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PubMed1990

Cervical intraepithelial neoplasia III treatments by carbon dioxide laser.

162 women underwent one or more carbon dioxide laser conservative treatments for lesions of severe dysplasia and cervical intraepithelial neoplasia (CIN III) between 1982 and 1987. Therapy involved destruction of lesions by vaporisation in 45% of cases and excisional conisation in 55% (32% performed with a hand-held apparatus and 23% colposcopically guided). Rates of cure were, respectively, 93, 96.1 and 94.4%, with an overall rate of 2.5% for dropouts. Recurrences (rates, respectively, of 8.5, 5.8 and 5.5%) were associated with human papilloma virus in 92% of cases. The increasing numbers of very young women affected, as well as the spread of intraepithelial and condylomatous neoplastic lesions along the endocervical canal, are major reasons for the use of colposcopically guided carbon dioxide laser treatment.

Adolescent↗
PubMed1994

Incomplete excision of CIN in conization: further excision or conservative management?

The aim of this study was to investigate the experience of the further management in 112 cases with histological diagnosis of incomplete excision of CIN in cone biopsy. Two groups of women were studied. The women in the first group (n = 78) had a second excision while the women in the second group (n = 34) underwent conservative management with cytology and colposcopy. The histologic, cytologic and colposcopic findings in the women of both groups were compared. From the first group 38% had a second cone, 62% an hysterectomy; in 5 cases the second cone was followed by hysterectomy and the histology was negative in 75% and 65%, respectively. No indication of residual disease was found within 2-10 years of follow-up in any of the women in the second group. According to our study and being aware of the natural history of CIN, we can conclude that the decision for further excision should not be based exclusively on the histology report of involved margins, but should only be taken after careful cytological and colposcopic selection of the cases.

Adult↗
PubMed1995

Comparison of management algorithms for the evaluation of women with low-grade cytologic abnormalities.

OBJECTIVE: To present our clinical experience using a repeat Papanicolaou smear and human papillomavirus (HPV) DNA testing to evaluate patients with low-grade cytologic abnormalities. METHODS: We performed a retrospective chart review of women who were referred for the evaluation of a Papanicolaou smear and were diagnosed as having either atypical cells of undetermined clinical significance or a low-grade squamous intraepithelial lesion (SIL). All women included in this review had a repeat Papanicolaou smear, HPV DNA testing with the Hybrid Capture method, and a colposcopic examination. RESULTS: The sensitivity and specificity of the repeat Papanicolaou smear for detecting biopsy-confirmed cervical intraepithelial neoplasia (CIN) were 0.74 and 0.67, respectively, in the 398 women referred for a previous low-grade SIL or atypical Papanicolaou smear. The sensitivity and specificity of a HPV DNA test positive for "high oncogenic risk" HPV types were 0.73 and 0.66, respectively. Triage using a repeat Papanicolaou smear and an HPV DNA test in combination correctly identified 92% of the women with biopsy-proven CIN, but 71% of the women would have been referred for colposcopy with this form of triage. CONCLUSIONS: A repeat Papanicolaou smear combined with a HPV DNA test is a sensitive alternative to colposcopic evaluation for the detection of CIN in women referred for a previous low-grade abnormal Papanicolaou smear. However, because of the low specificity of this approach, it results in only modest cost reductions compared to the more standard triage of performing colposcopy at the first visit.

Algorithms↗
PubMed1996

Loop electrosurgical excision procedure for squamous intraepithelial lesions of the cervix: advantages and potential pitfalls.

OBJECTIVE: to evaluate the advantages and pitfalls of the loop electrosurgical excision procedure as applied to the diagnosis and treatment of cervical cancer precursors. METHODS: Loop electrosurgical excision procedure using local anesthesia and colposcopic guidance was performed in an outpatient clinical setting in 1189 consecutive patients referred for colposcopy for an abnormal Papanicolaou smear during a period of 4 years. RESULTS: Of the 1189 patients, 915 (77%) were managed in one sitting with the "see and treat" approach, and in 274 patients endocervical curettage and cervical biopsies preceded loop electrosurgical excision procedure. One hundred nineteen (10%) patients were lost to follow-up. Twenty-one patients had either adenocarcinoma in situ (15) or microinvasive squamous cell carcinoma (six) in the loop electrosurgical excision procedure specimen, whereas the electroexcised specimens contained no lesional tissue in 166 (14%) patients. Cure (ie, disease-free at 6 months or longer) was observed in 92% of the 883 evaluable patients after a single treatment and 95% after a repeat loop electrosurgical excision procedure. High-grade squamous intraepithelial lesion was successfully treated with loop electrosurgical excision procedure in 287 (93%) of 309 patients. Complications, mainly intra- and postoperative bleeding, occurred in 7% of the patients. In most loop electrosurgical excision procedure-negative cases, the referral cytologic diagnosis or colposcopy and/or history were false-positive on review, or the biopsies performed before loop electrosurgical excision procedure removed smaller areas of abnormal tissue. CONCLUSION: Loop electrosurgical excision procedure using the see and treat approach should be limited to cytologically and colposcopically unequivocal intraepithelial lesions, and depth of excision should be controlled by colposcopy using loop electrodes of appropriate size. In doubtful cases, particularly in the young patient, disease should be ascertained by expert histology and colposcopy before definite therapy. Loop electroexcision represents an attractive means of diagnosing and treating cervical cancer precursors.

