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PubMed1996

Avoiding conization for inadequate colposcopy. Suggestions for conservative therapy.

OBJECTIVE: To determine if conservative treatment can safely be offered to patients with cervical intraepithelial neoplasia (CIN) and inadequate colposcopic examination. STUDY DESIGN: We reviewed the charts of 733 evaluable cone biopsies of the cervix performed for CIN at the University of Texas Medical Branch at Galveston from January 1981 to September 1990. RESULTS: Of 371 conizations that indicated inadequate colposcopy, there were 62 cases that fulfilled all the following conditions: cytologic smear suggesting CIN 2 or less, negative endocervical curettage (ECC) and cervical colposcopic biopsy showing CIN 2 or less. Pathologic examination of the cone biopsy specimen in these 62 cases revealed no dysplasia in 29.0%, CIN 1 in 16.%, CIN 2 in 37.0%, 3 in 17.7%, and no microinvasive or invasive lesions. Pathologic examination of the cone specimens of 309 patients with any high-risk factor--smear suggesting CIN 3 or invasive disease, colposcopic biopsy showing CIN 3 or positive ECC--revealed no dysplasia in 11.9%, CIN 1 in 11.3%, CIN 2 in 16.8%, CIN 3 in 49.8%, microinvasive carcinoma in 5.5% and frankly invasive carcinoma in 4.5%. CONCLUSION: Conservative therapy may be offered to patients with inadequate colposcopy, CIN 1-2 on both biopsy and cytology, and negative ECC without over-looking either invasive or microinvasive carcinoma. With these criteria, 16.7% of patients with an inadequate colposcopy in our study could have avoided cone biopsy.

Cervix Uteri↗
PubMed1996

Colposcopy as a tool for detection of human papillomavirus infection of uterine cervix in the setting of high prevalence of gynaecologic infections.

A cross sectional study involving 257 women from the Maternal and Child Health Centre (MCH) in Delhi was initiated for screening clinically, cytologically, colposcopically, and microbiologically for several gynaecologic infections. Eighty percent of the women had one or more gynaecologic infections and 31.1% had three or more infections. Cytology revealed changes suggestive of condyloma in 3 (1.2%) women only, while colposcopic examination suggested HPV changes in 117 (45.5%) women. A very high proportion of colposcopically detected lesions (78.6%) had evidence of HPV related changes in histology. The specificity of these lesions were further confirmed by Pan HPV DNA in-situ hybridisation, when 84% of the colposcopy is a valuable tool for detecting subclinical HPV lesions in a setting with high prevalence of gynaecologic infections.

Colposcopy↗
PubMedDate not supplied

[Cervical intraepithelial neoplasia (CIN) and human papillomavirus (HPV) infection].

Many studies have shown a strong correlation between CIN and HPV infection. Molecular biology has allowed identification of types of HPV which seem to be connected, more frequently than others, to dysplastic lesions. Physical state of HPV-genome seems to play an important role in the development of cervical cancer. In this study the HPV-genome has been searched in tissue specimens obtained from 34 women affected by CIN II and III. All patients underwent laser conization. Immediately before treatment, colposcopically directed biopsies of the cervical lesion and of the areas with no colposcopically apparent disease were taken and on these samples, HPV-DNA has been searched, isolated and analysed for HPV types and physical state. Histologic examination on cones showed 6 cases of CIN II (3 with HPV), 24 cases of CIN III (14 with HPV), 1 microinvasive carcinoma and 3 with no residual lesion. Southern blot analysis detected HPV-DNA in 4 cases of CIN II (16.7%) and in 20 cases of CIN III (70.6%). In 50% of CIN II and 85% of CIN III HPV 16 DNA has been found and in the remaining 50% of CIN II and 15% of CIN III HPV 31 DNA has been detected. All CIN II and 14 cases of CIN III showed episomal HPV-DNA. Integrated HPV-DNA has been found in 3 cases of CIN III and the other 3 cases of CIN III showed both integrated and episomal HPV-genome. Integrated form has been noticed only for HPV 16 type. In no case of colposcopically normal tissue has HPV-DNA been found. These data seem to confirm the strong correlation between HPV 16 type, which often has integrated form, and CIN III strengthening the hypothesis of its potential oncogenic action.

