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PubMed2003

Risk of cervical cancer associated with extending the interval between cervical-cancer screenings.

BACKGROUND: Although contemporary guidelines suggest that the intervals between Papanicolaou tests can be extended to three years among low-risk women with previous negative tests, the excess risk of cervical cancer associated with less frequent than annual screening is uncertain. METHODS: We determined the prevalence of biopsy-proven cervical neoplasia among 938,576 women younger than 65 years of age, stratified according to the number of previous consecutive negative Papanicolaou tests. Using a Markov model that estimates the rate at which dysplasia will progress to cancer, we estimated the risk of cancer within three years after one or more negative Papanicolaou tests, as well as the number of additional Papanicolaou tests and colposcopic examinations that would be required to avert one case of cancer given a particular interval between screenings. RESULTS: Among 31,728 women 30 to 64 years of age who had had three or more consecutive negative tests, the prevalence of biopsy-proven cervical intraepithelial neoplasia of grade 2 was 0.028 percent and the prevalence of grade 3 neoplasia was 0.019 percent; none of the women had invasive cervical cancer. According to our model, the estimated risk of cancer with annual Papanicolaou tests for three years was 2 in 100,000 among women 30 to 44 years of age, 1 in 100,000 among women 45 to 59 years of age, and 1 in 100,000 among women 60 to 64 years of age; these risks would be 5 in 100,000, 2 in 100,000, and 1 in 100,000, respectively, if screening were performed once three years after the last negative test. To avert one additional case of cancer by screening 100,000 women annually for three years rather than once three years after the last negative test, an average of 69,665 additional Papanicolaou tests and 3861 colposcopic examinations would be needed in women 30 to 44 years of age and an average of 209,324 additional Papanicolaou tests and 11,502 colposcopic examinations in women 45 to 59 years of age. CONCLUSIONS: As compared with annual screening for three years, screening performed once three years after the last negative test in women 30 to 64 years of age who have had three or more consecutive negative Papanicolaou tests is associated with an average excess risk of cervical cancer of approximately 3 in 100,000.

Adolescent↗
PubMed2001

Cold knife cone biopsy--a valid diagnostic tool and treatment option for lesions of the cervix.

We present a case series of cold knife cone biopsy with emphasis on validation of the technique for ongoing and future use. This involved: analysis of 100 cold knife cone biopsies performed between 1987 and 1997. Data were gathered relating to indications, technique, postoperative morbidity, histological findings and results of long-term follow-up. Mean age was 41.8 years, and mean parity 2. Smear abnormalities of moderate or severe dyskaryosis were present in 74% of cases, and glandular abnormalities in 8%. Colposcopic diagnosis of CIN II-III was made in 55% of cases, and invasion suspected in 12%. The main indications for conisation were inability to visualise the entire squamocolumnar junction (64%), disparity in cytological and colposcopic findings (26%), and colposcopic suspicion of invasion (12%). Mean blood loss was 90 ml. One patient (1%) required hysterectomy and blood transfusion to control secondary haemorrhage. Postoperative infection occurred in 5%, and cervical stenosis in 3%. All specimens were adequate for histopathological evaluation, including the margin, CIN was histologically proven in 67% of specimens, microinvasion in 4%, adenocarcinoma in-situ in 3%, and invasion in 3%. During a mean follow-up of 4.5 years (range 1.5-11 years), cure rate after complete excision was 97% and after incomplete excision was 85% (P > 0.05) Despite the advent of alternative methods of treatment, cold knife cone biopsy remains an acceptable option in the management of CIN and microinvasion of the cervix. There are valid indications for the technique. When properly performed, it gives accurate representation of the disease process, has low risk of complications and is curative in most cases.

Journal Article↗
PubMed1995

Large loop excision of the transformation zone.

