Conservative management of adolescents with abnormal cytology and histology

Patients with cervical intraepithelial neoplasms show different states of health-related quality of life and different coping styles depending on the choice of therapy: findings from the CIN study

Purpose

To examine the effects of type of therapy (conservative therapy vs conization) on the psychosocial well-being of patients with cervical intraepithelial neoplasia grade II (CIN II) in a prospective cross-sectional study designed to simplify future choice of therapy.

Patients and methods

In a cross-sectional study comparing 24 CIN II patients who were treated via conservative therapy with 17 CIN II patients who were treated via conization (not randomized), we examined the association between therapy type and psychosocial well-being after the treatment. Scores on the Hospital Anxiety and Depression Scale (HADS) (prevalence of depression/anxiety), SF-12 (health-related quality of life (HRQoL)) and Brief COPE (coping mechanisms) questionnaires were compared between the two subgroups via nonparametric Mann-Whitney U-tests.

Results

The prevalence of depression/anxiety and mental HRQoL did not differ between patients undergoing conservative therapy and those undergoing conization but differed significantly from those of the healthy population. Regarding physical HRQoL and coping strategies, the conservative therapy subgroup achieved higher scores and better performance.

Conclusion

Patients with CIN II are at risk of developing depressive or anxiety symptoms. The choice of therapy seems to have an influence on physical HRQoL and coping strategies but not on depression/anxiety and mental HRQoL.

Justifying conservative management of CIN2 in women younger than 25 years - A population-based study

OBJECTIVE

In 2012, the joint clinical practice guideline from the Society of Obstetricians and Gynaecologists of Canada (SOGC) changed from immediate treatment to a more conservative management of Cervical Intraepithelial Neoplasia (CIN) grade 2 in young women. In this study, the outcomes before and after this management change were reviewed in Nova Scotia, Canada.

METHODS

A retrospective population-based cohort study was performed among women younger than 25 years with biopsy-proven CIN2, who were diagnosed in one of the colposcopy clinics in Nova Scotia between 2010 and 2014. Regression and progression rates were compared pre- and post-guideline changes.

RESULTS

Of the 636 women included in the study, 286 women were diagnosed with CIN2 before and 350 women after the management in Nova Scotia was changed. After implementation of the 2012 guidelines patients were more likely to receive conservative management (78.6% versus 44.1%; p < 0.001); which differs from the patients who underwent treatment during follow-up prior to the change in guidelines (73.4% versus 38.9%; p < 0.001). Regression occurred in 73.1% of all women, but women seen in the post-guideline change period had a higher regression rate and lower progression rate (p < 0.05). Histologic results from treatment specimen did not show a significant difference in low-grade or high-grade lesions before or after the guideline had been changed (p = 0.59).

CONCLUSION

Conservative management seems a safe and justified approach for women younger than 25 years with CIN2.

[Pap smear before 25 years old]

OBJECTIVES

Current French recommendations advocate cervical-vaginal screening for cervical cancer from age 25 whereas earlier screening is mostly found in current clinical practice although its consequences are not well understood.

METHODS

A literature review using the MedLine database on the natural history of HPV infections, cytological screening, management of cytological and histological anomalies in adolescents and young women.

RESULTS

The adolescent and young woman have some characteristics that distinguish them from adult women: a high prevalence of HPV infections (making the use of the HPV test unprofitable), accompanied by a higher clearance; frequency of minor cytological abnormalities (for which a cytological surveillance without colposcopy is sufficient) and low-grade histological lesions of low grade the usual prognosis of which is complete recovery; and rarity of CIN3 lesions and absence of invasive lesions, allowing no treatment in patients with CIN2 lesions and compliant to cytological and colposcopic surveillance.

CONCLUSION

Cervical screening in the adolescent and young woman is not a logical attitude and the discovery of cytological or histological lesions requires specific behavior in this particular population.

Spontaneous regression of CIN2 in women aged 18-24 years: a retrospective study of a state-wide population in Western Australia

INTRODUCTION

CIN2 has a high rate of spontaneous regression in young women and may be managed conservatively in appropriately selected patients. This study aimed to investigate health outcomes in women aged 18-24 years with biopsy-confirmed CIN2.

