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PubMed2002

Evaluation of downstaging in the detection of cervical neoplasia in Kolkata, India.

Unaided visual inspection or "downstaging" has been suggested as a potential alternative method for cervical cancer screening in developing countries. Our study was designed to evaluate the accuracy of downstaging to detect cervical neoplasia in a low-resource setting. A total of 6,399 women aged 30-64 years were screened with downstaging by trained nonmedical health workers. Two thresholds were used to define positive downstaging: "low threshold" when any visible abnormality on the cervix was considered positive and "high threshold" when selected abnormalities such as bleeding on touch, bleeding erosion, hypertrophied oedematous cervix, congested stippled cervix and growth or ulcer constituted the positive test. All women underwent a colposcopy examination. Biopsies were directed when colposcopy revealed abnormal lesions. True disease status was defined as histologically proven moderate dysplasia and worse lesions. Since all the participants received a diagnostic (reference) investigation (biopsy and/or colposcopy), sensitivity, specificity and predictive values were estimated directly. Low- and high-threshold downstaging were positive in 1,585 (24.8%) and 460 (7.2%) women, respectively. The sensitivities of low- and high-threshold downstaging to detect high-grade precursors and invasive cancers were 48.9% and 31.9%, respectively. The specificities were 75.8% and 93.3%, respectively. These results indicate that downstaging is not suitable as an independent primary screening modality for cervical neoplasia.

Adult↗
PubMed1998

Does typing of human papillomavirus assist in the triage of women with repeated low-grade, cervical cytologic abnormalities?

OBJECTIVE: To evaluate the ability of testing for high-risk human papillomavirus (HPV) using the hybrid capture technique to detect cervical intraepithelial neoplasia (CIN) in patients with repeated low-grade cervical cytologic abnormalities and an adequate and normal colposcopy. METHODS: Hybrid capture testing and LEETZ were performed on 166 women with repeated low-grade cervical cytologic abnormalities who were referred for colposcopy which was to be adequate and normal. RESULTS: A highly significant correlation (P < 0.0001) was found between a positive test for high-risk HPV types and the finding of CIN II,III. In 67 women with atypical squamous cells of undetermined significance on repeated cytologic studies, a positive test for high-risk HPV types had a sensitivity and specificity of 90 and 96.5%, respectively, for detecting CIN II,III. In 99 patients with low-grade squamous intraepithelial lesions found on repeated cytologic study, a positive test for high-risk HPV types identified all patients as having CIN II,III on cone biopsy (sensitivity, 100%), with a specificity of 86.4%. Restriction of tissue sampling to women who were positive for high-risk HPV types would have reduced the number of tissue samplings performed to 20.4%, while identifying 20 of 21 patients with biopsy-confirmed CIN II, III. CONCLUSION: A positive hybrid capture test for high-risk HPV types is highly sensitive and specific for detecting CIN II,III in patients with repeated low-grade cervical cytologic abnormalities and an adequate and normal colposcopy and may be used in the triage of these women before performing tissue sampling.

Adolescent↗
PubMed1995

Psychological response to cervical screening.

BACKGROUND: Few studies have examined the psychological costs of cervical screening, despite expressed concern over possible negative sequelae. METHODS: Seventy-five women with mild or moderately dyskaryotic smears, under cytological surveillance, 75 women referred for colposcopy after a first-ever abnormal smear showing severe dyskaryosis, and 75 controls with recent negative cytology were interviewed at home, and their psychological adjustment was assessed. RESULTS: Levels of distress were higher among women with an abnormal smear than among controls with a recent negative smear. Anxiety (Hospital Anxiety and Depression Scale range 0-21, "normal" range 0-7) was highest among those referred for colposcopy (mean 8.12, controls 5.88, P < 0.001); afterward, distress fell (mean 6.61, P < 0.001) but more problems of social adjustment were evident (surveillance vs controls, P < 0.01). High anxiety was associated with social maladjustment (colposcopy, P < 0.001; surveillance, P < 0.01) and negative feelings about the self (P < 0.05). Current anxiety was unrelated to knowledge about abnormal smears, but in the surveillance group was related to satisfaction with the explanation provided (P < 0.05). CONCLUSION: A positive cervical smear may by psychologically traumatic for a significant minority of women, irrespective of management strategy.

Adaptation, Psychological↗
PubMed1990

A clinical review of cervicography.