During the early 1990s, the technique of LLETZ has acquired widespread approval throughout much of the colposcopic community, and its advantages over destructive methods of treatment have been described by several authors. 1. It allows for histologic audit of the colposcopic diagnosis. 2. It allows histopathologic examination to rule out microinvasion. 3. It allows excision of the dysplastic lesion and the transformation zone, which may be confirmed histologically. 4. It may be performed at the first (assessment) colposcopic examination. 5. It may be adapted to treat all cases of CIN, irrespective of the size and site of the transformation zone. 6. It is an easily learned technique. 7. It uses inexpensive, readily available equipment and has low operating costs. 8. It is usually an office or outpatient procedure performed using local anesthesia. The last five of these eight advantages are also potential disadvantages of the technique that may combine to increase the morbidity of the procedure. Women may be treated more easily and at a lower threshold of abnormality in the office with local anesthesia and with transformation zones of almost any dimension, situated on the ectocervix in the endocervical canal or both. If more women are treated (at a lower threshold of suspected abnormality), then procedure-related morbidity will increase. Because the technique allows sufficient flexibility to accommodate transformation zones of every site and dimension, it is inevitable that women who would otherwise have had a cone biopsy will now have a LLETZ procedure. The morbidity of a cone biopsy (LLETZ, laser, or cold knife) is related to the volume, and also probably the amount of endocervical tissue excised. It is important that the morbidity associated with removal of a long endocervical transformation zone be recognized as a consequence of the size and site of the transformation zone, rather than of the choice of excisional technique. EASE OF USE The method is technically straightforward and undemanding to an experienced and relatively dexterous colposcopist. COST When compared with the laser technique, the method is less expensive. However, the other destructive modalities are equally inexpensive (cold coagulation, cryocautery, and radical diathermy). Many of the electrosurgical units that are used for LLETZ also may be used for a variety of procedures in gynecology. EFFECTIVENESS It is evident that a method of excising the transformation zone will have the same likelihood of successfully treating women with CIN as do the destructive techniques, and this has been supported by the published series of patients treated by LLETZ. It is also true that LLETZ is unlikely to significantly improve on the success/failure rates of treatment achieved by the protagonists of each destructive method of treatment. This is because the success/failure rates of destructive methods are high when performed by experts. However, women with CIN cannot always be treated by experts of individual destructive techniques. Perhaps a more clinically important question is whether LLETZ is associated with a superior success/failure rate compared with destructive methods in which each are performed by the nonspecialized practicing gynecologist.

Biopsy↗
PubMed1995

Cervical cytology and conservative management of cervical neoplasias during pregnancy.

To elucidate the clinical significance of cervical cytology during pregnancy, 7,725 pregnant women were examined. Abnormal cytologic findings were recorded in 65 cases (0.8%). Colposcopically directed punch biopsies revealed cervical dysplasia and carcinoma in 27 cases (0.35%). The incidences in a massive examination for 714,119 women in Osaka Prefecture were 1.1% and 0.25%, respectively. Cytologic findings of the patients with cervical neoplasia during pregnancy agreed well (76%) with their histologic findings. Colposcopically, the squamo-columnar junction was visible in many cases, and white epithelium was most commonly observed during pregnancy. Pre- and postpartum follow-up study revealed that progression from dysplasia was seen only in two (20%) of 20 cases. Laser conization was performed on six women during pregnancy, and four were microinvasive carcinoma, all of which underwent normal vaginal delivery without any complication from conization. These results suggest that routine cervical cytology must be performed during pregnancy, and cytologic and colposcopic diagnosis may supply enough data to avoid unnecessary biopsies. Moreover, laser conization is recommended as an excellent diagnostic and therapeutic procedure for women with microinvasive carcinoma during pregnancy.

Adolescent↗
PubMed2002

Prevalence of preinvasive and invasive lesions of the cervix in sexual workers.

OBJECTIVE: To determine the prevalence of preinvasive and invasive lesions of the cervix in sexual workers. MATERIALS AND METHODS: A total of 438 prostitutes were analyzed. Each prostitute had a clinical history, gynecological examination, Pap smear, and a colposcopic examination of the cervix. A cervical biopsy was taken under colposcopic guidance when there was abnormal epithelium. RESULTS: The sexual workers' mean age was 32.2 + 8 years (mean + SD), age of first sexual intercourse was 15.9 + 2 years, parity mean was 4.1 + 2, births were 3 + 3, and age of first delivery was 16.6 + 4.7 years. Cervical biopsies were taken from 84 patients because of atypical epithelium under colposcopic examination. Sixty-four (76.2%) patients had preinvasive and invasive lesions: 41(64%) had cervical intraepithelial neoplasia (CIN) 1, 12 (18.8%) had CIN 2, 8 (12.5%) had CIN 3, 2 (3.2%) had microinvasive carcinoma (Ca), and 1 (1.5%) had invasive Ca 1. Sexual workers with cervical pathology were younger (p < .05) and had their first sexual intercourse experience earlier than those sexual workers who did not have lesions (p < .02).Preinvasive lesions were found in sexual workers in their 30s, and invasive lesions were found in sexual workers under the age of 40. CONCLUSIONS: Preinvasive lesions of the cervix have increased 2-fold in Venezuelan sexual workers and the invasive lesions are stable but found in younger sexual workers.