Adenocarcinoma↗
PubMed1996

Microcolposcopic topographic endocervical assessment before excisional treatment of cervical intraepithelial neoplasia.

OBJECTIVE: To evaluate whether microcolposcopic topographic endocervical assessment reduces the failures of excisional treatment of cervical intraepithelial neoplasia (CIN). METHODS: Three hundred fifty patients with colposcopic and histopathologic findings of endocervical CIN were recruited for excisional treatment. Three hundred forty-eight of these were randomized to have or not have microcolposcopy before excisional treatment. Measurement of endocervical lesion was the only aim of microcolposcopic evaluation. When an endocervical extension was available, the cone biopsy was cut according to microcolposcopic measurement. Excision status was evaluated and related to presurgical management on operative specimens. After excision, patients were followed-up for at least 5 years after treatment. Three hundred thirty (171 and 159 with and without preoperative microcolposcopy, respectively) patients completed the study. Disease persistences were defined by cytologic, colposcopic, and histologic results. Microcolposcopic value was defined as completeness of excision and/or lack of persistent disease. RESULTS. On surgical specimens, involved margins were detected in 19 (5.4%) cases. Presurgical microcolposcopy was performed in only one of these cases. The difference of incomplete excision between cases with or without microcolposcopy was statistically significant (P < .001). In patients who were followed-up, persistent disease was detected in one (0.6%) woman in the microcolposcopy group and in 16 (10%) women in the control group. Comparison between the two groups showed a significantly lower risk of persistent disease when presurgical microcolposcopy was performed (P < .001). CONCLUSION: By measuring endocervical extension of the lesion, preoperative microcolposcopy allows individualized cones, thus improving the prognosis after excisional treatment of CIN.

Adolescent↗
PubMed1983

Condyloma and cervical epithelial atypias in young women.

One hundred and three adolescent women with cervical cytology suggestive of mild to moderate dysplasia were studied for the presence of condylomatous lesion. The analysis of smears revealed cells suggestive of condyloma in 81% of the cases. In histopathologic studies cervical lesions typical of condyloma were observed in 59 preparations. Of these 16 were papillary and 35 were flat condylomas, and in 8 cervices both papillary and flat condylomatous lesions were present. Colposcopic examination showed an atypical transformation zone in 57 cases. Papillary condylomas were present in 24 cervices in 7 cases combined with an atypical transformation zone. In addition to the cervical epithelial atypias there were 18 cases in which colposcopic and histologic examination of vagina revealed papillary warts, 13 of them combined with cervical condylomas. In four patients vaginal leucoplakia was seen and all were histologically flat condylomas. Thus, in 68 cases or in 66% of adolescent women having abnormal cervical cytology, histological investigation revealed condylomatous changes.

Adolescent↗
PubMed1983

Cryosurgical treatment of cervical intraepithelial neoplasia (CIN III) in 102 patients.

Results of cryosurgical treatment in 102 patients with a histologically confirmed diagnosis of severe dysplasia or carcinoma in situ of the uterine cervix (CIN III) are presented. The colposcopic evaluation performed in all patients required full visualization of the squamocolumnar junction. In 95 of the 102 patients no significant cytological abnormalities were found during the follow-up period, which amounts to a success rate of 93%. In seven patients (7%) treatment was considered to have failed because cervical smears persistently suggested CIN II or III. In five of them this was in all probability due to a residual lesion, since the abnormal smears occurred within 12 weeks after cryosurgery. It is concluded that in selected cases cryosurgery is a safe alternative for conisation in the treatment of CIN III. However, thorough colposcopic expertise is essential for adequate preoperative screening, as is careful selection of patients, and the latter may result in the withholding of cryosurgical therapy from 30% of patients with CIN III.

