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PubMed1998

Colposcopy for the diagnosis of squamous intraepithelial lesions: a meta-analysis.

OBJECTIVE: To quantify by meta-analysis the performance of colposcopy to set a standard against which new technologies can be compared. DATA SOURCES: MEDLINE was searched for articles on colposcopy for diagnosis of squamous intraepithelial lesions (SIL). The search selected articles from 1960 to 1996 combining the key word "colposcopy" with key words "diagnosis," "positive predictive value," "negative predictive value," "likelihood ratio," and "receiver operating characteristic (ROC) curve." METHODS OF STUDY SELECTION: Articles were selected if the authors studied a population of patients with abnormal screening Papanicolaou smears and presented raw data showing for each cervical lesion type the number of patients judged positive and negative by colposcopic impression versus the standard of colposcopic biopsy results. Nine of 86 studies met these criteria. TABULATION, INTEGRATION, AND RESULTS: Biopsies had been categorized as normal, atypia, cervical intraepithelial neoplasia (CIN) I, CIN II, CIN III, carcinoma in situ, and invasive cancer; we recalculated performance measures using the Bethesda system. Overall sensitivity, specificity, likelihood ratios, ROC curves, and the corresponding areas under the curves were calculated. The average weighted sensitivity of diagnostic colposcopy for the threshold normal compared with all cervix abnormalities (atypia, low-grade SIL, high-grade SIL, cancer) was 96% and the average weighted specificity 48%. For the threshold normal cervix and low-grade SIL compared with high-grade SIL and cancer, average weighted sensitivity was 85% and average weighted specificity 69%. Likelihood ratios generated small but important changes in probability for distinguishing normal cervix and low-grade SIL from high-grade SIL and cancer. Areas under the ROC curve were 0.80 for the threshold normal cervix compared with all abnormalities and 0.82 for the threshold normal cervix and low-grade SIL compared with high-grade SIL and cancer. CONCLUSION: Colposcopy compares favorably with other medical diagnostic tests in terms of sensitivity, specificity, and area under the ROC curve. New diagnostic methods for the cervix can be compared with colposcopy using these quantified values.

Colposcopy↗
PubMed1999

Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions.

OBJECTIVE: To study the histologic regression and progression rates of cervical intraepithelial neoplasia (CIN) II and III after delivery and the effect the route of delivery has on the regression rates of CIN. METHODS: Pregnant patients with satisfactory colposcopic examinations and biopsy-proven CIN II and III were identified. Delivery information and postpartum biopsy results were obtained by chart review. RESULTS: Two hundred seventy-nine patients had antepartum biopsies of CIN II or CIN III. Of these, 126 women were excluded for the following reasons: lost to follow-up (75), human immunodeficiency virus positive (two), cesarean hysterectomy (four), and inadequate postpartum follow-up (45). This yielded a study group of 153 patients consisting of 82 with CIN II and 71 with CIN III. The regression rates were 68% and 70% among CIN II and CIN III patients (P = .78), respectively. Seven percent of patients with CIN II progressed to CIN III on postpartum evaluation. Twenty-five percent of those patients with CIN II and 30% of those with CIN III remained the same postpartum. No CIN lesions progressed to invasive carcinoma. There were no differences in regression rates or progression rates among the women who had vaginal deliveries (130), women who labored and then underwent cesarean (17), or women who proceeded to a cesarean without laboring (six). CONCLUSION: We found similar high postpartum regression rates despite the route of delivery. We recommend conservative antepartum management with postpartum colposcopic evaluation regardless of route of delivery because we are unable to predict which of these lesions are more likely to regress.

Adult↗
PubMed1978

Laser surgery in gynecology.