MATERIAL AND METHODS

A retrospective cohort study of Western Australian women aged 18-24 years diagnosed with CIN2 on cervical biopsy from 1 January 2001 to 31 December 2010. Women who had not received treatment at ≥4 months following CIN2 diagnosis were classified as managed 'conservatively'. Subsequent cervical cytology and/or biopsy test results were used to report lesion regression (absence of dysplasia or an epithelial lesion of lower grade than CIN2) and disease persistence (CIN2, CIN3 or ACIS).

RESULTS

Follow-up data were available for 2417 women of whom 924 (38.2%) were 'conservatively' managed. In all, 152 (16.4%) conservatively managed women had a lesion more severe than CIN2 detected within 24 months of initial diagnosis, of which 144 were CIN3 and eight were ACIS. There was no statistically significant association between rates of regression and patient age, Socio-economic Indexes for Areas or Accessibility/Remoteness Index of Australia indices. The 2-year regression rate for CIN2 was estimated to be 59.5% (95%CI 0.5-0.6) in this cohort of women.

CONCLUSION

In conservatively managed young women with CIN2 there was a high rate of spontaneous disease regression. Thus, excisional or ablative treatments may be avoided in selected patients who receive appropriate counseling and who are able to comply with more intensive and prolonged follow-up requirements.

Recurrence of high-grade cervical abnormalities following conservative management of cervical intraepithelial neoplasia grade 2

OBJECTIVE

Conservative management of cervical intraepithelial neoplasia (CIN) grade 2 in women younger than 25 years may reduce overtreatment. However, long-term efficacy remains uncertain. This retrospective cohort study aimed to determine the rate of recurrence of high-grade abnormalities among young women with a history of CIN 2 that spontaneously regressed within 2 years and compare this with the rate of high-grade abnormality in similar women with an initial diagnosis of CIN 1.

STUDY DESIGN

We identified all women aged younger than 25 years who were diagnosed with CIN 1 or CIN 2 between January 2005 and August 2009 within 2 colposcopy units. Follow-up data from the National Cervical Screening Programme were obtained to identify those women who developed recurrent high-grade lesions before October 2012. Comparisons were made using Cox proportional hazards regression.

RESULTS

A total of 683 women were included: 106 with CIN 2 that spontaneously regressed, 299 with treated CIN 2, and 278 with conservatively managed CIN 1. Median follow-up was 4 years. There was no significant difference in the risk of development of high-grade abnormalities after 2 years between the spontaneously regressing CIN 2 and CIN 1 groups (P = .83). Women with treated CIN 2 had a significantly lower risk of recurrence than women with untreated CIN 2 (P = .01).

CONCLUSION

CIN 2 that has spontaneously regressed appears to behave as a low-grade lesion. This study contributes to the growing body of evidence that careful observation of CIN 2 is an efficacious and appropriate initial management option for women aged younger than 25 years at diagnosis.

HPV mRNA is more specific than HPV DNA in triage of women with minor cervical lesions

Background

In Norway, repeat cytology and HPV testing comprise delayed triage of women with minor cytological lesions. The objective of this study was to evaluate HPV DNA and HPV mRNA testing in triage of women with an ASC-US/LSIL diagnosis.

Materials and Methods

We used repeat cytology, HPV DNA testing (Cobas 4800) and HPV mRNA testing (PreTect HPV-Proofer) to follow up 311 women aged 25–69 years with ASC-US/LSIL index cytology.

Results

Of 311 women scheduled for secondary screening, 30 women (9.6%) had ASC-H/HSIL cytology at triage and 281 women (90.4%) had ASC-US/LSIL or normal cytology. The HPV DNA test was positive in 92 (32.7%) of 281 instances, and 37 (13.2%) were mRNA positive. Of the 132 women with repeated ASC-US/LSIL, we received biopsies from 97.0% (65/67) of the DNA-positive and 92.9% (26/28) of the mRNA-positive cases. The positive predictive values for CIN2+ were 21.5% (14/65) for DNA positive and 34.6% (9/26) for mRNA positive (ns). The odds ratio for being referred to colposcopy in DNA-positive cases were 2.8 times (95% CI: 1.8–4.6) higher that of mRNA-positive cases. Compared to the mRNA test, the DNA test detected four more cases of CIN2 and one case of CIN3.

