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PubMed2003

[Wait-and-see policy versus loop excision after two consecutive Pap-2 cervical smears: over time less surgery and an equivalent outcome; no substantial contribution to be expected from the detection of high risk human papillomavirus].

OBJECTIVE: To determine the number interventions and outcomes in patients referred with two consecutive Pap 2 cervical smear results who were managed either by a wait-and-see policy or aggressively, and to determine whether triage with high-risk human papillomavirus (hr-HPV) detection, resulting in the referral of only hr-HPV positive patients, would lead to the detection of all patients with cervical intraepithelial neoplasia (CIN). DESIGN: Retrospective comparison and retrospective cohort study. METHOD: 282 patients referred in 1997/'99 with 2 consecutive Pap 2 cervical smears in the screening program were included. Patients referred to the UMC St Radboud Hospital (n = 140; mean age: 45 years) underwent a colposcopy during which only lesions suggestive for CIN 3 were treated. All other colposcopic lesions (CIN 2 or less) were not treated but followed prospectively. Patients referred to the Canisius Wilhelmina Hospital (CWZ) (n = 142; mean age: 44 years) underwent colposcopy during which all colposcopic lesions (including CIN 2 or less) were treated directly. The two groups were compared in terms of the final cytological follow-up, the number of loop excisions, and the number of patients with CIN. The mean follow up was 40 months. In the first group, the effect of triage using hr-HPV detection was also investigated retrospectively. RESULTS: With the wait-and-see approach, statistically significantly fewer diathermic loop excisions were done: 13 versus 124. After the follow-up period there was no statistically significant difference between the two groups in terms of the number of patients with persisting Pap 2: 16 (11%) versus 12 (8%). Triage with hr-HPV detection would identify all patients with CIN 3, 50% of the patients with CIN 2, and none of the patients with CIN 1; of the 48 hr-HPV-positive women, 1 had a CIN 3 lesion and 3 had a CIN 2 lesion; of the remaining 92 women, 2 had a CIN 1 lesion and 3 had a CIN 2 lesion. CONCLUSION: The wait-and-see approach led to fewer interventions, while the number of women with persisting Pap 2 smears was not higher than with the aggressive approach. Triage with hr-HPV may reduce the number of referrals and colposcopies, but follow-up remains necessary in all women regardless of hr-HPV status.

Adult↗
PubMed2003

[Value of acetic acid smear test for cervical cancer screening].

BACKGROUND & OBJECTIVE: At present, the incidence of cervical cancer is still high in less developed areas of China; one of the reasons is that cytology in screening for cervical cancer is not feasible in these areas. The aim of this study was to analyze the sensitivity and specificity of acetic acid smear test as a cervical cancer screening test, and evaluate the value of this method for cervical cancer screening. METHODS: Acetic acid smear test was performed on 1997 previously unscreened women aged 35-45 years in Xiangyuan County, Shanxi Province. All women had cervical cytology, testing for high-risk types of human papillomavirus DNA, colposcopy, an endocervical curettage and at least five cervical biopsies. Biopsies were done at the lesions, or one biopsy at 2, 4, 8, 10 o'clock at the squamocolumnar junction in each normal quadrant. RESULTS: According to histological diagnosis, 43 women had CIN II, 31 had CIN III, and 12 had invasive carcinoma. In two women only the endocervix was positive. Smear test yielded normal results in 1445 women (72.4%), low-grade squamous intraepithelial lesions (LSILs, CIN I) in 525 (26.3%), high-grade squamous intraepithelial lesions (HSILs, CIN II- III) in 21 (1.1%), and cancer in 6 (0.3%). With abnormal visual inspection defined as LSILs or worse, the sensitivity of acetic acid smear test for HSILs or worse was 70.9% (61 of 86), the specificity was 74.3% (1420 of 1911). The sensitivity was 64.9% for smaller lesions (37 of 57), and 88.9% for larger lesions (24 of 27) (P=0.03). The sensitivity of colposcopy for high-grade SILs or worse was 81.4% (70 of 86), the specificity was 76.5% (1462 of 1911). CONCLUSION: This study showed the high specificity and sensitivity of acetic acid smear test as a primary screening test for cervical cancer. Acetic acid smear test and colposcopy have similar specificity profiles for CIN II or more severe lesions. Acetic acid smear test as a primary screening test will be possible and effective with the benefits of low-cost and simple test in low-resource settings.

