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PubMed1992

The acetic acid test in evaluation of subclinical genital papillomavirus infection: a comparative study on penoscopy, histopathology, virology and scanning electron microscopy findings.

OBJECTIVES: To evaluate colposcopic criteria in acetowhite lesions of the penis ("penoscopy") for the diagnosis of subclinical genitoanal papillomavirus infection (GPVI) compared with histopathological criteria of HPV involvement and to various hybridisation assays for HPV DNA detection, and to depict typical lesions by scanning electron microscopy. DESIGN: The study included 101 randomly selected male partners of females with known GPVI, or with penile symptoms such as itching, burning and dyspareunia who did not exhibit overt genital warts but appeared to be afflicted with acetowhite penile lesions after topical application of 5% acqueous acetic acid. Lesions were judged by penoscopy as either typical, conspicuous or nontypical for underlying HPV infection. Biopsy specimens from 91 men were examined by light microscopy and by either Southern blot (SB), polymerase chain reaction (PCR) and/or in situ hybridisation (ISH) assays for the presence of HPV DNA of the HPV types 6, 11, 16, 18, 31, 33 and 42 (Group A). From another ten men lesions clinically typical for GPVI were also examined topographically by scanning electronic microscopy (Group B). SETTING: The STD out-patient clinic of the Department of Dermatovenereology of Karolinska Hospital, Stockholm, Sweden. RESULTS: Group A Seventy eight (86%) of the biopsied lesions met the penoscopy criteria of being either typical of or conspicuous for GVPI. The agreement between penoscopy and histopathology was fairly good, as HPV diagnosis was made by both methods in 56 (62%) of the cases. The reliability of applying strict colposcopic hallmarks was further substantiated by the finding that 55 (60%) of the biopsy specimens taken from penoscopically typical/conspicuous lesions contained HPV DNA. However, there are diagnostic pitfalls for the acetic acid test. Coexistence of an eczematoid reaction with changes indicative of HPV influence was detected in six (7%) of the cases, while an inflammatory response only occurred in 17 (19%) of the specimens. Additional histopathological diagnoses (normal epithelium, lichen sclerosus et atrophicus, balanitis circinata parakeratotica, verruca plana) were established in another eight (9%) of the cases. Among the HPV DNA positive cases, all of the HPV types tested for were detected with the exception of HPV 18. A severe penile intraepithelial neoplasia (PIN III) was revealed in five (5%) of biopsies; HPV 16 was present in two and HPV 42 in one of these biopsy specimens. GROUP B: Scanning electron microscopy depiction harmonised with the penoscopy findings showing that subclinical GPVI characteristically exhibits a well demarcated, slightly elevated border and that the central area of lesions often displays a "groove" in which the epithelium appears to be thin with protrusions from beneath that probably represent capillaries. CONCLUSION: Use of the acetic acid test for evaluation of GPVI should be combined with a colposcopic evaluation based on strict topographic hallmarks, followed by a directed biopsy for light microscopic evaluation. We found that the positive predictive value of colposcopy was as high when correlated with histopathological findings (72%) as when virological methods were used, whether HPV DNA hybridisation testing was performed with the well established SB and ISH assays (45%), or by applying the newly introduced and highly sensitive PCR assay as well (71%). False positivity from the acetic acid test occurs and is mainly due to inflammatory conditions but also to the presence of other conditions. Epithelial fissures are evidently associated with some subclinical GPVI lesions and may potentially represent loci minores for infectious stimuli and perhaps facilitate the transmission of some blood-borne STDs. We prose that the term "papillomavirus balanoposthitis" should be used for penile HPV infection associated with inflammatory responses. Our study indicates that PIN III frequently occurs in a subclinical form and may be associated with not only previously identified "high-risk" HPV types such as type 16, but also with the HPV type 42 that has not previously been considered as oncogenic.

Acetates↗
PubMed1992

Detection of genital human papillomavirus (HPV) DNA by PCR and other conventional hybridisation techniques in male partners of women with abnormal Papanicolaou smears.