Journal Article↗
PubMed2005

A prospective evaluation of "see and treat" in women with HSIL Pap smear results: is this an appropriate strategy?

OBJECTIVE: The evaluation of abnormal cervical cytologic results is time consuming and costly. Most patients with high-grade squamous intraepithelial lesion (HSIL)-cervical intraepithelial neoplasia 3 (CIN 3) Pap smear results require an excisional procedure for diagnostic or therapeutic reasons. "See and treat" is a surgical procedure that involves a loop electrosurgical excisional procedure (LEEP) simultaneously to diagnose and to treat premalignant cervical disease in one visit. This procedure eliminates a second visit that typically is required for treatment. Data is lacking on the incidence of CIN 2 and CIN 3 in patients with an HSIL (CIN 2) Pap smear result. The objective of this study was to determine the incidence of CIN 2 and CIN 3 in patients with an HSIL (CIN 2) Pap smear using a see-and-treat protocol. METHODS: Women referred from local health departments to our university-based colposcopy clinic for evaluation of an HSIL (CIN 2) Pap smear result were evaluated for inclusion in a see and treat protocol. All eligible patients underwent colposcopy to rule out an obvious cervical carcinoma followed by an immediate LEEP to remove the transformation zone. A colposcopic impression was made using the Reid colposcopic index. Pathologic specimens were analyzed for the presence of CIN and the incidence of CIN 2 and CIN 3 was determined. RESULTS: To date, 51 patients have been enrolled in the study. Exclusion criteria included age less than 19 years, pregnancy, or medical contraindications. The mean age of the patients was 26 years (range, 19-45 years). Forty-seven percent were white, 47% were black, and 6% were Hispanic. Of the 51 patients who underwent LEEP, 43 of 51 (85%) had satisfactory colposcopy and no patient had a lesion suspicious for cervical carcinoma. The average Reid colposcopic index was 3.5. Of the 51 LEEP specimens, 4 of 51 had no evidence of CIN (8%), 4 of 51 (8%) had CIN 1, 18 of 51 (35%) had CIN 2, and 25 of 51 (49%) had CIN 3. Eighty-four percent of patients had either CIN 2 or CIN 3, resulting in an overtreatment rate (CIN 1 or less) of 16%. CONCLUSIONS: The use of a see and treat protocol for patients with HSIL (CIN 2) Pap smear results may be an acceptable treatment option because of a high incidence of CIN 2 and CIN 3.

Adult↗
PubMed2002

High grade abnormalities following an 'inconclusive' smear.

OBJECTIVE: The National Health and Medical Research Council (NHMRC) recommends a report of 'inconclusive possible high grade epithelial abnormality', but many laboratories only report 'inconclusive' with reference to any possible high grade disease elsewhere in the report. This study was performed to determine possible reasons for cytological difficulties resulting in this category of report and to determine the rate of significant disease within this category. DESIGN: Retrospective record review. Clinical details were extracted without patient-identifying data. SETTING: Gynaecological Oncology Department, King George V/Royal Prince Alfred Hospital. POPULATION: Two hundred patients referred with the cytological abnormality. MATERIALS AND METHODS: An adequate colposcopic diagram documenting size, distribution and grade of lesion was required. All patients had colposcopy with management according to colposcopic and histological results as appropriate to their disease. OUTCOME MEASURES: Colposcopic features, topography and size of any lesion, histological results, treatments performed and subsequent review of untreated patients. RESULTS: Colposcopy found high-grade lesions in 43% and carcinoma in 1%. Histopathology found 49% and 4% respectively. Treatment was performed in 124 patients. Inflammation was found in 27%, a small lesion in 43% and endocervical disease in 21%. CONCLUSIONS: The high rate of endocervical disease, inflammation and small lesions may explain the cytological difficulties leading to an 'inconclusive' result. The authors believe that the term 'inconclusive' alone does not adequately convey the high level of risk faced by these patients.