Adult↗
PubMed1985

Colposcopy for postmenopausal women.

The number of postmenopausal women colposcopically diagnosed has markedly increased during the last 15 years. In some of them, a clear colposcopic impression, required for planning an appropriate therapy, was disturbed by severe senile cervicocolpitis, when examined by the conventional technique using acetic acid. With a 5-year experience of 79 paired colposcopies, it was concluded that estrogen administration is necessary as a routine precolposcopic procedure in such cases and oral administration of conjugated estrogens at 1.25 mg/day for 14 days is adequate for this purpose.

Aged↗
PubMed1990

A new way to expose endocervical lesions at colposcopy.

If there are atypical cells on a cytological smear and if the squamo-columnar junction can not be visualized during a colposcopic examination, then in order to exclude an early invasive cancer in the nonvisualized area within the endocervix it is mandatory to perform a diagnostic cone biopsy. A woman with abnormal cervical cytology and an unsatisfactory colposcopic examination who refused a cone biopsy was offered Lamicel in an attempt to expose the entire transformation zone. After 4 hr the sponge was removed and colposcopy repeated. The lesion and the squamo-columnar junction was then fully visible and she was spared a cone biopsy.

Adult↗
PubMedDate not supplied

Normal versus abnormal genital findings in children: how well do examiners agree?

In order to determine how well medical examiners agree on the significance of certain anogenital findings in children, preselected colposcopic photographs of the anogenital area of 16 patients were shown to 170 medical examiners (82% pediatricians) who were blinded as to the history on each patient. Findings rated most frequently as being suggestive or indicative of penetrating injury included immediate anal dilatation with no stool present (85%), hymenal transection (84%), marked narrowing of the hymenal rim with notching (81%), and a posterior fourchette scar (75%). The agreement between the participants and the experts on the abnormal cases (mean 81%) was significantly higher than on the normal cases (mean 71%, p < .001) and on genital findings (78%) than on anal findings (63%, p = .000). Higher experience level (more cases seen per month) was associated with significantly higher agreement between the participants and the experts on five of eight normal cases and two of four abnormal cases. Use of a colposcope was also associated with higher overall agreement with the experts (74% vs. 44%, p < .0001).

Anal Canal↗
PubMed1990

Cervical intraepithelial neoplasia III in an adolescent with Bowenoid papulosis.

Bowenoid papulosis (BP) is a cutaneous condition of the external genitalia seen primarily in young adults. Evidence supports an etiologic role of human papillomavirus (HPV), particularly type 16. HPV-16 is also associated with an increased risk for cervical intraepithelial neoplasia (CIN) and invasive carcinoma. A 17-year-old female, referred to the adolescent dysplasia clinic with a diagnosis of condyloma acuminatum, was presented. She had multiple smooth, shiny, brown 3- to 4-mm papules on the external genitalia. Biopsy confirmed BP. Colposcopic examination of the cervix and biopsy showed CIN III. The patient's sexual partner was examined colposcopically, and no suspicious lesions were seen. The patient underwent laser vaporization of her external genital and cervical lesions. At the time of treatment, some of the initial BP lesions had spontaneously regressed. This case highlights the need to evaluate females with BP for possible CIN, to examine sexual partners, and to use ablative therapy, as there is the potential of malignant progression in BP.

Adolescent↗
PubMed1996

Cervical intraepithelial neoplasia in pregnant intravenous drug users infected with human immunodeficiency virus type 1.

OBJECTIVE: The purpose of this study was to evaluate the frequency and natural history of cervical intraepithelial neoplasia (CIN) during pregnancy in past or current intravenous drug users infected with human immunodeficiency virus type 1 (HIV-1). STUDY DESIGN: We prospectively evaluated 48 pregnant HIV-1 seropositive patients and 38 HIV seronegative controls. All the subjects were current or past intravenous drug users. Follow-up visits were carried out each trimester of pregnancy and 8-12 weeks post-partum with Papanicolau smears, colposcopic examinations and, when necessary, colposcopically directed cervical biopsies. RESULTS: Thirteen of 48 HIV-seropositive women (27.1%) and three of 38 HIV-seronegative controls (7.9%) (P = 0.027 by Fisher exact test) had biopsy-proven CIN at the beginning of pregnancy. High-grade CIN was detected in 10 cases (20.8%) and in two (5.3%) controls (P = 0.058 by Fisher exact test). None of the cervical squamous intraepithelial lesions progressed throughout pregnancy, in both cases and controls. Post-partum cold-knife cervical conization was performed on seven patients with CIN III and examination of the cone biopsy specimens demonstrated persistence of CIN III. CONCLUSIONS: HIV-infected intravenous drug users are at high risk of CIN during pregnancy, thus requiring adequate screening programs. Our preliminary data suggest that the progression rate of CIN during gestation is low in this high-risk group.