Acetic Acid↗
PubMed2004

Management and follow-up of abnormal Papanicolaou tests.

Although less prevalent than breast cancer, cervical cancer has a lower 5-year survival rate. Cervical cancer is nearly always due to human papillomavirus (HPV). Increased screening and DNA typing for oncogenic HPV have begun to reduce the number of cases. Interpretation of Papanicolaou test results and disease management decisions require a comprehensive grasp of recent revisions in classification and management practice. This article reviews the recommendations of the multidisciplinary Bethesda 2001 Workshop and the American Society for Colposcopy and Cervical Pathology. Practice changes include: new criteria for using liquid-based collection, a streamlined borderline category of atypical squamous cells (ASC), and a new category of ASC-cannot exclude high-grade lesion (ASC-H). Management includes colposcopy for all categories suspicious for epithelial abnormality and clearer guidelines for diagnostic colposcopy and endocervical sampling for glandular cell abnormalities (AGC, AGC-favor neoplasia). Adolescents and postmenopausal women have some variations from the recommended protocol. Reflex HPV DNA typing reflects the advances in research regarding risks for progression to cervical cancer. Treatment options include surgical removal of the lesions via laser, cryosurgery, loop excision, or cold-knife conization. Medical options include local treatments of cervical condyloma with tricloroacetic acid or 5-fluorouracil. Visible and sometimes functional cervical changes may result. Clinicians now have clearer guidelines with which to manage abnormal Papanicolaou test results, using the latest technology and research. Discussing abnormal results with patients requires great sensitivity.

Adolescent↗
PubMed1992

Natural history of the minimally abnormal Papanicolaou smear.

OBJECTIVE: We sought to determine the natural history of the cytologic and colposcopic changes in patients with minimal abnormalities on their Papanicolaou smears (atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion [SIL]). METHODS: Between November 1988 and November 1990, 632 women with abnormal Papanicolaou smears as listed above were evaluated at Los Angeles County-Olive View Medical Center. Each had review of cytology, repeat Papanicolaou smear, and colposcopy of the lower genital tract. We excluded those who were pregnant or had findings demonstrative of moderate dysplasia or worse, or had a cervical biopsy for any other indication. Women with symptomatic vaginal discharge were treated and remained in the study. Subjects were followed every 3 months with repeat Papanicolaou smear and colposcopy for a minimum of 9 months. If at any time the Papanicolaou smear or colposcopy was consistent with moderate dysplasia or worse, directed biopsies and endocervical curettage were performed, and treatment was given accordingly. Two hundred ninety-four patients fulfilled all inclusion criteria and had adequate follow-up data. RESULTS: Nine months after enrollment, 42 of 91 women (46.2%) with atypical squamous cells had persistent changes, none had progression, and 49 (53.8%) had regression to normal. In those with low-grade SIL, 37 of 203 cases (18.2%) persisted, seven (3.4%) progressed, and 159 (78.3%) regressed by 9 months. Patients in the first group were more likely to have persistence of the cytologic abnormalities than were those in the second (P less than .01). Only the latter group progressed to high-grade dysplasia during the 9-month study interval. CONCLUSION: The majority of women with confirmed minimal cytologic changes on Papanicolaou smear will have complete colposcopic and cytologic regression over a short interval.

Adult↗
PubMed2004

Endocervical curettage. Does it contribute to the management of patients with abnormal cervical cytology?

OBJECTIVE: To conduct a prospective analysis of whether endocervical curettage contributes to the management of patients with abnormal cervical cytology. STUDY DESIGN: Three hundred four consecutive patients being evaluated for abnormal squamous cervical cytology at the University of Virginia underwent routine endocervical curettage at the time of diagnostic colposcopy. RESULTS: Among the 304 patients evaluated colposcopically, the information provided by endocervical curettage changed treatment planning in only 13, or 4.27%. In none of these 13 patients would the omission of endocervical curettage at the time of diagnostic colposcopy have resulted in overlooking an occult invasive or microinvasive carcinoma. CONCLUSION: This prospective analysis did not find the information provided by the routine application of endocervical curettage at the time of diagnostic colposcopy to be helpful in the subsequent treatment planning of patients undergoing evaluation for cervical intraepithelial disease.