Adolescent↗
PubMed1981

Colposcopy in pregnancy. A twelve year review.

In a 12-year period, 195 patients with abnormal cervical cytology in pregnancy had colposcopy, of whom 73 had Grade IV cytology. Colposcopic findings in pregnancy correlated closely with the postpartum colposcopic assessment and this in turn predicted the ultimate histological diagnosis. Wedge biopsies were taken in two women in whom invasive disease could not be excluded colposcopically. Cone biopsy was avoided in all patients. No frank or occult invasive disease was missed but one patient was ultimately found to have a small focus of microinvasive disease six months post partum. Postpartum cytology gave a reasonable guide to the ultimate histology, although postpartum colposcopy was found to be of value even where cytology had by then reverted to normal.

Biopsy↗
PubMed1993

The value of cytology and colposcopy in the follow up of cervical intraepithelial neoplasia after treatment by laser excision.

OBJECTIVE: To determine the value of colposcopic assessment in the follow up of cervical intraepithelial neoplasia (CIN) treated by laser excision. DESIGN: Retrospective analysis of case records of women with CIN treated by laser excision over the period 1986 to 1990. SETTING: A colposcopy clinic in a district general hospital. SUBJECTS: Five hundred-forty consecutive patients with either CIN or microinvasion diagnosed on laser excision specimens. RESULTS: Of 452 patients followed up for 10 months, 14 were diagnosed as having persistent CIN. Eleven of these were detected at the first follow up visit at four months using both colposcopic and cytological assessment. Elimination of colposcopic assessment in follow up would have reduced the number detected to five patients. CONCLUSION: For patients undergoing laser excision for CIN involving the endocervical canal, a normal initial, post-treatment colposcopy is necessary before surveillance may be reduced to cytology alone.

Adolescent↗
PubMed1997

Investigation of 100 consecutive negative cone biopsies.

OBJECTIVE: To investigate the reasons for cone biopsies reported as not containing intraepithelial or invasive malignancy and thereby find ways to decrease their incidence. DESIGN: One hundred cone biopsies reported as negative were identified out of a total of 436 consecutive cone biopsies. The patients' cytology, colposcopy and histology reports and cytology and histology slides were reviewed. Further opinions in cases of doubt were obtained in cytology and histology. In cone biopsies still considered negative after reviews, deeper levels were cut, exhausting all paraffin blocks. Follow up cytology, colposcopy and histology were reviewed. SETTING: Gynaecological oncology unit in a university teaching hospital. RESULTS: After re-evaluation the final diagnoses of cone biopsies initially reported as negative were positive (n = 21), unsatisfactory (n = 27) and true negative (n = 51), with one case excluded because of insufficient material for review. The positive cases were diagnosed on review (n = 11) or extra levels (n = 10). The unsatisfactory cases were all due to denudation. The 51 true negative cases were divided into those which never had had histologic confirmation by punch biopsy or endocervical curettage (n = 47) and those with a previously confirmed histological abnormality (n = 4). CONCLUSIONS: The number of negative cone biopsies can be reduced by: 1. taking Pap smears after correction of atrophy and inflammation; 2. more scrupulous colposcopy aimed at reducing the number of unsatisfactory colposcopies or misinterpreted colposcopic findings; this through examination should include the vagina and vulva; 3. confirmation of smear and colposcopic findings by biopsy prior to cold-knife conisation and performing a large loop excision of the transformation zone (LLETZ) for cases where there is a discrepancy between the smear abnormality and colposcopy/biopsy findings; 4. good quality cone biopsies using a technique that does not handle the mucosa and is performed after the mucosa has had time to regenerate following the colposcopic investigations; and 5. exhausting all blocks with multiple levels before reporting a cone biopsy as negative.