OBJECTIVE: To study the prevalence of human papillomavirus (HPV) infection, using several different hybridisation techniques, in men whose female sexual partners had cervical HPV and/or cervical intraepithelial neoplasia (CIN). METHODS: The male genital area was examined colposcopically and areas suspicious of HPV changes were biopsied. Each biopsy was subjected to histological examination and HPV DNA analysis by conventional DNA analysis such as Southern, reverse and dot blot as well as with polymerase chain reaction (PCR). RESULTS: Colposcopic examination of men showed 133 to be normal whilst 82 (38%) had clinical or subclinical lesions. Of 55 colposcopically directed biopsies from the male lesions taken, detection of HPV DNA by hybridisation with conventional techniques and by PCR showed HPV DNA in 29 (53%) and 47 (85%) of biopsies respectively. Overall HPV types 6/11 were the predominant types. In 18 (33%) biopsies positive by PCR, multiple types were found. CONCLUSION: HPV DNA was present in the majority of biopsy specimens taken, with HPV 6/11 being the predominant type. Among methods for HPV DNA detection, PCR was the most sensitive and useful technique.

DNA Probes, HPV↗
PubMed1995

Cervical dysplasia in HIV-seropositive women: role of human papillomavirus infection and immune status.

OBJECTIVE: In the present study we investigated the cytologic and colposcopic characteristics of a cohort of HIV-infected women, with the aim to determine a relationship between immunologic status and frequency and/or severity of cervical abnormalities. MATERIALS AND METHODS: 21 women, who tested positive for the HIV antibody and who were admitted as outpatients because of various gynecologic complications or because of an HIV infection that was under regular clinical surveillance. A pelvic examination was performed and Papanicolaou smears were obtained from endocervix and ectocervix before colposcopic examination. Cytologic samples for human papillomavirus (HPV) detection by polymerase chain reaction were also collected. Results obtained in the group of HIV-infected women were compared with findings in a group of 473 seronegative women recruited consecutively from our outpatient population. Serum samples for T lymphocytes were drawn within 2 weeks of cytologic and colposcopic examination. CD4 and CD8 monoclonal antibodies were purchased from Becton Dickinson (Mountain View, Calif., USA). RESULTS: HIV-infected women had a significantly higher percentage of HPV DNA positivity with respect to the outpatient population (67 vs. 7%, respectively, p < 0.001). Analysis of cytologic specimens revealed 9 women (43%) with cytologic evidence of cervical dysplasia in the HIV-seropositive group vs. 23 (5%) of 473 in the outpatient population (p < 0.001). All the HIV-seropositive women with cervical dysplasia presented an associated HPV DNA positivity; in particular, the percentage of associated HPV DNA type 16 in cervical dysplasia was 78% (7/9 cases). In HIV-infected women, the evaluation of T lymphocyte subset distribution suggested a significant relationship between CD4+ cell decrease and severity of cytologic findings (p = 0.03). DISCUSSION: The HIV-infected women had a tenfold higher prevalence of both HPV infection and cervical dysplasia than the outpatient population; this increased risk seems to be limited mainly to those who also had genital HPV infection. The analysis of immunologic status confirmed previous observations that an impaired immune system results in increased cervical disease.

Adult↗
PubMedDate not supplied

A thin-layer, liquid-based pap test for mass screening in an area of China with a high incidence of cervical carcinoma. A cross-sectional, comparative study.

OBJECTIVE: To confirm the accuracy of the ThinPrep Pap Test (Cytyc Corp., Boxborough, Massachusetts, U.S.A.) on the basis of histologic diagnosis by biopsy and the detection of human papillomavirus (HPV) DNA in mass screening. STUDY DESIGN: A total of 1,997 women residing in Xiangyuan County, Shanxi Province, P.R.C., an area with a high incidence of cervical carcinoma, were enrolled in this study. We collected exfoliative cervical samples from all subjects into a liquid buffer (Preserv-Cyt [Cytyc]) and utilized for both cytologic screening using the ThinPrep Pap Test and HPV DNA testing. Subsequent colposcopic biopsies were taken on all subjects. All the tests were performed in an independent and blinded fashion. We compared the ThinPrep Pap test with colposcopic biopsy and HPV test. RESULTS: High grade squamous intraepithelial lesions (HSIL) (CIN 2/3) were identified in 74 (3.7%) of 1,993 women adequately assessed, and there were 12 cases of squamous cell carcinoma (SCC). The false negative rate of ThinPrep cytology was 3.2% for biopsy-confirmed CIN 3 and 9.3% for CIN 2. Twenty-seven (87%) of the 31 women with biopsy-confirmed CIN 3 and 12 (100%) of 12 with biopsy-confirmed SCC had a diagnosis of either HSIL or greater abnormalities on ThinPrep cytology. In addition, the HPV DNA detection rates offered a good correlation between cytology and biopsy. CONCLUSION: The ThinPrep Pap performed extremely well in this primary screening trial. We found a good correlation between ThinPrep cytology and colposcopic biopsy on detection of HSIL and SCC; cervical specimens collected in ThinPrep liquid buffer serve as a direct test for HPV as well.

