and cervical transformation zone (TZ) type III (P < 0.05, OR = 6.10, 95% CI = 1.65-22.56). Based on these factors, the nomogram demonstrated good differentiation and calibration (area under the curve [AUC]: 0.744, 95% CI: 0.674-0.839). DCA indicated high clinical predictive value.

Conclusion

HPV16/18/52/53/58 high-risk types, TCT HSIL/ASC-H/AGC, and colposcopic cervical TZ type III are independent risk factors for post-operative pathologic escalation in LSIL. Consideration of pre-operative HPV, TCT results, and cervical TZ type is crucial for effective triage and patient management. The constructed nomogram provides a practical tool for risk assessment of patients with LSIL undergoing cervical conization.

Follow-up of women with cervical adenocarcinoma in situ treated by conization: A single centre clinical experience

OBJECTIVE

Hysterectomy has been the historical gold standard final step in the treatment algorithm of adenocarcinoma in situ (AIS) recommended by most North American colposcopy guidelines. AIS disproportionately affects young childbearing age women, therefore a fertility sparing treatment option is desirable. Our study examines the impact of conservative treatment of AIS with conization followed by serial surveillance.

METHODS

A retrospective chart review was completed of patients treated for AIS from 2006 to 2020. Charts were identified by pathologic diagnosis of AIS on cervical and uterine specimens. Charts were excluded if AIS was not treated with conization, if AIS was not confirmed on initial conization specimen, or if invasive disease was found at initial conization.

RESULTS

121 patient charts were analyzed. Median age of patients at first conization and hysterectomy was 34.8 and 40.9, respectively. First conization was by Cold Knife Cone in 58% of patients, and by Loop Electrosurgical Excisional Procedure in 42% of patients. Median follow-up period in our study was 609 days. 5% of patients had recurrence, with only one patient who recurred as cancer. One case of recurrence had a positive initial conization margin. Median time to recurrence was 700 days. 47% of patients underwent eventual hysterectomy. Residual AIS was found in 23% of hysterectomy specimens. Adenocarcinoma was diagnosed on hysterectomy specimen in four patients.

CONCLUSION

Our study demonstrates the oncologic safety of treating AIS with conization and serial surveillance. Routine hysterectomy completed as a part of the AIS treatment algorithm, as in current clinical guidelines, is unnecessary.

Enhancing Cervical Cancer Screening: Review of p16/Ki-67 Dual Staining as a Promising Triage Strategy

Cervical cancer, primarily caused by high-risk human papillomavirus (HR-HPV) types 16 and 18, is a major global health concern. Persistent HR-HPV infection can progress from reversible precancerous lesions to invasive cervical cancer, which is driven by the oncogenic activity of human papillomavirus (HPV) genes, particularly E6 and E7. Traditional screening methods, including cytology and HPV testing, have limited sensitivity and specificity. This review explores the application of p16/Ki-67 dual-staining cytology for cervical cancer screening. This advanced immunocytochemical method allows for simultaneously detecting p16 and Ki-67 proteins within cervical epithelial cells, offering a more specific approach for triaging HPV-positive women. Dual staining and traditional methods are compared, demonstrating their high sensitivity and negative predictive value but low specificity. The increased sensitivity of dual staining results in higher detection rates of CIN2+ lesions, which is crucial for preventing cervical cancer progression. However, its low specificity may lead to increased false-positive results and unnecessary biopsies. The implications of integrating dual staining into contemporary screening strategies, particularly considering the evolving landscape of HPV vaccination and changes in HPV genotype prevalence, are also discussed. New guidelines and further research are necessary to elucidate the long-term effects of integrating dual staining into screening protocols.

Screening for Cervical Cancer in Pregnancy

Cervical cancer remains a leading cause of cancer related morbidity and mortality in low/low-middle income countries. Lack of screening is the leading cause of cases being diagnosed in advanced stages and screening is still opportunistic in a majority of these countries. Hospital visits during pregnancy provides a window of opportunity to screen these susceptible women and reduce the burden of disease. Screening women during pregnancy is not practiced widely due to concerns of pregnancy loss, bleeding and a lack of clear information among patients as well as healthcare professionals.