Adult↗
PubMed1998

Inter- and intra-observer variation in the histopathological reporting of cervical squamous intraepithelial lesions using a modified Bethesda grading system.

OBJECTIVE: 1. To assess inter- and intra-observer variation in the histopathological reporting of cervical colposcopic biopsies using a histologic modification of the cytological Bethesda grading system; 2. to determine the histologic profile of those cases which resulted in diagnostic disagreement. METHODS: Consecutive cervical colposcopic biopsies (n = 125) were assessed independently by six experienced histopathologists. Cases were classified as normal, low grade squamous intraepithelial lesion or high grade squamous intraepithelial lesion. Six months later the process was repeated. The degree of inter and intra-observer variation was assessed by kappa statistics. All cases in which there was less than perfect inter and intra-observer agreement were reviewed by the coordinator of the study. RESULTS: In the first round of the study inter-observer agreement was generally poor, with unweighted and weighted kappa values ranging from 0.15 to 0.58 (average 0.30) and from 0.21 to 0.61 (average 0.36) respectively. In the second round inter-observer agreement was better, with unweighted and weighted kappa values ranging from 0.08 to 0.55 (average 0.33) and from 0.22 to 0.59 (average 0.42). Ten of the 15 pairs of observers achieved fair inter-observer agreement using weighted kappa analysis. The degree of intra-observer agreement was better, unweighted and weighted kappa values ranging from 0.26 to 0.61 (average 0.47) and from 0.34 to 0.62 (average 0.51) respectively. Two of the six participants achieved fair intra-observer agreement and two achieved good intra-observer agreement using weighted kappa analysis. There were marked difficulties in the separation of normal squamous epithelium from low grade squamous intraepithelial lesion and in the separation of low grade from high grade squamous intraepithelial lesions. Histopathological review revealed that many of the difficulties in the separation of normal and low grade squamous intraepithelial lesion were in the distinction between superficial vacuolated cells and true koilocytes. Difficulties also resulted in the separation of basal cell hyperplasia, inflammatory associated changes and immature squamous metaplasia from low grade squamous intraepithelial lesion. Conditions which resulted in difficulty in the separation of low grade and high grade squamous intraepithelial lesions included florid koilocytotic change and immature metaplastic squamous epithelium with atypia. In some cases, there was a full spectrum of diagnoses from normal to high grade squamous intraepithelial lesion. These were largely cases of immature metaplastic squamous epithelium with atypia and of thin or atrophic squamous epithelium with atypia. CONCLUSIONS: Most pairs of observers can achieve fair inter-observer agreement in the reporting of cervical colposcopic biopsies using a modified Bethesda system. Intra-observer agreement is also generally fair to good using this system. It may be that a two tier grading system is more appropriate for the histopathological reporting of these biopsies than the traditional three-tier intraepithelial neoplasia (CIN) system.

Biopsy↗
PubMed1998

Can women at risk of cervical abnormality be identified?

OBJECTIVE: To determine if use of a detailed risk factor profile accurately predicts the presence of cytological abnormality of the cervix or improves the appropriateness of referral for colposcopic assessment when women are found to have these abnormalities. DESIGN: Cross-sectional survey. SETTING: Family planning clinic. POPULATION: 1219 consecutive women, aged between 15 and 19 years, attending for contraceptive advice. Variables included age, social class, educational status, hormonal and obstetric history, smoking and alcohol habits, history of sexually transmitted diseases, the age of first intercourse, number of sexual partners, duration of each relationship, frequency of intercourse, contraception used and the age of each partner. MAIN OUTCOME MEASURES: Presence or absence of cytological abnormality and the presence or absence of histological abnormality in those with cytological abnormality referred for colposcopic assessment. RESULTS: Univariate analysis confirmed many of the known associations of cervical abnormality. Discriminant analysis identified five independent significant predictors of cytological abnormality and four independent predictors of dyskaryotic cytology. At best models, derived from identified variables correctly predicted 10.1% of individuals with cytological abnormality and 13.5% of those with dyskaryotic cytology. Of those referred for colposcopic assessment because of abnormal cytology, models were able to predict 23.5% of those with histological evidence of cervical intraepithelial neoplasia. CONCLUSIONS: Despite the availability of detailed information regarding the known correlates of cervical neoplasia in this age group, it was not possible to identify the majority of women with cervical abnormality. It is concluded that the strength of these associations is not sufficient to allow useful prediction of membership of a high risk group.