Adult↗
PubMedDate not supplied

Feasibility of cytology-based cervical cancer screening in rural Cameroon.

OBJECTIVE: To determine the prevalence of cervical cancer and its precursors in a rural population in Cameroon and to evaluate the feasibility of a cytology-based screening program in such areas. STUDY DESIGN: A prospective study was conducted in the rural town of Bafang. Following an advocacy campaign, 750 women were recruited. After a clinical examination, all women had a Pap smear with the Cervex Brush. Each sample had two preparations, conventional and liquid based. The conventional smears were interpreted in Bafang. Cytologically abnormal cases, those with clinical inflammation and/or macroscopic cervical lesions, had a colposcopic examination and directed biopsy. HSIL and colposcopically abnormal cases were treated with large loop excision of the transformation zone (LLETZ). The liquid-based preparations and histopathology were performed in Geneva and the results sent to Cameroon for patient follow-up. RESULTS: Mean age and parity of the women screened were 43.7 years and 7.8, respectively. The conventional smears showed 3.6% cervical abnormalities: 2% (15/740) ASCUS/LSIL and 1.6% (12/740) HSIL. The liquid-based preparations showed 12.6% (91/722) cervical abnormalities: 10.1% (73/722) ASCUS/LSIL and 2.5% (18/722) HSIL. Fifty percent of samples in both preparations showed evidence of inflammation. Histology was performed on 64 colposcopically directed punch biopsies and LLETZ specimens. The histologic diagnoses agreed with the cytologic findings in 60% (14/23) of conventional smears and 85% (12/14) of liquid-based preparations. CONCLUSION: There is a high rate of cervical intraepithelial neoplasia in the unscreened rural population of Cameroon. The situation is complicated by a high rate of cervical infection. A population-based cytologic screening program for cervical cancer would not be feasible in rural Cameroon because of high cost, low quality and limited technical facilities. Rural Africa requires an algorithm using a simple, low-cost technique of mass screening and an improved cytology service only to triage selected patients.

Adult↗
PubMedDate not supplied

High-grade cervical intraepithelial neoplasia (CIN) in pregnancy: clinicotherapeutic management.

UNLABELLED: An increasing incidence of cervical intraepithelial neoplasia (CIN) among young women has been noticed in recent years. For this reason pregnancy might represent a peculiar opportunity to undergo cytocolposcopic examination for those women who do not take part in a screening program for cervical carcinoma. Diagnosis of CIN during pregnancy poses the question of the management of this disease and particularly of whether it is better to treat the lesion or not during pregnancy. To contribute to the solution of this issue we initiated a study on the management of high-grade CIN in pregnancy. MATERIAL AND METHODS: Five hundred and seventy-one pregnant women underwent cytologic, colposcopic and, when necessary, histologic examination. Those in whom a CIN was discovered in the first four months of gestation underwent laser conization. When the diagnosis of CIN was made after the sixteenth week of gestation, cytocolposcopic monitoring was performed every eighth week during pregnancy and two months after childbirth. Laser conization was performed under colposcopic guidance in the outpatient setting in all cases. All treated patients were submitted to cytologic, colposcopic and, if necessary, histologic examination every third month in the first year after treatment, every sixth month in the second year and yearly from the third year onwards. RESULTS: In 14 (2.4%) of the 571 examined women a CIN III was discovered, 6 of which associated with a human papilloma virus (HPV) infection. Of these, 8 patients, whose diagnosis was made within the sixteenth week of pregnancy, underwent laser conization. In one case a minor hemorrhage occurred during treatment. Two patients reported minor bleeding up to ten days after treatment. No major hemorrhages or cervical stenosis were observed. Histologic examination of the cones confirmed the preoperative diagnosis based on cervical biopsies and the lesion was entirely removed by conization in all cases. Seven of the 8 patients who underwent laser conization during pregnancy had a spontaneous delivery at term. The remaining patient, who had had a previous cesarean section, was again delivered by cesarean section. All treated patients were cured after the first-year follow-up visit. In 6 patients CIN was diagnosed after the sixteenth week of pregnancy. These women underwent cytocolposcopic examination every eighth week during pregnancy and two months after delivery, when the cervical changes associated with gestation had disappeared. Four of these patients showed persistence of CIN at postpartum follow-up and therefore underwent laser conization. In two patients spontaneous regression of the lesion was observed. In no case did progression to invasive carcinoma occur. CONCLUSIONS: Given the increasing incidence of CIN in young women, the beginning of pregnancy may represent a peculiar opportunity for all pregnant women who do not take part in cervical screening programs to undergo a cytocolposcopic examination. In case of a diagnosis of high-grade CIN within the first 16 weeks of pregnancy, a conservative excisional treatment, which does not expose the pregnancy to any risk, should be carried out in order to confirm the intraepithelial localization of the lesion.