Adult↗
PubMed1980

The treatment of postmenopausal vaginal atrophy with Ovestin vaginal cream or suppositories: clinical, endocrinological and safety aspects.

Seventy-four postmenopausal women presenting with vaginal atrophy were treated with either Ovestin vaginal cream (Group A, 23 women: 1 mg/day E3; Group B, 30 women: 0.5 mg/day E3) or vaginal suppositories (Group C, 21 women: 0.5 mg/day E3), applied daily for 3 wk (A and B) or 2 wk (C) before retiring. Ten women from A and 10 from B applied a maintenance dose (1 application twice weekly) during wk 4-16. Effects on vaginal cytology, cervical mucus and clinical and colposcopic findings were studied. Endometrial biopsies were done in 16 patients (A) before and after 3 wk of treatment, and, in 8 of the cases, at 16 wk. A routine laboratory screening program was performed before and after 16 wk of treatment in 10 patients (A). Plasma samples for hormone level determinations were obtained in 32 patients. Clinical and colposcopic findings showed a beneficial effect of treatments, confirmed by vaginal smears, and persisting during maintenance therapy. Effect on cervical mucus was slight to moderate. No side effects occurred and tolerance was very good. Endometrium remained atrophic under treatment. Screening program revealed no abnormalities. Treatments induced a sharp rise in plasma E3, followed by a gradual decline. Gonadotropins were slightly suppressed. E1, E2, PRL and SHBG capacity remained unchanged.

Adult↗
PubMed2006

Management of multicentric lesions of the lower genital tract.

OBJECTIVES: To report management and outcome of multicentric lesions of the lower genital tract. To define risk factors of recurrence. STUDY DESIGN: Retrospective review of multicentric dysplasias treated in our colposcopic clinic between 1996 and 2003. Multicentric dysplasias included CIN with VAIN and/or VIN. After primary treatment, follow-up was colposcopic, cytologic and virologic. RESULTS: Forty-four patients presented multicentric lesions out of 998 patients referred for CIN (4.4%). The average age was 36.8 years. Immunologic disorders were present in 20.4%. Ninety-one percent had cervicovaginal or cervicovulvar lesions, only 9% had three sites of genital dysplasia. 53.3% of lesions were concomitant. 79.5% of CIN were high grade, 62.5% of VAIN low grade and 62.5% of VIN high grade. Therapeutic modalities were as follows: conization for CIN (70.4%), CO2 laser for VAIN (33.3%) and surgery for VIN (41.7%). Forty patients were followed and had at least one post-treatment cytologic control; 55% of them had residual disease. Out of the 23 patients with at least two negative controls after treatment, 43.5% presented recurrence. Risk of recurrence was not statistically bound to such parameters as tabagism, immunologic disorder, high grade lesions, non-surgical treatment, and persistence of HPV infection after treatment. CONCLUSION: Multicentric dysplasias are associated with high rate of residual lesion and recurrence. Management of these lesions require long term follow-up.

Adolescent↗
PubMed2006

Improved cervical cancer screening in premenopausal women by combination of Pap smear and speculoscopy.

OBJECTIVE: This study was done to evaluate the efficacy of the Pap smear, speculoscopy, and a combination of Pap smear and speculoscopy (PapSure examination) in pre- and postmenopausal women. STUDY DESIGN: All women were screened using the Pap smear and speculoscopy and combination of both (PapSure examination) in the multicenter trial. Final diagnosis of each patient was based on a histological evaluation of the colposcopic target biopsy. Results were analyzed using a proportional comparison test, sensitivity, specificity, and predictive value with significance determined at p<0.05. RESULTS: Of 1813 women screened, 1701 were eligible for analysis. Two hundred and fourteen women (12.6%) received at least one positive screening test result. Of the 1084 colposcopic biopsy specimens obtained, 24 showed low-grade squamous intraepithelial lesion (LSIL) and 19 high-grade SIL (HSIL). HSIL were considered test-positive. Rate of colposcopy was 21.5% (125/582) in the premenopausal group and 63.9% (321/502) in the postmenopausal group (p<0.001). For premenopausal women, speculoscopy (75.0%) or PapSure (91.7%) provided higher sensitivity than Pap smear (50%) (p<0.05). In postmenopausal women, no statistical significance in sensitivity existed between PapSure (85.7%) and Pap smear (57.1%). Speculoscopy (96.8%) or PapSure (96.5%) had lower specificity than Pap smear (99.6%) (p<0.001). CONCLUSION: PapSure was an accurate alternative screening method to Pap smear or speculoscopy for cervical intraepithelial lesions because of a significantly higher sensitivity along with adequate specificity for premenopausal women; however, PapSure was not a more effective cervical screening method for postmenopausal women.