Adolescent↗
PubMed2000

High risk human papillomavirus in women with normal cervical cytology prior to the development of abnormal cytology and colposcopy.

OBJECTIVE: To study the significance of the presence of high risk human papillomavirus (HPV) in women with initially normal cervical cytology for the development of abnormal cytology and an abnormal colposcopic impression. DESIGN: Prospective, observational study PARTICIPANTS AND METHODS: Sixty-eight women with cytomorphologically normal smears and at least one positive HPV test result were evaluated every six months by cytology, colposcopy and HPV testing. The endpoint of the study was abnormal cervical cytology. RESULTS: The median time of follow up from the first positive HPV test was 34 months. A total of 17 women developed abnormal cytology, of whom 16 (94%) had persistence of a high risk HPV infection. Women with persistent high risk HPV were more likely to develop abnormal cervical cytology than women without high risk HPV (hazard ratio 28.2, 95% CI 3.72-215.2); they also had an increased risk of developing an abnormal colposcopic impression (hazard ratio 4.4, 95% CI 1.69-11.7). Among the 17 women with abnormal cytology, high grade dysplasia was histopathologically demonstrated in eight women. CONCLUSION: Persistent presence of high risk HPV in normal cervical smears is associated with a significantly increased risk of developing abnormal cytology and to a lesser degree with developing an abnormal colposcopic impression.

Adolescent↗
PubMed2000

A clinical review of borderline glandular cells on cervical cytology.

OBJECTIVE: To review the diagnoses and diagnostic pathway of women presenting with borderline glandular cells on cervical cytology. To outline the basis of clinical approach of these women. DESIGN: Retrospective review. POPULATION: Forty-three women referred to the hospital department over a 32-month period. METHODS: Review of the casenotes for the demographic data, previous cervical cytology and/or histology report, indication for the smear resulting in borderline glandular cells, colposcopic findings, diagnostic and/or treatment procedures, final diagnosis and current status. RESULTS: The average age was 36.7 years. Twenty-four women (56%) had clinically significant lesions: seven women (16%) presented with cancers, of which one was endometrial in origin, and 17 (40%) with intraepithelial neoplasia (CIN and cervical glandular intraepithelial neoplasia (CGIN)). Sixty-seven percent of all clinically significant lesions were of squamous origin. Thirty-seven had histological diagnosis, while six went on to cytological surveillance. Colposcopy was the most significant predictor for clinically significant lesions (P < 0.05). Punch biopsies and loop excisions were diagnostic when based on abnormal colposcopic findings. Brush cytology was appropriate follow up for asymptomatic, premenopausal women with no colposcopic abnormality. In addition, endometrial sampling was recommended in the peri- and postmenopausal women. CONCLUSION: Borderline glandular cells have a high incidence of clinically significant lesions. Immediate referral for colposcopy and assessment is strongly recommended in women with two borderline glandular smears to avoid delays in potential cancer diagnosis.

Adult↗
PubMed2005

A comparative study of two methods of large loop excision of the transformation zone.