A new investigative modality, cervicography, has been advocated for cervical screening. In the first 51 patients referred for colposcopy because of an abnormal cervicogram, none had invasive cancer and 75% had preinvasive cancer. The cervicogram appears superior to cytology but inferior to colposcopy in the detection of cervical pathology. Based on the available evidence, however, cervicography cannot be recommended for universal screening. It may have a role in the follow-up of patients with a mildly abnormal cervical smear, but the optimum management remains early referral for colposcopy.

Adult↗
PubMed2005

A study of abnormal cervical cytology in pregnant women.

During the 4 year routine study of smears in 2,919 pregnant women, 33 cases of abnormals of the uterine cervix were detected (1.13%). The patients were followed with uterine cervical cytology and colposcopy and in case of need, sometimes punch biopsies were performed. The results of the cytologies, 33 cases with abnormalities were detected. There were 26 cases classified as class IIIa, 7 cases were class IIIb. All the cases underwent colposcopy. For the 17 cases that showed lesions by colposcopy, and punch biopsies were performed. The results of histologic examination were wide variety, five chronic cervicitis, one condyloma, one mild dysplasia, three moderate dysplasia, three severe dysplasia, three carcinoma in situ, and one microinvasive carcinoma. Only two cases were treated during pregnancy; one with condyloma underwent Laser vaporization and another with microinvasive carcinoma underwent LEEP conization. Other cases were given conservative treatment during pregnancy. Excluding one case for persistence smear class IIIa of histology condyloma, all the cases showed regression of dysplasia and carcinoma in situ with treatment after delivery. We conclude that lesions up to carcinoma in situ do not require intervention during pregnancy but microinvasive carcinoma is suspected, diagnostic LEEP conization is necessary, even during pregnancy.

Carcinoma↗
PubMed2005

A study of abnormal cervical cytology in pregnant women.

During the 4-year routing study of smears in 2,919 pregnant women, 33 cases of abnormalities of the uterine cervix were detected (1.13%). The patients were followed with uterine cervical cytology and colposcopy, and in case of need, sometimes punch biopsies were performed. As a result of the cytologies, 33 cases with abnormalities were detected. There were 26 cases classified as class IIIa and 7 cases were class IIIb. All cases underwent colposcopy. For the 17 cases that showed lesions by colposcopy, punch biopsies were performed. The results of histologic examination were wide: 5 chronic cervicitis, 1 condyloma, 1 mild dysplasia, 3 moderate dysplasia, 3 severe dysplasia, 3 carcinoma in situ, and 1 microinvasive carcinoma. Only two cases were treated during pregnancy, condyloma underwent Laser vaporization and microinvasive carcinoma underwent Loop electrosurgical excision procedure (LEEP) conization. Other cases were conservative treatment during pregnancy. Excluding one case for persistence smear class IIIa of histology condyloma, all the other cases with regression of dysplasia and carcinoma in situ with treatment after delivery. We conclude that lesions up to carcinoma in situ do not require intervention during pregnancy but microinvasive carcinoma is suspected, diagnostic LEEP conization is necessary, even during pregnancy.

Adolescent↗
PubMed1975

Colposcopic evaluation of the abnormal Papanicolaou test in pregnancy.

Colposcopy, including colposcopically directed biopsies in selected cases, was employed to evaluate over 300 pregnant patients with abnormal Papanicolaou tests suggestive of mild dysplasia or worse (Class III to V). Over half of the patients had benign disorders determined by colposcopic examination. All cases of invasive disease were diagnosed by colposcopy and biopsy, and the patients were treated accordingly. Only 3 diagnostic conizations were necessary in the antepartum period. The majority of patients with cervical intraepithelial neoplasia were seen post partum, and appropriate therapy was instituted. In the pregnant patient with an abnormal Papanicolaou test, colposcopy has proved to be a reliable and safe method of evaluation and has virtually eliminated the need for conization.

Biopsy↗
PubMed1982

Diagnostic significance and sequelae of cone biopsy.

All cone biopsies from our institution over a 10-year period were reviewed. Two hundred seventy-one patients underwent 274 procedures. Preoperative colposcopic evaluation markedly reduced the proportion of patients with residual cervical epithelial neoplasia (CIN). No patient in our series required conization for diagnosis of frankly invasive carcinoma. Following colposcopy and conization, 8% of patients had disease extending to the surgical margins; eight of 11 such patients (72%) with adequate follow-up had no further CIN. Colposcopy and cytology underestimate the final pathologic diagnosis in many patients with incomplete visibility of the transformation zone, so conization is mandatory in this circumstance. Conization in pregnancy was associated with increased hemorrhage; colposcopy has reduced the need for this operation in gravid patients.