More experience and time are required to determine the advantages of laser surgery in gynecology. For precision surgery through the colposcope, the carbon dioxide laser beam appears to be useful in the control of neoplastic lesions of the vaginal mucosa and possibly of the cervix uteri. Tumor volume reduction through laser vaporization, especially when a recurrent tumor is attached to the bony pelvis, is an outstanding advantage. Adhesiolysis during myomectomy and reconstructive surgery of the fallopian tubes might be facilitated by the laser beam. Laser surgery on the vulva, both colposcopically directed and grossly with the CO2 laser scalpel, might prove to be important for the treatment of various lesions. Detailed technical knowledge, rigid safety precautions, and judicious clinical considerations are essential for competent laser surgery.

Abdomen↗
PubMed2003

Cytologic detection of human papillomavirus DNA in normal male urethral samples.

OBJECTIVES: To quantify the existence of human papillomavirus (HPV) infection without detectable lesions in the male urethra, and to verify the sensitivity and specificity of ureteral cytology. We compared the results of clinical and colposcopic examinations, ureteral cytology, and HPV DNA testing by polymerase chain reaction amplification in the male partners of women with genital HPV disease. METHODS: A total of 110 cytobrush samples of urethral cells from male sexual partners of women with genital HPV-associated lesions were analyzed by cytology and for virologic detection of HPV 6/11, 42, 16/18 by polymerase chain reaction followed by Southern blot hybridization. The results were correlated with the presence or absence of genital HPV-associated lesions. RESULTS: HPV DNA was detected in 1 sample (3%) from men without visible lesions, in 5 samples (15%) from men with penile lesions but without urethral lesions, and in 16 men with urethral lesions (78%). Cytology showed cellular changes suggesting HPV infection in 81% of men with urethral lesions, but also in 15% of men without lesions. CONCLUSIONS: Our results show that HPV-DNA positivity in the absence of clinically or colposcopically detected lesions is a rare event. Although sensitive enough, cytology is not specific, and its use as a screening tool may lead to a high number of false-positive results.

Adult↗
PubMed2003

Laser CO2 vaporization for high-grade cervical intraepithelial neoplasia: a long-term follow-up series.

OBJECTIVE: The goal of this study was to evaluate the effectiveness of laser CO(2) vaporization for conservative treatment of ectocervical high-grade cervical intraepithelial neoplasia (CIN) particularly by the evaluation of the reappearance risk of disease in long-term follow-up. METHODS: One hundred fifty-nine patients were submitted to CO(2) laser vaporization for high-grade CIN and followed up for a minimum of 5 years. Selection of cases, depth of ablation, complications, and cure rate (percentage of treated patients in whom there was no recurrent/persistent high-grade CIN at the 5-year follow-up examination) were retrospectively evaluated. RESULTS: Selected cases for colposcopy were submitted to a 6-mm mean depth of vaporization without intra- or postoperative complications. The cure rate for a single treatment was 97.5% and a satisfactory colposcopic follow-up was possible in 99.4% of treated patients. No case of invasive carcinoma occurred after a mean follow-up of 7.1 years. Four cases (2.5%) were high-grade CIN persistence observed after a mean time of 3.75 months, suggesting incomplete destruction of the deepest part of the lesion involving the glandular crypt base. CONCLUSIONS: Long-term follow-up proves that laser CO(2) vaporization still has a place in the treatment of CIN. In selected cases it represents a safe alternative for conization in the treatment of high-grade CIN, but colposcopic expertise is essential for adequate preoperative selection of cases.

Colposcopy↗
PubMed2001

Treatment of CIN after menopause.

OBJECTIVES: To characterise cervical neoplasia after the menopause. MATERIAL AND METHODS: We studied our computerized files of CIN from 1993-1999. Of the 738 cases, 78 were after menopause (11%). RESULTS: We made a report of the specificities of cytological and colposcopical diagnosis and the treatment given. Cytological results are the same after and before menopause. On the other hand, colposcopical patterns are significantly different because of a particular topography of the lesion. The majority of CIN after menopause are localized in the canal and are 44% versus 12. Incomplete conization is no more frequent after menopause than before. However, stenosis is higher: 73% unseen junction against 15%. Therefore, at this age, a total hysterectomy could possibly be preferable. In this study, we will outline the positive and the negative aspects of this form of treatment.