OBJECTIVE: To determine whether the conventional large loop excision of the transformation zone (CLLETZ) and the "top-hat" technique (THLLETZ) differ in (a) completeness of excision of the cervical lesion, (b) depth of cervical tissue excised and (c) adequacy of follow up by cytology and colposcopy. DESIGN: Retrospective case review. SETTING: University Teaching Hospital, London. SAMPLE: Five hundred and thirteen consecutive patients matched for age, parity, smoking history and referral cytology who had either CLLETZ (286-5%) or THLLETZ (227-44%) for cervical intraepithelial neoplasia (CIN). METHODS: All procedures were performed or supervised by BSCCP-accredited colposcopists. All cytology and histology were reviewed by two specialist cytohistopathologists. Cervical stenosis was defined as difficulty in or inability in obtaining an endocervical brush smear. MAIN OUTCOME MEASURES: Depth of cervical tissue excised, histology of endocervical margins, post-LLETZ cytologic and colposcopic findings. RESULTS: The mean depth of excision in the CLLETZ group was 12.1 mm (SD = 4.4 mm) and 20.8 mm (SD = 6.4 mm) in the THLLETZ group. The incidence of involved endocervical margins was 2.8% in the CLLETZ group and 5.2% in the THLLETZ group (P= 0.1). There was CIN in the "top-hat specimen" of 10 THLLETZ cases (4.4%, CI = 95%). The first post-treatment cervical smear was inadequate in 5 (4.1%) cases in the CLLETZ group and 20 (11.7%) in the THLLETZ group (P= 0.022). Cervical stenosis was found in 21 (7.7%) cases in the CLLETZ group and in 64 (30.9%) cases in the THLLETZ group (P < 0.0001). Eleven (4%) patients in the CLLETZ group had cytological and/or colposcopic evidence of residual CIN compared with 12(5.8%) patients in THLLETZ group (P= 0.4). In the first follow-up assessment, 21.7% of the CLLETZ group had incomplete colposcopy compared with 48.7% in the THLLETZ group (P < 0.0001). CONCLUSIONS: Compared with the CLLETZ, the THLLETZ (1) removed more cervical tissue but did not have a lower incidence of involved endocervical margins, and (2) resulted in significantly higher incidence of inadequate post-treatment colposcopic and cytological follow up. These data indicate that there is no justification to performing a "top-hat" LLETZ routinely.

Blood Loss, Surgical↗
PubMed2001

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.

Acetic Acid↗
PubMed1990

Loop diathermy excision of the cervical transformation zone in patients with abnormal cervical smears.

OBJECTIVE: To determine the efficacy and morbidity of fine loop diathermy excision of the cervical transformation zone as applied to the management of outpatients with abnormal cervical smears. DESIGN: Prospective programme trial with six month follow up. SETTING: Two hospital based colposcopy clinics. PATIENTS: 616 Patients aged 16-60 with abnormal cervical smears. INTERVENTIONS: After colposcopic and cytological assessment excision of the cervical transformation zone by fine loop diathermy under local anaesthesia in the outpatient department. MAIN OUTCOME MEASURES: Time to complete the treatment, immediate morbidity in terms of discomfort and bleeding, and cytological and colposcopic findings at six months. RESULTS: Treatment was completed in a mean of 3.47 minutes (SD 1.99). Immediate morbidity was minimal, and histological specimens were adequate in over 90% of cases. Almost two thirds of patients were treated at their first visit to the clinic. 58 Patients (9.4%) failed to attend for follow up at six months and one had had a hysterectomy. Of the 557 patients who attended for colposcopic and cytological follow up at six months, 506 (91%) were normal cytologically and 19 (3.4%) had histologically confirmed persistence of cervical intraepithelial neoplasia. The overall confirmed failure rate of the technique was 4.4%. CONCLUSION: Loop diathermy excision is an effective treatment with low morbidity and is an appropriate modality for patients with abnormal cervical smears.

Adolescent↗
PubMed1988

Risk factors in the development of cervical intraepithelial neoplasia in women with vulval warts.

Of 59 women referred with vulval warts whose cervices were assessed colposcopically for the presence of cervical intraepithelial neoplasia (CIN) before local treatment of the wart lesions, 17 had histologically proved CIN, 12 had histologically proved cervical wart virus infection, and 30 had abnormality on colposcopy or cytology. Seven of the 17 with CIN had no abnormality on cervical cytology. No differences in sexual behaviour, smoking habit, or oral contraceptive use were seen between women with CIN and those with no cervical abnormality. Viral DNA typing of the vulval lesions was carried out, but there were no differences in the distribution of viral types between the three different histological groups. Of the 30 women with no abnormality at the initial visit, 23 were followed up colposcopically and cytologically for one to two years. Three of them developed CIN after adequate treatment of the vulval lesions despite the absence of cervical abnormalities on colposcopy at the time of treatment. Studying the known factors linked with CIN failed to show why some women with vulval warts develop CIN, even after treatment of the warts, and others do not. The large number of false negative results on cervical cytology in our patients suggests that women presenting with vulval warts should be screened colposcopically in the first instance. Close follow up of women whose warts are treated and who are thought to have no cervical abnormality at that assessment is essential.

Adult↗