Adult↗
PubMedDate not supplied

[The infected cervix].

Cervico-vaginal infections while easily identified, can in certain cases, in fact quite frequently, be under-diagnosed because of the absence of visible symptoms. Colposcopic access to the cervix or vagina can aid diagnosis of cervico-vaginal infections but may not be adequate to pinpoint the agent of the infection except in certain cases such as Herpes and HPV. On the other hand, cervical-vaginal infections can impede a colposcopic interpretation such as identifying the squamo-columnar junction or the location of a directed biopsy. Cervical infections can equally cause unexpected complications (notably Haemorrhagie or pelvic infections) during or after surgical Colposcopic procedures.

Acute Disease↗
PubMed1998

Assessment of cytologic follow-up as the recommended management for patients with atypical squamous cells of undetermined significance or low grade squamous intraepithelial lesions.

BACKGROUND: The optimal management of low grade Papanicolaou (Pap) smear abnormalities remains controversial. This center's experience with recommending cytologic follow-up for women with atypical cells of undetermined significance (ASCUS) or low grade squamous intraepithelial lesions (LSIL) was reviewed to determine outcome and patient/physician compliance. METHODS: The records were reviewed on women with Pap smears reported as either ASCUS (320) or LSIL (112) who did not have a history of dysplasia. The cytologic and colposcopic follow-up for a 2-year period was obtained from the laboratory data base that includes the colposcopy and cancer referrals for this region. Repeat Pap smear in 6 months was recommended. If patients subsequently demonstrated high grade SIL (HSIL) or persistent ASCUS or LSIL over three time intervals, colposcopic evaluation was recommended. RESULTS: The outcome was determined by the most significant diagnosis among the follow-up Pap smears or colposcopic biopsies. 29% of patients were lost to follow-up. Of the remaining patients, 70.5% reverted to normal or benign cellular changes, 25.3% persisted as ASCUS or LSIL, and 5.2% progressed to HSIL. The majority of patients (68%) were referred for colposcopy for persistent mildly abnormal Pap smears. The timing of referral ranged from 3-30 months. CONCLUSIONS: These results suggest that cytologic follow-up of women with low grade Pap smear abnormalities will identify a large number whose smears will regress to normal. A small but significant proportion of women showed subsequent HSIL. Most HSIL was detected within 1 year of the initial abnormal Pap smear and the majority of intervening Pap smears also were abnormal. Approximately one third of patients did not have follow-up within the study system and their outcome was uncertain. Although the recommendations are standard, patterns of follow-up and referral to colposcopy varied widely, suggesting that the guidelines need to be reinforced to both patients and physicians. [See editorial on pages 1-4, this issue.]

Carcinoma, Squamous Cell↗
PubMed1976

The management of DES-exposed women: one physician's approach.

The female offspring of DES-treated mothers are examined cytologically and colposcopically annually, starting at the age of seven years no treatment is indicated until a colposcopic atypical transformation zone occurs. With its occurrence all the abnormal epithelium(squamous or columnar) is excised from the vagina and cervix under colposcopic guidance in the hospital or in the office under local anesthesia. The procedures are done in stages to minimize scarring and to eliminate the possibility of vaginal-cervical adhesions or vaginal shortening. The finding of an incidence of 47% of cervical or vaginal intraepithelial neoplasia in 34 patients aged 10 to 26 years so treated to date indicates a high risk of potential candidacy for squamous carcinoma of the vagina or cervix in later years.

Adolescent↗
PubMed1998

The value of colposcopy in screening cervical carcinoma.