Adult↗
PubMed1981

Severe cervical dysplasia. Control by biopsies or primary conization? A comparative study.

During the period 1967-75 severe cervical dysplasia was diagnosed in 87 consecutive cases by means of colposcopically directed biopsies of the portio and by cervical curettage. Thirty-eight of the patients were treated, 3-6 weeks after diagnostic biopsy, by conization (conization group) and subsequently followed with smears and colposcopy. The remaining 49 patients (the biopsy group) were followed up at regular intervals by colposcopically directed biopsies of the portio and cervical curettage. The follow-up period for all 87 patients ranged from 9 to 106 months, mean 47.6 months. The groups were comparable with respect to the most important epidemiological factors. During the follow-up period progression to carcinoma in situ and to microinvasive carcinoma was found in 57.1% of the biopsy group but in 0% of the conization group. Of the whole material, 69 patients had conization (the 38 patients of the conization group plus 31 of the biopsy group). In 3 cases (4.35%) the cone diagnosis was 1 grade more serious than the biopsy diagnosis. The mean transit time of progression from severe dysplasia to CIS/MIC was 12-15 months. It is concluded that severe dysplasia is a rapidly progressing state which can be safely diagnosed by colposcopically directed biopsies of the portio and cervical curettage and effectively treated by conization. In view of the fact that not less than 32.7% of the cases with severe dysplasia in the biopsy group regressed during follow-up, we recommend that the diagnosis be established by portio biopsies and cervical curettage, twice with an interval of 3 months to restrict the number of superfluous conizations.

Biopsy↗
PubMed1997

Cytobrush and endocervical curettage in the diagnosis of dysplasia and malignancy of the uterine cervix.

BACKGROUND: The validity of cytobrush and endocervical curettage combined with colposcopically directed biopsies in the diagnosis of cervical dysplasia and malignancy has not been evaluated in randomized trials. We aimed to elucidate the diagnostic validity of the two methods. METHODS: A prospective, randomized study of 180 consecutive patients. All patients were examined without anesthesia by colposcopically directed biopsies of the ectocervix and randomly assigned to either cytobrush or endocervical curettage. Patients with < or = CIN 1 were investigated with the alternative method three months later. Patients with > or = CIN 2 had a cone biopsy. RESULTS: One hundred and thirty-one patients were evaluable. The sensitivity of cytobrush and endocervical curettage combined with colposcopically directed biopsies of the ectocervix was 96% and 84% (p = 0.08), respectively. The specificities of the two investigations were 95% and 88%, respectively (p = 0.78). All cytobrush specimens were evaluable but because of a low recovery of endocervical material a diagnosis could not be made in 12% of the patients examined by endocervical curettage. CONCLUSION: The sensitivity of the combined use of cytobrush and biopsies of the ectocervix was equal to or higher than the sensitivity of endocervical curettage and ectocervical biopsies. The specificities of the two investigations were much alike. All cytobrush specimens were evaluable but a diagnosis could not be performed in 12% of the endocervical curettage specimens because of too little endocervical material. Furthermore, cytobrush is less inconvenient to the patient. Therefore, in the follow-up of patients with cervical dysplasia endocervical curettage may be replaced with cytobrush.

Adolescent↗
PubMed1999

[Diagnostic and therapeutic concepts of HPV infection in HIV-positive women].