Adult↗
PubMed2003

[Management of cervical intra-epithelial neoplasm during pregnancy].

Approximately 30% of women diagnosed with cervical cancer are in their childbearing years. Prenatal care provides an excellent opportunity for cervical cancer screening. The incidence of abnormal Pap smear has been reported in 5-8% of pregnant women. But we must know that Pap smears have cytologic modifications because of pregnancy. All abnormal smears have to be referred to colposcopic examination. The squamocolumnar junction is visualized in almost 100% of cases. The sensitivity of colposcopy is nearly 87% with complete concordance in 72.6%. Colposcopically directed biopsies have a good correlation with the final diagnosis with very minimal risks for both mother and fetus. The high rate of complications (hemorrhage, abortion, premature labor) and residual lesions in half of cases do not encourage conization during pregnancy. The final treatment is carried out after delivery. The only absolute indication for conization in pregnancy is to rule out microinvasive disease or make the diagnosis of invasive carcinoma when such a diagnosis will alter the timing of delivery but also when there is a no satisfactory colposcopy and a high-grade Pap smear. In these cases conization is performed for diagnostic and not therapeutic purpose. We must be aware of the high rate of loss of follow-up (6-33%).

Adult↗
PubMed2005

Digital camera assessment for detection of cervical intraepithelial neoplasia in rural El Salvador.

OBJECTIVE: To explore the feasibility of digital photography for primary cervical cancer screening in a low-resource setting in El Salvador. METHODS: Three independent examiners performed Pap test, visual inspection, digital camera assessment and colposcopy on each subject. RESULTS: Lesions were detected in 99 of 504 patients (20%) by visual inspection, 72/504 (14%) by DART and 90/504 (18%) by colposcopic impression. Seven of 504 patients (1.3%) had CIN on histology. Pap detected 2 of 7 subjects (29% sensitivity) (C.I. 4%, 56%), visual inspection detected 5 of 7 (71% sensitivity, C.I. 34%, 95%), digital assessment detected 6 of 7 (86% sensitivity C. I. 45%, 99%), and colposcopic impression detected 5 of 7 (71% sensitivity, C.I. 34%, 95%). CONCLUSION: This small pilot trial demonstrates the potential value and feasibility of performing digital camera assessment of the reproductive tract on women in a developing country setting.

Adult↗
PubMed2004

Is electrosurgical loop excision with negative margins sufficient treatment for cervical ACIS?

OBJECTIVES: A recent clinical practice guideline supports the conservative management of adenocarcinoma in situ of the cervix (ACIS) diagnosed or suspected before treatment. However, patients may be diagnosed with unsuspected ACIS found in a loop electrosurgical excisional procedure (LEEP) specimen done for squamous dysplasia. To assess the outcome in this group of patients, we retrospectively analyzed all our cases of cervical ACIS and endocervical glandular dysplasia (EGD) to determine if LEEP was sufficient treatment. STUDY METHOD: A retrospective review of all patients treated for ACIS-EGD from 1990 to 2003 at Kingston General Hospital Colposcopy Clinic was undertaken. Sixty patients were identified. RESULTS: Of the 60 patients, 31 were diagnosed with ACIS-EGD only from the LEEP specimen. Twenty-two patients had ACIS and nine had EGD. Seven had further surgical procedures (five hysterectomies and two cold knife cone biopsies CKC) for positive LEEP margins. All seven of these specimens were disease free. Three of 31 LEEP patients were not compliant with colposcopic follow up. The remaining 28 patients were followed in our colposcopy clinic or by their family doctor for 6-107 months (median: 42; mean: 51) and have remained free of persistent or recurrent ACIS-EGD. CONCLUSION: Colposcopic follow-up with cytology and endocervical curettage (ECC) is acceptable for patients with ACIS-EGD found unexpectantly in LEEP specimens with negative margins. This is an alternative to proceeding to repeat LEEP, cold-knife conization, or simple hysterectomy, especially in patients desiring conservative management or preservation of fertility. Patients with positive margins, however, require further histologic evaluation.

Adenocarcinoma↗