The value of colposcopy and cytology in screening CIN was analyzed in a retrospective study of 1,504 patients treated at the Department of Gynecologic Oncology, National Institute of Oncology, Budapest from 1980 to 1991. The majority (1,451) of the patients were admitted for histological confirmation of atypical colposcopic and/or cytologic findings, and 53 women were treated for cervical repair. All women underwent either cervical excision or conization. Cytologic and colposcopic findings were compared with the histological results. Sensitivity and specificity rates of cytology were 47% and 77%, respectively. The corresponding figures for colposcopy were 87% and 15% and for cytology and colposcopy together, 96% and 14%. The low sensitivity of cytology suggests that as many as 50% of CIN lesions may be overlooked if cytology alone is used for screening, i.e. in 50% of CIN associated with abnormal colposcopy the cytology was negative. We found 194 asymptomatic patients with carcinoma in situ, 40 with microinvasive and 8 with frank invasive carcinoma. This finding emphasizes the importance of cervical cancer screening. Our data suggest that, with colposcopy as a screening tool, the rate of false-negative cytology can be significantly reduced. Clinical implications of the "cytology-negative abnormal colposcopy and cytology-negative CIN" have yet to be determined. The major drawback of primary colposcopy is its low specificity with the consequence of high false-positive rate and over-treatment in a substantial number of cases. To overcome the problem of low specificity, further studies are required to identify those atypical colposcopic changes that most likely represent CIN--and high-grade CIN in particular.

Adult↗
PubMed1997

[Colposcopy images of cervix in women with Gardnerella vaginalis infection].

Among micro-organisms infecting vagina whose dominant genus is GV anaerobic bacteria are often present. There are reports that GV infections of vagina and uterine cervix, apart from their well-known negative role in obstetrics practice can play a role in carcinogenic processes of uterine cervix. The aim of the study was to assess characteristic colposcopy images of cervix in women with Gardnerella vaginalis infection. The research was carried out on 1180 women hospitalised in the period of 14 months. Many observations lead to conclusions that pathognomic clinic feature of Gardnerella vaginalis infection of uterine cervix is visible in colposcope presence of clean, translucent mucus in external cervical os and opaque vaginal contents in the rear vaginal vault. High hydrogen ion concentration in vaginal contents (pH 6.0 and over) correlates with positive "fishy odour test" of this contents. Gardnerella vaginalis infection of vagina and uterine cervix concerns women with existing erosion-type changes of uterine cervix. Visible in colposcopic test restless and "spotted" images visible after Schiller test are pathognomic colposcopic features of Gardnerella vaginalis infection.

Adult↗
PubMed1993

Cryotherapy precision. Clinician's estimate of cryosurgical iceball lateral spread of freeze.

OBJECTIVE: To examine physicians' ability to estimate the lateral spread of freeze (LSF) of a cryosurgical iceball using three techniques. DESIGN: A nonrandomized control trial of in vitro nitrous oxide cryosurgical procedures. SETTING: Primary care residency training programs. PARTICIPANTS: A convenience sample of 80 resident and faculty physicians from four family practice residency programs and one obstetrics and gynecology residency program. INTERVENTIONS: After performing cryosurgery with standard naked-eye and colposcopic-assisted techniques, subjects used a new experimental cryosurgical iceball gauge (CIG) to estimate the LSF during cryotherapy. MAIN OUTCOME MEASURES: LSF estimations reported physicians were compared simultaneously with those measured by an observer. RESULTS: The mean (+/- SD) LSF estimation errors at the termination of freeze were as follows: 2.62 +/- 2.42 mm for the colposcopy technique, 2.00 +/- 2.16 mm for the naked-eye method, and 1.28 +/- 0.87 mm for the CIG technique. The range of maximum error was 6.5 to 11 mm for the colposcopic technique, 5.5 to 12.5 mm for the naked-eye method, and 3.0 to 4.0 mm for the CIG technique. CONCLUSIONS: Overestimation of the LSF, which increases the risk of undertreatment and residual disease, was more common than underestimation. The CIG minimized perceptual error and provided the best cryosurgical precision.