Among HIV-seropositive women there is a high prevalence of anogenital human papillomavirus (HPV) infection. HPV-DNA is more frequent detected in cervicovaginal-lavage specimens from HIV-seropositive women as in those from HIV-seronegative women. We and others suggest that HIV-infection increases the risk to have HPV-associated lesions of the lower female genital tract, especially the risk for developing a squamous intraepithelial lesion of the cervix. In this report we describe the current diagnostic and therapeutic strategies in HIV-seropositive women with HPV-infection. The gynecological examination should be performed at six to twelve month intervals, including the colposcopy and the Pap smear test. We hope to improve the quality of our screening program by doing an additional HPV-test. At last we investigate the CD4+ T-lymphocyte counts because it is observed that women with low CD4+ cell counts (< 200/microliter) were more likely to have persistent HPV-infection as those with higher counts (> 500/microliter). The treatment method is dependent on the development of the HPV-associated lesion and the clinical status of the HIV infected women. In cases with external warts local application of Condylox should be the first line treatment. Probably in about few months we could use other drugs like Wartec or Aldara in Germany. But the effectiveness of these drugs in HIV-positive women has to be proven yet. In the cause of persistence of external warts or recurrence of the disease the systemical application of Intron A or Roferon A is possible. The CO2-lasertreatment is performed under colposcopic guidance, especially in cases with multicentric condylomatous lesions. The treatment of cervical intraepithelial neoplasia (CIN) by CO2-laservaporisation or Loop Electrosurgical Excision Procedure (LEEP) is based on the clear colposcopic visualisation of the upper limit of the lesion. If CIN reaches the endocervix, being out of colposcopic view, and the squamocolumnar junction is localised in the endocervical canal conisation by laser or cold knife has to be performed. Before performing the treatment of CIN one should exclude multicentric cervical, vaginal and vulval intraepithelial neoplasia by colposcopy, because multicentric intraepithelial neoplasia of the lower female genital tract is more frequently than in HIV-seronegative women. Multicentric disease seems to be one cause of the high recurrence of HIV-seropositive women. However, higher levels of immunosuppression (CD4+ T-lymphocyte counts < 200/microliter) are also important determinants of recurrence of the disease. Therefore, an accurate short-term follow-up with colposcopy, Pap test and HPV test should be carried out after the treatment of HIV-seropositive women with low CD4+ counts.

Comorbidity↗
PubMed1998

Diagnostic dilemma in high intracanalar carcinoma of the cervix.

The use of colposcopy for follow up of patients with abnormal cervical smears has considerably increased the rate of detection of cervical malignancies and intraepithelial lesions in recent years. In case the lesion is situated high up in the cervical canal however, the chances of missing out the lesion are considerable. In our case the malignancy was detected only on endocervical sampling, but was missed on scrape as well as on colposcopically directed biopsy. The patient who was in perimenopausal age group, had complaints of post coital bleeding. The initial cervical scrape smear showed only squamous metaplasia. Colposcopically directed biopsy also showed the same findings. On a high index of suspicion clinically, the endocervical sampling was done with a cytobrush, which showed squamous cell carcinoma (SCC) of the cervix. Subsequent hysterectomy of the patient confirmed the diagnosis. Simultaneous endocervical sampling considerably increases the chances of finding an intracanalar lesion, particularly in older women, in whom the transitional zone (TZ) is situated high up in the cervical canal. In such a situation, even a colposcopically directed biopsy may prove inadequate. This was amply proved in our case.

Biopsy↗
PubMed1999

The use of carbon-dioxide laser surgery in the treatment of intraepithelial neoplasia of the uterine cervix.

From October 1989 to June 1997, 1841 patients (pts) suffering from different diseases of the lower genital tract have been treated with CO2 laser surgery in our Institution: among them, 782 were affected by cervical intraepithelial neoplasia (CIN). All pts underwent CO2 laser procedure for CIN after adequate colposcopic evaluation of the entire lower genital tract, colposcopic guided biopsy of the lesion, adequate pre-surgical work-up for possible infectious and coagulation associated disease. In 736 (94.1%) pts, the procedure was performed on an ambulatory basis while 46 pts (5.9%) were admitted for 1 or 2 days. A CO2 laser Sharplan 55 associated to a Zeiss operative colposcope was employed. The preoperative diagnosis of the 782 pts treated for CIN was 297 CIN1, 255 CIN2, 171 CIN3 and 59 CIS. Mean age was 33.6 years without statistical difference among the grade of disease: 605 pts underwent laser vaporization according to specific selection criteria. The depth of cervical destruction was less than 6 mm in 26 cases, between 6 and 10 mm in 549, between 11 and 15 mm in 157, more than 15 mm in 50 pts. 742 procedures were performed under local anesthesia and pain was absent in 667 pts. (89.9%), mild in 51 (6.8%), moderate in 19 (2.5%) and severe in 5 (0.7%). Intraoperative bleeding was severe in 30 pts. (3.8%), moderate in 77 (9.8%), mild in 204 (26.1%) and absent in 471 (60.2%). The conization procedure was shown to have a higher risk of bleeding but no direct relation was observed with the depth of cervical destruction. Late complications were scarce: 1.3% of late hemorrhages, 1.4% of stenosis of cervical external orifice and cervical endometriosis in 0.3%. In 76 pts (42%) of the 177 conizations the final pathology report was in accordance with the previous biopsy, in 56 (30.9%) a lower grade of CIN was observed, in 53 (29.3%) a worse grade of the lesion was retrieved. Among these latter pts. 10 showed a microinvasive and 2 an invasive cancer: both the invasive but only 3 of the 10 microinvasive cancer pts underwent a surgical procedure (2 radical and 3 extrafascial hysterectomies, respectively). After a mean follow up of 37 months our incidence of recurrence is 2.3% (18 pts): 5 CIN1, 7 CIN2, 3 CIN3, 2 CIS and 1 microinvasive disease. In 78% of the instances the recurrence has occurred within the first year of follow up. All 18 recurrences were successfully treated with further vaporization in 8 cases, conization in 9 and hysterectomy in 1. 93 term pregnancies occurred in 83 pts after CO2 laser treatment of CIN. No cervical incompetence occurred (no cervical cerclage employed) while the incidence of spontaneous abortion was not statistically significant. 82 pregnancies were delivered vaginally without significant variation of labor phase duration. The incidence of caesarian section (11.8%) was lower than the mean incidence in our Institution. These data confirm the successful complete restitutio ad integrum of the cervix after an adequate CO2 laser surgical procedure without any further risk of cervical incompetence, premature delivery or premature rupture of membranes. The use of CO2 laser surgery is recommended as modality treatment of choice in the management of cervical intraepithelial neoplasia.