Biopsy↗
PubMed1996

Comparison of spermicides on vulvar, vaginal, and cervical mucosa.

The objective of this study was to compare the tolerability of Advantage 24 to two other spermicides containing non-oxynol-9 (N-9). These spermicides were Today Sponge (Sponge) and Conceptrol. In order to examine the incidence of complaints and the clinical observation of vaginal ulceration and irritation of the three spermicides, a randomized, open label, three period cross-over trial was conducted. Thirty-three women, ages 18-45, with a normal vaginal environment based on physical exam, Pap smear, vaginal wet prep, colposcopy, and serum N-9 were randomized into four treatment groups. Each treatment was for seven consecutive days with a 21-day washout. Data obtained were studied by one-way analysis of variance, chi-square, and Kruskal-Wallis test. No vulvar or vaginal abnormality was observed from either spermicide. Subjects had fewer and less severe cervical lesions by colposcopy during treatment with Advantage 24 than with Conceptrol or Sponge (p < 0.01). Comparison of the incidence of abnormal gynecological findings, serum N-9 levels, and the incidence of adverse events before and after treatment with the three study drugs indicate that most subjects had normal examinations pre- and post-treatment. Pap smear and colposcopy changes from normal to abnormal accounted for about 50% of all gynecological findings during the Conceptrol and Sponge treatments, but less than 20% during treatment with Advantage 24. All serum N-9 levels were below the level of detection (< 1.9 microgram/ml). Advantage 24 is better tolerated than Conceptrol or the Sponge. Furthermore, the cervical mucosa appears to be less resilient to spermicides than vulvo-vaginal mucosa.

Adolescent↗
PubMed1985

Evaluation of the cerviscope as a screening instrument.

The cerviscope has been proposed as a screening tool for use in conjunction with the Papanicolaou smear as a system offering many of the same advantages as colposcopy and cytology. One hundred twenty-five patients were evaluated with the cerviscope who had been referred to this colposcopy clinic with a diagnosis of dysplasia. The purpose of this study was to evaluate the instrument's potential as a screening adjunct in the context of simultaneous evaluation by colposcopy. Thirty-nine percent (49 patients) were unevaluable due to technical problems (defective cervicogram, nonvisualized squamocolumnar junction). Significantly, 67% (26 patients) of the 39 patients reported as having negative cervicograms had a biopsy-proven dysplasia (19 mild, 4 moderate, 3 severe). By the chi 2 method, this is statistically significant (P less than 0.001).

Adult↗
PubMed2004

Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse.

OBJECTIVES: The purpose of this study was to determine the relative importance of colposcopically directed biopsy, random biopsy, and endocervical curettage (ECC) in diagnosing > or =cervical intraepithelial neoplasia (CIN) II. Study design During a screening study, 364 women with satisfactory colposcopy and > or =CIN II were diagnosed. All colposcopically detected lesions were biopsied. If colposcopy showed no lesion in a cervical quadrant, a random biopsy was obtained at the squamocolumnar junction in that quadrant. ECC was then performed. RESULTS: The diagnosis of > or =CIN II was made on a colposcopically directed biopsy in 57.1%, random biopsy in 37.4%, and ECC in 5.5% of women. The yield of > or =CIN II for random biopsy when cytology was high grade (17.6%) exceeded that when cytology was low grade (2.8%). One of 20 women diagnosed solely by ECC had invasive cancer. CONCLUSION: Even when colposcopy is satisfactory, ECC should be performed. If cytology is high grade, random biopsies should be considered.

Adult↗
PubMed2006

Preliminary results of 5% imiquimod cream in the primary treatment of vulva intraepithelial neoplasia grade 2/3.