Calibration↗
PubMed1995

Synthetic hygroscopic cervical dilator use in patients with unsatisfactory colposcopy.

OBJECTIVE: To assess the ability of a synthetic hygroscopic cervical dilator to make an unsatisfactory colposcopic examination satisfactory, thereby avoiding cervical conization. MATERIALS: From April 1991 to March 1993, 30 women with unsatisfactory colposcopic examinations underwent repeat colposcopy after a synthetic hygroscopic cervical dilator had been placed in the endocervical canal for approximately 2 hours. RESULTS: The reasons for initial unsatisfactory colposcopy in the 30 patients were squamocolumnar junction not seen in its entirety (18 patients, 60%), lesion not seen in its entirety (ten, 33%), and neither transformation zone nor lesion seen in their entirety (two, 7%). Complications were encountered in one patient from whom the dilator could not be removed completely. Of 29 patients undergoing repeat colposcopy, 23 (79%) had satisfactory examinations. In 15 of 30 patients, conization was avoided; it was required in six of 30 (20%) women for persistent unsatisfactory colposcopy (including the patient in whom the dilator broke) and in nine of 30 (30%) for other indications. CONCLUSIONS: This experience suggests that a synthetic hygroscopic cervical dilator can be used in patients with an unsatisfactory colposcopy to achieve a satisfactory examination, thus avoiding cervical conization.

Abortifacient Agents↗
PubMed1988

Medical forensic photography of the sexually abused child.

The dramatic increase in reports of sexual abuse has resulted in increasing referrals to physicians for medical evaluation and has placed demands on physicians to adequately and expertly assess these children. High quality, close-up photographs of significant lesions can be an important part of this evaluation. Camera systems recommended vary from colposcopes to close-up 35-mm systems to instant cameras. Physicians who examine sexually abused children should have ready access to an adequate photographic system, as well as basic knowledge of camera operation, film procedures, and medicolegal implications. Case studies and discussion are used to review colposcopic and close-up 35-mm camera techniques available to the physician to photograph the sexual abuse victim.

Child Abuse, Sexual↗
PubMed1985

Cervicography: a preliminary report.

Cervicography is a photographic method to document abnormal cervical lesions. Screening for abnormal cervical lesions, one of the seven proposed purposes for cervicography, was investigated in this study. We evaluated 578 cervigrams obtained from patients with normal cervical cytologic tests. The evaluated cervigrams were placed in one of four categories. Seventy-nine (13.7%) of the patients had normal cervigrams; in 152 (26.4%) the result was unsatisfactory; in 159 (27.5%) the cervigram was technically defective; and in 188 (32.5%) the result was suspicious. One hundred one of the patients with suspicious cervigrams had colposcopic evaluations. In 69 patients colposcopically directed biopsies were done; 14 patients had koilocytotic atypia, seven had grade 1 cervical intraepithelial neoplasia, three had grade 2 cervical intraepithelial neoplasia, and one patient had an invasive cervical carcinoma. Although cervicography has not been proved to be cost effective, it is a method worthy of further evaluation.

Biopsy↗
PubMed1997

Office procedures. Colposcopy.

Colposcopy is a clinical procedure to examine the epithelium of the uterine cervix and surrounding anogenital area with a magnifying instrument to detect the presence of cervical neoplasia and to identify abnormal tissue for biopsy. The procedure is enhanced by the use of chemical solutions that assist discrimination of normal tissue and abnormal lesions. Colposcopic examination and directed biopsy of the most severe focus of cervical neoplasia ensure a valid representation of the status of cervical disease. The results from the cytologic smear, histologic evaluation, and colposcopic impression collectively determine appropriate patient management.

Biopsy↗
PubMed1981

[Micro-endoscopy of the uterine cervix (author's transl)].