Adult↗
PubMed1999

Evaluation of the risk of cervical intraepithelial neoplasia and human papilloma virus infection in renal transplant patients receiving immunosuppressive therapy.

OBJECTIVE: To investigate the risk of cervical intraepithelial neoplasia and the coexistence of human papilloma virus (HPV) infection in renal transplant patients receiving immunosuppressive therapy. MATERIALS AND METHODS: Cervical Papanicolaou (Pap) smear and colposcopic examinations were performed in 48 renal transplant patients receiving immunosuppressive therapy. Microbiological and histopathologic findings were discussed. RESULTS: The patients were evaluated as to cervical neoplasia risk factors and the results were found to be statistically insignificant (p>0.05). Genital neoplasia was encountered in 20 of the 48 renal transplant patients. Koilocytosis developed in 6 out of 8 (75%) patients who were receiving high dose immunosuppressive therapy due to transplant rejection. HPV was found in 2 out of 48 patients; these 2 patients had koilocytosis in their cervical biopsies. The difference between the positive predictive value of colposcopic evaluation and the Pap smear was found to be insignificant (p>0.05). However, if colposcopy had not been performed in two cases of cervical intraepithelial neoplasia class I (CIN-I) and in one case of cervical microinvasive carcinoma, the cases would have been incorrectly diagnosed as normal by the false-negative results of the Pap smear. CONCLUSION: Renal transplant patients who were undergoing immunosuppressive therapy were found to be at increased risk of developing cervical intraepithelial neoplasia. All the patients using immunosuppressive agents should be followed-up by Pap smears every six months and by colposcopic evaluation every year. Avoiding high-risk sexual acts will decrease the risk of HPV transmission and the risk of genital neoplasia as well.

Adolescent↗
PubMed1999

Colposcopy and microcolpohysteroscopy qualification for large loop excision of the transformation zone (LLETZ) in the management of cervical intraepithelial neoplasia.

OBJECTIVE: Large loop excision of the transformation zone is more and more often used as a treatment for cervical intraepithelial neoplasia. There is still debate as to whether this method should be performed in cases when the lesion extends into the cervical canal. Some colposcopists consider loop excision equal to cone biopsy, while others confine its application to satisfactory colposcopy findings. The purpose of the study was to compare the effectiveness and morbidity of LLETZ performed due to CIN in patients with and without extension of the lesion into the cervical canal. DESIGN: Prospective study of 143 women treated by LLETZ due to cervical intraepithelial neoplasia. METHODS: A series of 143 patients cytologically and colposcopically suspected of cervical intraepithelial neoplasia received outpatient treatment by large loop excision of the transformation zone (LLETZ). Microcolpohysteroscopy examinations of the cervix were performed on all patients. Depending on the involvement of the endocervix the material was divided into two groups. Group A comprised 83 women with a colposcopically visible upper margin of the lesion. Group B consisted of 60 patients with the lesion ranging in the endocervix, but not exceeding 10 mm from the external os. Chi square analyses of indication, morbidity and recurrence of the lesions in the two groups were done. Results were considered significant at p less than 0.05. RESULTS: Minimal thermal damage of excised tissue did not interfere with histological examination in either group. In 139 cases (97.20%) histology examination confirmed the presence of CIN. There were no significant differences between the two treatment groups with respect to mean age, mean parity and indications for LLETZ. The women in the group with an entirely visible lesion experienced less perioperative blood loss. There was no significant difference in secondary haemorrhage, infection, stenosis, incomplete excision of the lesion, visibility of neosquamocolumnar junction and residual disease between the two groups. CONCLUSIONS: On the basis of the results obtained it can be stated that LLETZ performed with colposcopic guidance complemented by microcolpohysteroscopy constitutes a valuable method in the treatment of CIN and it may in selected cases replace cone biopsy.