Cervix Uteri↗
PubMed2002

Human papillomavirus testing for triage of women referred because of abnormal smears. a decision analysis considering outcomes and costs.

The objective of this article was to evaluate the utility of high-risk human papillomavirus (HR-HPV) testing for triage of women referred for colposcopy because of abnormal smears. We considered women with persistent mild or moderate dyskaryosis and women with severe dyskaryosis who were referred for colposcopy. For both patient groups we evaluated three alternative management policies: (1) conventional management based on histological assessment; (2) HR-HPV-triage with direct treatment without prior histologic assessment for HR-HPV-positive women and conventional management for HR-HPV-negative women; and (3) direct treatment without histologic assessment for all referred women. For each policy the average number of medical procedures, doctor visits, and the costs per referred woman were calculated. Based on a literature review, the results were tested and translated to other patient groups. Per woman with persistent mild or moderate dyskaryosis and compared with conventional policy, HR-HPV-triage will avoid 0.51 colposcopically directed biopsies, but adds 0.05 local treatments of the cervix (i.e., loop excision of the transformation zone) and 0.09 outpatient visits, and will cost $134 US dollars extra. HPV triage is less efficient in women with borderline or mildly dyskaryotic cytology. In women with severe dyskaryosis, direct treatment is more efficient as conventional management or HPV triage. The decision to introduce HPV testing or direct treatment in women with persistent mild or moderate dyskaryosis strongly depends on the relative burden attributed to a colposcopically directed biopsy and an outpatient visit compared to loop excision of the transformation zone treatment of the cervix. For women with severe dyskaryosis, direct treatment should be seriously considered.

Adult↗
PubMed1999

Should gynecologic maturity change the management of cervical cytologic atypia during adolescence?

STUDY OBJECTIVE: To test the hypothesis that atypical cytology (ASCUS) portends ominous histologic diagnoses during adolescence. METHODS: The prevalence of squamous intraepithelial lesions (SILs) was determined in a racially diverse group of thirty-six 14- to 21-year-olds who were undergoing colposcopic evaluation of ASCUS cytology. The prevalence of 10 widely accepted risk factors for SIL was also qualified. RESULTS: SILs were detected in biopsies obtained from 20 (56%) of the 36 study subjects. There were 15 (39%) low-grade SILs and 5 (17%) high-grade SILs. No single risk factor or combination of risk factors distinguished subjects with SIL histology from those with more benign diagnoses. CONCLUSION: The hypothesis was supported. More than half (56%) of the adolescents we studied with ASCUS cytology had SIL histology. The findings suggest that immediate colposcopic evaluation may be prudent for adolescents with ASCUS cytology that cannot be attributed to concurrent lower genital tract infections.

Adolescent↗
PubMed1997

Child abuse examination enquiry.

OBJECTIVE: To determine how police surgeons in the United Kingdom performed examinations of child abuse victims because wide variations in protocols and procedures have been reported. METHOD: Practising members of the Association of Police Surgeons were requested to complete an enquiry form. Replies were anonymous and subjects covered included gender, work area, training, procedures and protocols for joint examinations with paediatricians and the use of digital or instrument examinations in alleged penetrative sexual abuse. RESULTS: Of all those eligible, 47.7% had responded. Males made up 74.7% of respondents. Published guidelines were followed by 85.3% and 69.8% used purpose-built examination suites while 8.8% still used police station facilities. Procedures for joint examinations were working satisfactorily, according to 79.2% of respondents who also considered that the forensic physician should take the lead role in examinations. Clinical findings were recorded on a prepared aide memoire by 35.2%. Colposcopes were used by 3.4% while 23.3% of respondents considered that a colposcope should be used but cost was an inhibiting factor. CONCLUSIONS: Reported variations in procedures and protocols in examining child abuse victims were confirmed. More discussion and liaison between agencies concerned is required and a firm commitment to the paramountcy of the child's interests is needed.