Conclusions

The higher positivity rate of the DNA test in triage leads to higher referral rate for colposcopy and biopsy, and subsequent additional follow-up of negative biopsies. By following mRNA-negative women who had ASC-US/LSIL at triage with cytology, the additional cases of CIN2+ gained in DNA screening can be discovered. Our study indicates that in triage of repeated ASC-US/LSIL, HPV mRNA testing is more specific and is more relevant in clinical use than an HPV DNA test.

Human papillomavirus testing versus repeat cytology for triage of minor cytological cervical lesions

BACKGROUND

Atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intra-epithelial lesions (LSIL) are minor lesions of the cervical epithelium, detectable by cytological examination of cells collected from the surface of the cervix of a woman.Usually, women with ASCUS and LSIL do not have cervical (pre-) cancer, however a substantial proportion of them do have underlying high-grade cervical intra-epithelial neoplasia (CIN, grade 2 or 3) and so are at increased risk for developing cervical cancer. Therefore, accurate triage of women with ASCUS or LSIL is required to identify those who need further management.This review evaluates two ways to triage women with ASCUS or LSIL: repeating the cytological test, and DNA testing for high-risk types of the human papillomavirus (hrHPV) - the main causal factor of cervical cancer.

OBJECTIVES

Main objective To compare the accuracy of hrHPV testing with the Hybrid Capture 2 (HC2) assay against that of repeat cytology for detection of underlying cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) or grade 3 or worse (CIN3+) in women with ASCUS or LSIL. For the HC2 assay, a positive result was defined as proposed by the manufacturer. For repeat cytology, different cut-offs were used to define positivity: Atypical squamous cells of undetermined significance or worse (ASCUS+), low-grade squamous intra-epithelial lesions or worse (LSIL+) or high-grade squamous intra-epithelial lesions or worse (HSIL+).Secondary objective To assess the accuracy of the HC2 assay to detect CIN2+ or CIN3+ in women with ASCUS or LSIL in a larger group of reports of studies that applied hrHPV testing and the reference standard (coloscopy and biopsy), irrespective whether or not repeat cytology was done.

SEARCH METHODS

We made a comprehensive literature search that included the Cochrane Register of Diagnostic Test Accuracy Studies; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (through PubMed), and EMBASE (last search 6 January 2011). Selected journals likely to contain relevant papers were handsearched from 1992 to 2010 (December). We also searched CERVIX, the bibliographic database of the Unit of Cancer Epidemiology at the Scientific Institute of Public Health (Brussels, Belgium) which contains more than 20,000 references on cervical cancer.More recent searches, up to December 2012, targeted reports on the accuracy of triage of ASCUS or LSIL with other HPV DNA assays, or HPV RNA assays and other molecular markers. These searches will be used for new Cochrane reviews as well as for updates of the current review.

SELECTION CRITERIA

Studies eligible for inclusion in the review had to include: women presenting with a cervical cytology result of ASCUS or LSIL, who had undergone both HC2 testing and repeat cytology, or HC2 testing alone, and were subsequently subjected to reference standard verification with colposcopy and colposcopy-directed biopsies for histologic verification.

DATA COLLECTION AND ANALYSIS

The review authors independently extracted data from the selected studies, and obtained additional data from report authors.Two groups of meta-analyses were performed: group I concerned triage of women with ASCUS, group II concerned women with LSIL. The bivariate model (METADAS-macro in SAS) was used to assess the absolute accuracy of the triage tests in both groups as well as the differences in accuracy between the triage tests.

MAIN RESULTS

The pooled sensitivity of HC2 was significantly higher than that of repeat cytology at cut-off ASCUS+ to detect CIN2+ in both triage of ASCUS and LSIL (relative sensitivity of 1.27 (95% CI 1.16 to 1.39; P value < 0.0001) and 1.23 (95% CI 1.06 to 1.4; P value 0.007), respectively. In ASCUS triage, the pooled specificity of the triage methods did not differ significantly from each other (relative specificity: 0.99 (95% CI 0.97 to 1.03; P value 0.98)). However, the specificity of HC2 was substantially, and significantly, lower than that of repeat cytology in the triage of LSIL (relative specificity: 0.66 (95% CI 0.58 to 0.75) P value < 0.0001).