Adult↗
PubMed2000

The technical performance and clinical feasibility of telecolposcopy.

BACKGROUND: The purpose of our study was to demonstrate the technical performance and clinical feasibility of a telecolposcopic system through assessment of image transmission veracity, ease of office system implementation, and the patient's acceptance of the electronic image transmission. METHODS: We used a telecolposcopic system incorporating a custom software package that integrated patient history, current gynecologic status, epidemiologic risk factors, and colposcopic images for local medical documentation and transmission. Satisfaction questionnaires were developed to measure ease of implementation at the remote sites and the patients' acceptance of telecolposcopy. RESULTS: Seventy-nine women participated in our trial. From 3 to 20 images were captured for each woman, documenting cervical squamous intraepithelial lesions and vaginal and vulvar diseases. All images were received without distortions in color, size, or orientation. With complete visualization of the squamocolumnar junction there was an 86% agreement between the remote and review sites (kappa=.533, P=.019). The interobserver agreement for colposcopic impressions was 86% (kappa=.684, P <.001), and for colposcopic impressions with histology within one level of disease severity, 86% (kappa=.78, P <.001). Colposcopists' and patients' satisfaction with telecolposcopy was excellent. More than 95% of the women stated that they would rather have their colposcopy locally with electronic transmission if an experienced colposcopist were more than 25 miles away. CONCLUSIONS: The telecolposcopic system described in our study is technically feasible, can be implemented in an office system with limited technical support, and is preferred by women who have to travel many miles to receive referral health care.

Adolescent↗
PubMed1999

Outpatient procedures for cervical dysplasia: a 3 year review of laser vaporisation and LEEP.

A 3 year retrospective review (1995 to 1997) of 127 patients with cervical dysplasia who underwent Laser Vaporisation of the cervix and LEEP at the Gynaecological Cancer Centre, KK Women's & Children's Hospital, Singapore, was undertaken. Amongst the patients in the Laser Vaporisation group, the mean age was 37.7 years (SD 8.8), the mean operating time was 14.8 minutes (SD 8.5), 63.6% were given prophylactic antibiotics and the mean follow up period was 15.3 months (SD 12.0), whilst in the LEEP group, mean age was 40.3 years (SD 8.4), mean operating time, 11.8 minutes (SD 4.9), prophylactic antibiotic rate, 53.8% and mean follow up period was 19.1 months (SD 9.3). Mild and moderate haemorrhage post procedure were the only complications encountered, 10.2% (5/49) in the Laser group and 3.8% (3/78) in the LEEP group. 98% (48/49) and 97.4% (76/78) of the Laser and LEEP groups, respectively, were free of disease on follow up. None of the 3 patients with persistent or recurrent disease were diagnosed as having invasive cancer. Overall, there were no significant differences in the patient characteristics, histopathology, operating times, follow up period, the use of prophylactic antibiotics, and complications in the 2 groups. The low complication rate, high disease-free rate and the relatively short operating time of Laser Vaporisation and LEEP in our study suggests that, indeed, both the procedures can be done safely and efficiently in the outpatient setting. However the discrepancy between the histology of colposcopically directed biopsy and that of LEEP specimens suggests that colposcopically directed biopsy may not be as accurate as one might believe, and further studies analysing the concordance between colposcopically directed biopsy and LEEP biopsy histologies are needed.

Adult↗
PubMed2000

[Colposcopy in human papilloma virus infections of the distal uro-ano-genital tract].