Journal Article↗
PubMed2004

Human papilloma virus testing knowledge and attitudes among women attending colposcopy clinic with ASCUS/LGSIL pap smears.

OBJECTIVE: To study women's knowledge regarding the role of human papilloma virus (HPV) in cervical intraepithelial neoplasia and their attitudes toward the integration of HPV testing as part of routine follow-up of atypical squamous cell of uncertain significance/low-grade squamous intraepithelial lesion (ASCUS/LGSIL) abnormalities. METHODS: Over a 12-month period, all women attending the University of Ottawa colposcopy clinic for evaluation and follow-up of ASCUS/LGSIL Pap smears were recruited. Demographic data included age, nature of the Pap smear abnormality, gravidity, parity, occupation and education level, smoking history, previous history of abnormal smears, colposcopic examination and treatment, and current method of contraception. The women were asked to rate their level of concern over their Pap smear abnormality, from 0 (not concerned) to 10 (very concerned). Women's knowledge regarding the role of HPV in cervical intraepithelial neoplasia and the rationale behind the use of HPV testing was assessed by the clinic nurse as being minimal, moderate, or good, as defined by pre-specified criteria. Upon explanation by the nurses of the results of the recent ALTS (ASCUS/LGSIL Triage Study) trial, the women were asked to state whether they preferred to continue with regular colposcopic surveillance every 6 months, or to use the results of the HPV test, if negative, to reduce the number of colposcopy examinations to one annually. Descriptive statistics and logistic regression analysis were used to identify significant demographic factors associated with the women's preference for incorporation of HPV testing in their follow-up. All P values less than.10 were considered to be statistically significant, due to the exploratory nature of the study. RESULTS: Of the 100 women who participated in the study, 42% presented with ASCUS. The mean age (+/- SD) of the women was 33.63 +/- 11.25 years (range, 18-75 years); 66% were office workers with at least a community college degree, 86% reported previous abnormal Pap smears, and 67% had previously been seen for colposcopy. Fifty-eight percent of the women rated their concern level as being 6 or more, while 15% ranked their concerns as maximal at 10. In terms of knowledge about HPV, 75% of the women had no or very minimal knowledge of the role of HPV in cervical intraepithelial neoplasia. With regard to HPV testing, 84% of the study group had either never heard of the test or had only a minimal knowledge of HPV testing. After being informed of the ALTS results, 64% of the women chose to use HPV testing to help in triaging the needs for frequent colposcopy. Logistic regression modelling showed that a college level education (odds ratio [OR], 2.27; 95% confidence interval [CI], 0.95-;5.45; P =.06) and history of previous treatment for abnormal Pap smears (OR, 3.31; CI, 0.88- 12.46; P =.07) were closely associated with the adoption of HPV testing in clinical management. CONCLUSION: There exists a significant lack of knowledge about HPV and its role in the pathogenesis of cervical intraepithelial neoplasia. Women who have received previous treatments for cervical intraepithelial neoplasia and those with college-level educations were more likely to adopt this new technology as part of their care.

Adolescent↗
PubMed2002

Situation analysis of atypical squamous cells of undetermined significance smears in Songklanagarind Hospital.

OBJECTIVE: To review the incidence, management, follow-up rate and colposcopic diagnosis of atypical squamous cells of undetermined significance (ASCUS) detected on cervical smears in Songklanagarind Hospital, Thailand. METHODS: A retrospective study of ASCUS smears taken during January 2000 to March 2001 at Songklanagarind Hospital was performed. The type of management was classified and the follow-up rate was detected. Cases with colposcopy, tissue biopsy, endocervical curettage, conization and hysterectomy specimen were reviewed. In the cases without tissue biopsy, the final diagnoses were based on the colposcopic examination. RESULTS: Among the 25068 Pap smears examined, the incidence of ASCUS was 0.62%. Of these, only 56.13% received the further evaluation. The non-compliance rate was 18.71%. The incidences of cervical intraepithelial neoplasia (CIN) and invasive cancer among the cases who received colposcopy were 15.96% and 2.13%, respectively. The incidence of CIN or invasive cancer in ASCUS favor reactive and ASCUS favor neoplasia were not different statistically significant. CONCLUSIONS: Management of ASCUS smears by follow-up may be inappropriate. A practice guideline which consists of active management, intensive follow-up system and well-organized data management should be used to improve the situation.