AUTHORS' CONCLUSIONS

HPV-triage with HC2 can be recommended to triage women with ASCUS because it has higher accuracy (significantly higher sensitivity, and similar specificity) than repeat cytology. When triaging women with LSIL, an HC2 test yields a significantly higher sensitivity, but a significantly lower specificity, compared to a repeat cytology. Therefore, practice recommendations for management of women with LSIL should be balanced, taking local circumstances into account.

p16INK⁴a and p14ARF mRNA expression in Pap smears is age-related

Expression of high-risk HPV oncogenes results in a strong overexpression of cellular protein p16(INK4a). Immunohistochemical staining for p16(INK4a) is widely used as diagnostic marker. However, p16(INK4a) upregulation was also described as a biomarker of age. Here we analyzed p16(INK4a) expression in cervical smears to investigate if patient age may influence p16(INK4a)-based cervical cancer diagnosis. p14(ARF) was analyzed as a related supportive biomarker. Cervical scrapes were taken and stored in RNAlater. Total RNA was extracted, and cDNA was analyzed for expression of p16(INK4a) and p14(ARF) relative to β-actin, by real-time reverse transcriptase PCR SYBR-Green I assays. Patient-derived smears referred as HSIL (n=45) had 6.27-fold higher p16(INK4a) mRNA expression than smears of cytologically normal and HPV-negative persons (n=48). Expression of p14(ARF) was 4.87-fold higher. When women with normal diagnoses were stratified for age, a significantly enhanced p16(INK4a) (2.88-fold) and p14(ARF) (1.9-fold) expression was observed as a consequence of ageing. A significant age-dependent upregulation was also observed in older HSIL patients (2.54-fold). Our study revealed significantly enhanced expression of p16(INK4a)/p14(ARF) mRNA in cervical scrapes referred to as HSIL compared with normal women. An age-dependent bias has to be considered when quantifying these tumor suppressor genes, with respect to cervical cancer development.

Is the treatment of CIN 2 always necessary in women under 25 years old?

OBJECTIVE

The purpose of this study was to review the outcome of conservatively managed cervical intraepithelial neoplasia (CIN) 2 in women <25 years old.

STUDY DESIGN

This was a retrospective review that included women who were <25 years old with biopsy proven CIN2 between 2005 and 2009. Analysis was performed that compared women who had immediate treatment with women whose treatment was deferred >4 months. The primary outcome measure was spontaneous regression of CIN2. Secondary outcomes were treatment rates and loss to follow-up evaluation.

RESULTS

Of the 452 women who were identified, 256 women (57%) received immediate treatment; 157 women (35%) met the definition for conservative management, and 39 women (9%) had unknown subsequent management. Of the 157 women who were managed conservatively, 98 women (62%) showed spontaneous regression, with a median of 8 months observation. No conservatively managed women progressed to cancer.

CONCLUSION

Based on the 62% regression rate in this study, routine treatment may not be necessary for all women with CIN2 who are <25 years old.

Analysis of 4 Single-Nucleotide Polymorphisms in Relation to Cervical Dysplasia and Cancer Development Using a High-Throughput Ligation-Detection Reaction Procedure

Background

Host genetic characteristics and environmental factors may correlate with risk for cervical cancer development. Here we describe a retrospective screening study for single nucleotide polymorphisms (SNPs) in genetic markersTP53, MTHFR, CYP1A1,andCYP2E1in 749 patients.

Methods

A multiplex ligation-dependent polymerase chain reaction approach was applied. We used archived material from human papillomavirus tests and correlated SNP genotypes to the corresponding clinical data. Semantic integration was used to identify and evaluate the clinical status from electronic health records.

Results

An association with cervical cancer and high-grade dysplasia was found for the rare homozygous CC genotype (rs4646903) inCYP1A1(odds ratio [OR], 8.862). Odds ratios were also significantly elevated for heterozygousMTHFRCT genotype (rs1801133; OR, 1.457). No significant association was found inTP53(rs1042522) andCYP2E1(rs3813867). In addition, we found smokers at higher risk (OR, 2.688) and identified pregnancies as a significant risk factor (OR, 1.54).

Conclusions

Our protocol enables a feasible way for further retrospective large sample size evaluation of potential genetic markers. This study revealed genetic associations of a rare SNP genotype with cervical dysplasia in one of the largest patient sample to date that warrants further investigation.

Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause

The true value of colposcopy in pregnancy is under debate; the examination may be more difficult depending on the gestation at which a woman presents. Cervical intraepithelial neoplasia does not have an accelerated progression during pregnancy, and treatment is usually deferred until postpartum. The prevalence of cervical intraepithelial neoplasia is greater in women with immune compromise. Those with human immunodeficiency have a higher prevalence, more persistence and less regression of human papillomavirus-related infections. Cervical cancer remains an AIDS-defining illness. Women who have had renal transplants also have a higher risk of developing cervical intraepithelial neoplasia. By contrast, other chronic illnesses that require immunosuppressant therapy do not seem to show this added risk. In young women, human papillomavirus infection is common and cervical intraepithelial neoplasia is also evident, but regression of these lesions is frequent and so conservative review may be appropriate. At the menopause, colposcopy is often unsatisfactory. The use of human papillomavirus testing for triage of low-grade cytological abnormalities may benefit this age group.

Prognosis of intraepithelial cervical lesion during adolescence in up to two years of follow-up

Our objective was to describe the evolution of cervical SIL within 24 months of the initial diagnosis, in a cohort study of 147 sexually active adolescents attending a public health service in Rio de Janeiro, between 1993 and 2006. The participants were divided in two groups, according to whether cervical biopsy was performed or not. The median of the interval between sexual debut and the atypical cytopathology was 12 months and in 8.2% of patients there was a diagnosis of HSIL at the first abnormal smear. After a two-year follow-up by cytology, the regression (ASCUS 91%, LSIL 63.6%, HSIL 50%) and progression (LSIL 6.1%) were verified. In the group undergoing biopsy, the final histological regression reached 59.4% for CIN1 and 71.4% for CIN2, while the progression from CIN1 to CIN 2/3 was 3.1%. Our results corroborate the recommendation for conservative management in compliant adolescents due to a high regression rate. However, there should be maintained a careful follow-up based on the possible evolution of the lesion.

Use of misoprostol for management of unsatisfactory colposcopy in the adolescent: a case report and review of the literature

STUDY OBJECTIVE

To document the ability to use a prostaglandin analogue to achieve satisfactory colposcopy in a patient with cervical stenosis and unsatisfactory colposcopy.

DESIGN

Case report.

RESULTS

Satisfactory colposcopy was achieved by using 100mg of Misoprostol orally, administered the night before the planned colposcopic evaluation.

CONCLUSION

In the presence of persistent atypia in an adolescent female with an unsatisfactory colposcopy, consider using a prostaglandin analogue for adequate evaluation of the endocervix, prior to proceeding with an ablative or excisional therapy.

HPV infection in women: psychosexual impact of genital warts and intraepithelial lesions

INTRODUCTION

Genital Human Papillomavirus (HPV) infection is the most commonly occurring sexually transmitted viral infection in humans. HPV is a wide family of DNA viruses, which may cause benign skin and mucosal tumors (genital, anal, or oral warts), intraepithelial neoplasias, and/or malignant cancers in different organs. Women are more susceptible to the oncogenic effect of HPVs, mostly at the genital site on the uterine cervix.

AIMS

This review analyzes the impact of: (i) genital warts (GWs) and their treatment; (ii) HPV-related genital, oral, and anal precancerous lesions on women's sexual function.

METHODS

A Medline search was carried out. Search terms were HPV, GWs, intraepithelial neoplasia, cervical cancer, anal cancer, oral cancer, epidemiology, HPV risk factors, sexual dysfunctions, desire disorders, arousal disorders, dyspareunia, vulvar vestibulitis, vulvodynia, orgasmic difficulties, sexual repertoire, couple sexual problems, depression, anxiety, pap smear, screening program, therapy, and vaccines.

MAIN OUTCOME MEASURES

Sexual consequences of HPV infection in women, specifically GWs and intraepithelial HPV-related neoplasia.

RESULTS

Psychosexual vulnerability increases with number of recurrences of HPV infections. Depression, anxiety, and anger are the emotions most frequently reported. However, to date, there is no conclusive evidence of a specific correlation between HPV infection and a specific female sexual disorder. The relationship between HPV and vulvar vestibulitis/vulvodynia-related dyspareunia seems not to be direct. Counseling problems, the role of anti-HPV vaccine, and the concept of the high-risk partner are discussed. The reader is offered a practical approach with clinically relevant recommendations that may prove useful in his/her daily practice when dealing with HPV-infected women and couples.

CONCLUSION

The evidence of psychosexual consequences of HPV-related GWs and intraepithelial lesions is limited. Specific research on the sexual impact of GWs and intraepithelial HPV-related lesion in women is urgently needed.