HPV infections fall within the STDs and certain high-risk types have a significant role in the cancer genesis of the distal genital tract. The infection results can be clinically evident or be subclinical and in this latter case they are revealed by a highly-sensitive colposcopic examination after acetic acid application at 3% followed by Schiller's test with Lugol solution in weak iodine concentration. Indeed, the distal districts of male and female uroano-genital tracts takes advantage of the colposcopic diagnostics although complementary analysis like histology or DNA tests for HPV typing have sometimes to be performed to confirm the results or to evaluate the prognosis. HPV subclinical lesions, above all at cervical and vaginal level, are those mostly involved with the cancer genesis: the bright-white acidophilia often combined with irregular surface, atypical vascularization and discrete iodine caption represents a colposcopic indication to complementary diagnostic analysis aiming at choosing the most suitable therapy for which colposcopy can show the lesion topography and its frequent plurilocalizations.

Anus Neoplasms↗
PubMed2001

Variables associated with squamous intraepithelial lesions among women with a cytologic diagnosis of atypical squamous cells of undetermined significance.

OBJECTIVE: To identify factors among women with atypical squamous cells of undetermined significance (ASCUS) cytologic diagnosis that are associated with either low grade squamous intraepithelial lesions (LSILs) or high grade squamous intraepithelial lesions (HSILs). STUDY DESIGN: From January 1992 to June 1995, 1,660 women with a diagnosis of ASCUS were followed until the next follow-up appointment after the ASCUS diagnosis. Logistic regression analysis with either LSIL or HSIL at follow-up examination as a dependent variable was done with the following independent variables: patient age, method of follow-up, follow-up time, type of health care coverage and household income. RESULTS: In multivariate analyses, there was a 2.7-fold increase in the odds of LSIL (OR = 2.7, 95% CI = 1.3-5.8) for young women (< or = 25 years), a 2-fold decrease in the odds of LSIL (OR = .5, 95% CI .3-.9) for long time to follow-up (> 18 weeks after ASCUS diagnosis) and an 7.8-fold increase in the odds of LSIL (OR = 7.8, 95% CI = 5.1-11.9) for follow-up by colposcopic biopsy. For the odds of HSIL, there was a 6.8-fold increase (95% CI = 3.2-14.5) for follow-up by colposcopic biopsy as compared to Pap smears and a 3-fold decrease in the odds of HSIL (OR = 3, 95% CI = .1-.7) for high-income women (> $34,857). CONCLUSION: Our findings suggest that among ASCUS patients, younger women and those with shorter follow-up time are more likely to be diagnosed with LSIL. Women with a high income showed a protective association for HSIL. Colposcopic biopsy identified more LSIL and HSIL as compared to repeat Pap smear.

Adult↗
PubMed2001

Early detection of cervical cancer through acetic acid application--an aided visual inspection.

OBJECTIVE: To assess the sensitivity and specificity of visual inspection of cervix for detection of precancerous and early cancerous lesions of cervix. METHODS: In a Maternal and Child Health Care setting of New Delhi women underwent a detailed pelvic examination, visual inspection of cervix after 5% acetic acid application, cytology (pap smear), detailed colposcopic examination and colposcopic directed biopsy when indicated. RESULTS: Findings of aided visual inspection using 5% acetic acid and of cytology were evaluated among symptomatic 402 women against colposcopic findings and/or histologic reports. Seventy-three mild dysplasias, 50 moderate dysplasias, 45 severe dysplasias/Carcinoma in-situ and 40 early invasive cancerous cases were diagnosed histologically. The sensitivity of cytology (75.3%) was higher compared to that of acetic acid application (52.0%) for mild dysplasias. On the other hand, the sensitivity for detecting moderate dysplasias was 78% for cytology and 81.6% for acetic acid; for severe dysplasias/carcinoma in-situ it was 73.3% for cytology and 86.7% for acetic acid. For invasive cancers sensitivity for acetic acid application and cytology (95% for both modalities) was comparable. The specificity of cytology (99%) was higher compared to that of acetic acid application (94.3%). The false positive rate for cytology was 1.0% as against 5.7% for acetic acid application. The results of acetic acid application also showed a remarkable improvement in the sensitivity of unaided visual inspection for early cancerous lesion which was about 60% for early cancerous lesion and only 12% for mild dysplastic and 20% for moderate and severe dysplastic lesions in our earlier experience. It also reduced the false positive rates from 12% by unaided visual inspection to 5.7% by acetic acid application. Furthermore, cost of detection of one true lesion through acetic acid application (Rs.1689.00) was much lower as compared to the cost involved in cytology detected true lesions (Rs.2227.00). Visual inspection without acetic acid incurred Rs.6608.60 for detection of true lesion. CONCLUSION: Screening for cervical precancerous and cancerous lesions using visual inspection aided by acetic acid may be a suitable low-cost and a feasible alternative modality for control of cervical cancer in a resource poor setting.

Acetic Acid↗