Adult↗
PubMed1996

Primary cervical lymphoma: the role of cervical cytology.

Two cases of primary malignant lymphoma of the uterine cervix are reported. Both were confirmed by histology as high grade B cell lymphomas. In one case, the diagnosis was made on a second colposcopic biopsy after an initial cervical smear and colposcopic biopsy were negative. In the second case, dyskaryotic cells of uncertain type were identified in a cervical smear taken at colposcopy performed as part of follow up for previous cervical intraepithelial neoplasia (CIN)I. The cytologic features and differential diagnosis of this rare cervical neoplasm are discussed, with emphasis on the role of the Papanicolaou smear in the initial diagnosis of this tumour.

Adult↗
PubMed1994

Human papillomavirus DNA and genotypes: prognostic factors for progression of cervical intraepithelial neoplasia.

A retrospective study of 227 patients presenting with abnormal cervical cytology was conducted to investigate the relationship between human papillomavirus (HPV) and progression of untreated cervical intraepithelial neoplasia (CIN) lesions. All patients had colposcopically directed biopsies for histologic diagnosis. The patients were followed cytologically and colposcopically for a mean of 19 months (range 6-42 months). Progression of a cervical lesion was defined as progression to a higher CIN grade confirmed histologically by directed biopsy. HPV DNA detection was done on material remaining from the cervical swabs by the general primer polymerase chain reaction (PCR) and type-specific PCR method, which made the detection of HPV types 6, 11, 16, 18, 31, 33 and not yet sequenced DNA types (X) possible. The presence of HPV DNA increased with the severity of the lesion (P < 0.001). In CIN III, a 100% HPV DNA prevalence was found, with HPV type 16 being the most prevalent type in 75%. Progression was significantly related to the presence of HPV DNA, in particular HPV type 16. The percentage of progressive disease was 21% in the case of HPV DNA positive lesions (n = 130) and 29% in the presence of HPV type 16, whereas HPV DNA negative lesions (n = 97) showed no progression. The detection of HPV DNA and HPV genotype can be used to identify patients with high-risk cervical lesions, since the presence of HPV DNA and genotype 16 in particular are closely related to CIN progression.

Journal Article↗
PubMedDate not supplied

Visual inspection with acetic acid and cytology in the early detection of cervical neoplasia in Kolkata, India.

Visual inspection of the cervix after application of 3-5% acetic acid (VIA) is a potential alternative to cytology for screening in low-resource countries. The present study evaluated the performance of VIA, magnified visual inspection after application of acetic acid (VIAM), and cytology in the detection of high-grade cervical cancer precursor lesions in Kolkata (Calcutta) and suburbs in eastern India. Trained health workers with college education concurrently screened 5881 women aged 30-64 years with VIA, VIAM, and conventional cervical cytology. Detection of well-defined, opaque acetowhite lesions close to the squamocolumnar junction; well-defined, circumorificial acetowhite lesions; or dense acetowhitening of ulceroproliferative growth on the cervix constituted a positive VIA or VIAM. Cytology was considered positive if reported as mild dysplasia or worse lesions. All screened women (N = 5881) were evaluated by colposcopy, and biopsies were directed in those with colposcopic abnormalities (N = 1052, 17.9%). The final diagnosis was based on histology (if biopsies had been taken) or colposcopic findings, which allowed direct estimation of sensitivity, specificity, and predictive values. Moderate or severe dysplasia or carcinoma in situ (CIN 2-3 disease) was considered as true positive disease for the calculation of sensitivity, specificity, and predictive values of screening tests. 18.7%, 17.7% and 8.2% of the women tested positive for VIA, VIAM, and cytology. One hundred twenty two women had a final diagnosis of CIN 2-3 lesions. The sensitivities of VIA and VIAM to detect CIN 2-3 lesions were 55.7% and 60.7%, respectively; the specificities were 82.1% and 83.2%, respectively. The sensitivity and specificity of cytology were 29.5% and 92.3%, respectively. All the tests were associated with negative predictive values above 98%. VIA and VIAM had significantly higher sensitivity than cytology in our study; the specificity of cytology was higher than that of VIA and VIAM.