OBJECTIVE: This study was undertaken to study the tolerability and efficacy of 5% imiquimod cream in the primary treatment of vulva intraepithelial neoplasia (VIN) grade 2/3. STUDY DESIGN: VIN grade 2/3 patients were recruited from regional colposcopy units. Imiquimod cream was applied over the abnormal area by the patient using an escalating dose regime for total treatment duration of 16 weeks. At the end of study, repeat colposcopy and biopsy of the target lesion were performed to assess for response. RESULTS: Twenty-three patients participated. Twenty patients (87%) had VIN grade 3. Nine patients (39%) had multifocal disease on colposcopy. Therapy was well tolerated with the most commonly observed side effects being irritation at the application site. Responses were evaluable in 17 patients. Complete responses were observed in 9 patients with partial responses in another 5 (relative risk 82%). The median time to response was 7 weeks. CONCLUSION: Imiquimod cream can induce histologic regression of high-grade VIN lesions and is well tolerated using a slow dose-escalating regime.

Adjuvants, Immunologic↗
PubMed2004

Quality of follow-up of women with high grade squamous intra-epithelial lesion (HGSIL) cervical smears: results from a population-based organised screening programme.

OBJECTIVE: After a HGSIL cervical smear, to appraise the diagnostic and treatment modalities by comparing with national recommendations. STUDY DESIGN: A clinical audit concerning 444 women with a HGSIL cervical smear, within the first 3 years of the programme. RESULTS: Among the 413 women followed-up (98%), the colposcopy rate reached 71% at 3 months and 81% at 1 year. It was lower for women who had a history of other abnormal Pap smears than for those with no gynaecological symptoms or past history (66% versus 87%, P = 0.02), it was higher when the cytology report showed a CIN III than when a CIN II was reported (84% versus 78%, P = 9 x 10(-4). After the colposcopy, 23 women (7%) were lost to follow-up. Among the 76 women without a colposcopy, 17 (22%) did not have any histological examinations during their follow-up. CONCLUSION: Measures to improve women's follow-up compliance and ensure appropriate physician behaviours are necessary to achieve better quality in this screening programme.

Adult↗
PubMed2005

Visual inspection of the cervix with acetic acid for cervical intraepithelial lesions.

OBJECTIVE: Evaluation of visual inspection of the cervix with acetic acid (VIA) for screening cervical intraepithelial neoplasia. METHODS: In this prospective study, 400 women were screened using the Papanicolaou (PAP) smear, VIA and colposcopy. Those who had positive results with any of the screening methods underwent large loop excision of the transformation zone (LLETZ). The sensitivity and specificity of each of the screening methods was analyzed. RESULTS: The sensitivity of VIA (96.7%) was much higher than that of the Pap smear (50%), and almost as high as that of colposcopy (100%). The specificity of VIA (36.4%) was lower than that of the Pap smear (97%) and colposcopy (96.9%), resulting in high false-positive rates for VIA. Two cases of endocervical lesions were missed with VIA. CONCLUSION: Visual inspection of the cervix with acetic acid is very sensitive for ectocervical lesions. The advantages of the VIA method are its low cost and ease of use (it can be used by paramedical workers), its high sensitivity and its immediate results (it is possible to "see and treat" at the first visit). Its main limitation is a high rate of false-positive results, which may lead to overtreatment if a "see and treat" policy is applied.

Acetic Acid↗
PubMed2006

Screening for cervical carcinoma using visual inspection with acetic acid.

OBJECTIVE: To assess the performance of visual inspection with acetic acid (VIA) as a screening test for early detection of cervical carcinoma in the Dakahlia Governorate in Egypt. METHODS: Diluted acetic acid (5%) was applied to the cervix during routine gynecologic examination. Women with positive results were referred for colposcopy. Those with negative results were referred for colposcopy only when they had clinical indications. RESULTS: Among the 5,000 women who were screened using VIA, 409 were referred for colposcopy. Cervical intraepithelial neoplasia (CIN) was diagnosed in 151 (60%) of the 253 women with positive screening results and in 4 of the 156 women with negative screening results. There were 39 women with high-grade and 116 with low-grade CIN. The sensitivity and negative predictive value of the VIA screening test was 97%. Its positive predictive value was 60% for all grades of CIN and 90% for high-grade CIN. CONCLUSION: Visual inspection with acetic acid, although associated with a relatively high rate of false-positive results, is a valuable test for the screening of cervical carcinoma.

Acetic Acid↗
PubMed2005

Detection of persistent high risk human papillomavirus infections with hybrid capture II and SPF10/LiPA.