Since 1978 micro-endoscopy of the uterine cervix was added to routine colposcopic and cytologic evaluation of the cervix for the purpose of early diagnosis of cancer. Especially, in cases of a typical transformation zones important diagnostic information about the malignity or benignity of the lesion can be obtained. Under colposcopic guidance a suspect point is vitally stained with Cresyl violet acetate 10% solution. Colposcopy is not only supplemented by micro-endoscopy, but colposcopy with the micro-endoscope. The new micro-endoscope gives a magnification of 130 times, a diameter of 5 mm, a length of 200 mm and in a fibre-optic light cable a light source of 280 volts with 150 watts/second from a Xenon Arc Lamp, focal depth of 0.8 mm, an internal visual field of 35 mm. In 356 micro-endoscopies 3.92% showed positive findings, 12.75% showed suspicious findings, 73.04% showed negative findings and 10.29% showed other findings such as necrotic cells, bleeding or were impossible to evaluated with the micro-endoscope.

Cervix Uteri↗
PubMed1983

Cervicography.

Cervicography represents a natural development of colposcopy and replaces subjective colposcopic evaluation with objective cervicographic assessment. It is a situation similar to radiology many years ago. Radiologists used to sit in front of the sciascopic screen to screen chests for disease. Today, the sciascopic screening has been almost completely replaced by evaluation of a chest x-ray film. I believe that in the future, subjective colposcopic examination will be replaced in most cases by objective cervicographic assessment.

Carcinoma in Situ↗
PubMedDate not supplied

[Cervicography--a useful method for the early detection of changes in the uterine cervix].

Cervicographic findings were analysed in 156 patients of whom 71 had previously been found to have cervical changes (group I) and 85 were regularly examined within the periodic systematic examination programme (group II). In group I there were 15.5% negative cervicographic findings, 80.3% suspect, and 4.2% technically inadequate. Out of suspect findings, carcinoma in situ or invasive carcinoma were detected in 54.4%, of which 9.7% were cytologically false negative. In group II, in 69.4% of cases, some colposcopic changes (non-malignant) were observed, while in 3 out of 26 colposcopically normal findings, there were some changes in the cervicogram.

Colposcopes↗
PubMed2003

Comparison of visual inspection of cervix and Pap smear for cervical cancer screening.

OBJECTIVE: To evaluate the performance of visual inspection of cervix (VIA) after application of 3% acetic acid in cervical cancer screening in comparison with Pap smear. DESIGN: Comparative study. PLACE AND DURATION OF STUDY: This study was conducted at Sir Ganga Ram hospital, Lahore, from January 1996-December 1999. SUBJECTS AND METHODS: Speculum examination was carried out to see the cervix in 501 women. All subjects were screened simultaneously by Pap smear and VIA after application of 3% acetic acid. Positive cases by both screening methods and grossly abnormal cervix even with negative screen were subjected to colposcopy. In case of colposcopic abnormality of atypia or advanced lesions, biopsies were taken. Histology of colposcopically directed biopsy was taken as gold standard to evaluate the performance of the test. RESULTS: Out of 540 subjects, 356 were negative with both screening techniques. One hundred and fifty-six subjects were positive with VIA(28.9%) while Pap smear was positive in seventy-eight subjects (14.4%). The sensitivity of VIA was 93.9% and of Pap smear was 46.9%. Corresponding specificities were 30.4% and 69.5%. There was no significant difference between the positive predictive value (PPV) of both test (p < 0.05). The accuracy of VIA was 77.5% compared to 52.8% of Pap smear. The difference was highly significant (p < 0.01). CONCLUSION: These results indicate that VIA is more sensitive and has a higher accuracy as compared to Pap smear. It could, therefore, be valuable in detection of precancerous lesions of cervix. Low cost, easy applicability and immediate results make VIA a useful screening test in developing countries like Pakistan as compared to Pap smear.

Acetic Acid↗