Acetic Acid↗
PubMed2001

Home study course: winter 2001.

OBJECTIVE: The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management, or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION: The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category I of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.

Journal Article↗
PubMed2001

Identification of cervical neoplasia using a simulation of human vision.

OBJECTIVE: To determine whether a computer simulation of human vision could detect and discriminate cervical cancer precursors and cancer from normal epithelium. METHODS: The Georgia Tech Vision (GTV) system was trained to recognize normal and abnormal cervical features. GTV then assessed a new series of images to determine whether it could detect and diagnose cervical neoplasia without any a priori information about the images. RESULTS: After training on one set and testing on another set of images, GTV demonstrated 100% sensitivity and 98% specificity to detect cervical intraepithelial neoplasia 3 (CIN3). GTV also had 88% sensitivity and 93% specificity to detect cervical cancer following training on one set and testing on another set of digitized cervical colposcopic images. CONCLUSION: This study demonstrated that GTV can detect CIN3 and cancer from digitized cervical colposcopic images. Furthermore, GTV could discriminate cervical cancer precursors and cancer from normal cervical epithelium, including immature metaplasia.

Journal Article↗
PubMed2001

[Colposcopy of CIN and microinvasive cervical carcinoma].

The colposcopist must distinguish between two patterns: nonsuspicious findings and suspicious findings. With experience, the colposcopist will succeed more and more in distinguishing between the two, thereby markedly reducing the number of biopsies. Suspicious findings are not synonymous with abnormal findings because the latter are not always due to premalignant lesions. A number of features are of value in the different diagnosis of colposcopic findings: sharp borders, response to acetic acid (white epithelium), surface contour, appearance of blood vessels, surface extent (size), combinations of abnormalities, iodine uptake, and keratinization. The diagnostic features described above can be expressed to varying degrees, and can be found singly or in combination. The more distinct a feature is and the greater the variety of features seen in combination, the higher the index of suspicion. Attempting to differentiate between the various grades of CIN (SIL) colposcopically is more questionable, as these lesions are regarded now as forming a spectrum of the same biologic process.

Acetic Acid↗
PubMed1994

[The advantages of CO2 laser use in treatment of cervix dysplasia].

We use two kinds of laser treatment, namely, laser vaporisation and laser excision conisation. Laser vaporisation is a widely used method of localised ablative treatment based on both histologically confirmed cervical intraepithelial neoplasia and clear colposcopic visualisation of the upper limit of the lesion. Laser excision conisation is performed, if cervical intraepithelial neoplasia reaches the endocervix, being out of colposcopic view, and the squamocolumnar junction is localised in the endocervical canal. 116 patients with cervical intraepithelial neoplasia were treated with the CO2 laser. 81 (70%) were subjected to laser vaporisation, 35 (30%) to laser excision conisation. Intraoperative bleeding was rarely seen. After laser vaporisation, no complications were observed, but laser excision conisation complications occurred in one patient who developed postoperative cervical stenosis, and in another patient, who had postoperative bleeding requiring surgical examination. Follow-up with colposcopy and cytologic smears was carried out every 6 months. Recurrence of disease 6 months or later after laser treatment was seen in 6 patients (7.4%) after laser vaporisation and in 2 patients (5.7%) after laser excision conisation. This report shows the advantages of the carbon dioxide laser in comparison to cold knife conisation in the treatment of cervical intraepithelial neoplasia.

Cervix Uteri↗