BACKGROUND: HPV infection in young women is common. However only a certain number of HPV genotypes are oncogenic. It is necessary for high risk HPV infection to persist at the cervix for a considerable time before oncogenesis occurs. OBJECTIVES: To look for persistence of high risk HPV in women attending a colposcopy clinic. Two DNA detection methods were used and the results compared to determine the rates of persistent, resolved and acquired infections over a 6-month period. HPV genotyping was used to determine type specific persistence. STUDY DESIGN: One hundred and thirty-eight women were tested for HPV infection when attending the colposcopy clinic at UCLH and then tested again at a subsequent visit approximately 6 months later. HPV DNA was detected by the Digene HC II assay using the high risk probes only and by PCR with the SPF10 primer set. All SPF10 PCR-positive samples were then specifically genotyped by a Line Probe Assay (LiPA) [Kleter et al. 1999. J. Clin. Microbiol. 1999;37:2508]. RESULTS: At entry of the study high risk HPV was detected in 43% of the samples by Digene HC II and in 60% of the samples by SPF10/LiPA. Thirty-eight (28%) of the women had a true persistent infection with the same high risk HPV genotype over a median period of 6.3 months. Nine (7%) women resolved one HR HPV infection after their first colposcopy visit, but obtained a different high risk HPV infection by the time they were tested at their second visit as identified by LiPA. Thirty-seven (27%) of the 138 women had mixed HPV infections, representing 45% of all those infected. CONCLUSIONS: The SPF10/LiPA assay detected more high risk infections than the Digene HC II assay. The Digene HC II assay was unable to distinguish between persistent infections with the same high risk genotype and those where the genotype had changed between visits.

Colposcopy↗
PubMed1987

Colposcopic evaluation of abnormal Papanicolaou smears in pregnancy.

Colposcopy was used to examine 401 pregnant patients with cytologic or clinical abnormalities of the cervix to determine if routine biopsy could be safely omitted except where the colposcopic impression was one of possible invasive carcinoma. A comparison of the antepartum colposcopic impressions with the postpartum histologic diagnosis revealed agreement to within one degree in 87% of patients, with 3% of patients showing a more advanced lesion than that anticipated. Only 2% of patients showed a progression of cytologic abnormalities at postpartum examination; 39% showed marked improvement. Four of nine patients with invasive carcinoma were diagnosed at antepartum colposcopy, with an additional two patients recognized as having invasive cancer at the postpartum colposcopic examination. The omission of routine biopsy is less than ideal if only one antepartum colposcopy is performed, since a considerable period of time may elapse before the patient is seen again postpartum. Those situations in which it may be omitted, together with guidelines for the management of pregnant patients with abnormal cervical cytologic findings, are presented.

Adolescent↗
PubMed1997

Management of low-grade squamous intraepithelial lesions during pregnancy.

OBJECTIVE: Our purpose was to determine whether prenatal colposcopy is beneficial in pregnant women with squamous atypia, atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesions on an initial screening Papanicolaou smear. STUDY DESIGN: A retrospective chart review identified a cohort of pregnant patients referred to the colposcopy clinic at Carolinas Medical Center between October 1991 and December 1994 with squamous atypia, atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesions. Results of the colposcopic examination, cervical biopsy specimens, postpartum evaluation, and postpartum treatment were recorded. Descriptive statistics were used to tabulate numbers and percentages for all variables with 95% confidence intervals to determine disease progression. RESULTS: Prenatal colposcopy was performed on 253 women during the study period. The colposcopic impression was normal or consistent with low-grade squamous intraepithelial lesions in 235 (93%) of the women. Of the 67 women who had a cervical biopsy, 6 had a histologic diagnosis of high-grade squamous intraepithelial lesions. Postpartum Papanicolaou smears were obtained in 224 patients; 71 (32%) were normal, 145 (65%) were unchanged, and 8 (3%) showed high-grade squamous intraepithelial lesions. Of the 69 patients who had a postpartum cervical biopsy, 4 were found to have high-grade squamous intraepithelial lesions. Eight of the 10 women with biopsy-proved high-grade squamous intraepithelial lesions were compliant with treatment after delivery. Histologic examination of the cervix with tissue obtained by either loop conization or cold knife conization showed no evidence of invasive carcinoma. CONCLUSION: Squamous atypia, atypical squamous, cells of undetermined significance, or low-grade squamous intraepithelial lesions on a Papanicolaou smear in a pregnant patient does not require colposcopic evaluation during pregnancy. Progression of low-grade dysplasia to carcinoma during pregnancy is unusual, and no patient in this study was found to have invasive cancer.

Adolescent↗