Carcinoma, Squamous Cell↗
PubMed2004

Colposcopic proficiency-disease spectrum in a single family practice colposcopists' clinic.

PURPOSE: We sought to assess colposcopic proficiency in a family practice teaching clinic. METHODS: Subjects were a prospective cohort of women age 13 to 68 who were colposcopy clinic attendees from 1991 to 2002. Data recorded on each subject included demographic variables, sexual history, history of sexually transmitted diseases, reason for referral to colposcopy, Pap smear results, colposcopic impression, colposcopic biopsy results, and diagnoses. The Kappa statistic was used to measure agreement between clinical colposcopic assessment and biopsy results. RESULTS: Eight hundred twenty-six patients were enrolled. Compared to biopsy, colposcopic impression overall correctly predicted normal cervical biopsy in 55.8% (95% CI: 45.8%, 65.8%) of cases, and predicted abnormal biopsy 84.9% (95% CI: 81.6%, 88.1%) of the time. Colposcopic impression of low-grade squamous intraepithelial lesion (LSIL) correctly predicted LSIL on biopsy in 64.6% of cases, and correctly predicted the absence of LSIL 74.2% of the time. Colposcopic impression of high-grade squamous intraepithelial lesion (HSIL) correctly predicted biopsy results of HSIL in 70.05% of cases (Kappa = 0.544, P<.0001). There was a 12.7% error rate in discriminating normal from LSIL (Kappa -.258, with P<.0001). CONCLUSION: Family physicians perform colposcopy with good correlation between colposcopic impression and subsequent histology.

Adolescent↗
PubMedDate not supplied

Activity level and process indicators of organised programmes for cervical cancer screening in Italy.

The target population of Italian organised cervical screening programmes that were active (that invited at least 1000 women) in 2004 was 10,206,741 women, corresponding to 64% of the Italian female population in the 25-64 year age range. This proportion was 66%, 83% and 49% in Northern, Central, and Southern Italy respectively. Some 27% of this target population was invited during 2004. Among women invited in 2004, 37.7% had cytology within organised programmes up to April 2005 (46.2%, 36.0% and 26.2% in Northern, Central, and Southern Italy respectively). It must be kept in mind that many women have spontaneous tests that are not registered in organised programmes. Further data on women invited in 2003 were collected as aggregated tables, provided by the local screening registration systems. We obtained data from 99 programmes with an overall target population of 8,698,480 women. At least 70% of programmes could provide data for most indicators. Overall, 3.2% of smears were classified as unsatisfactory. At a national level 6.6% of women was advised to repeat cytology and 62.2% of them actually did. However 13/71 programmes recommended repeat cytology to > 10% of screened women. Nationwide, 2.6% of screened women were referred to colposcopy. The Positive Predictive Value (PPV) of detecting a biopsy-proven Cervical Intraepithelial Neoplasia grade 2 (CIN2) or more severe among women referred because of cytology "Atypical Squamous Cells of Undetermined Significance" or more severe was 15.0%. There was however a relevant variability: 9/90 programmes had a referral rate >5%. There was an inverse correlation between referral rate and PPV. Compliance with recommended colposcopy was 86% (91% among women with high-grade cytology). The raw detection rate of biopsy-proven CIN2+ was 2.7 per 1000 screened women (2.8 per 1000 when standardised on the Italian population). In conclusion, during 2004 there was a further increase of active organised programmes, especially in Southern Italy. This is important, as spontaneous activity is known to be low there. Despite this rise, quality indicators were stable. However, in a few programmes, the use of excessively broad criteria in the interpretation of cytology decides an excessively high rate of referrals to colposcopy.

Adult↗
PubMed1991

Inflammatory atypia on cervical smears. A diagnostic dilemma for the gynecologist.

In light of the current controversy on the significance, follow-up and management of women with cervical smears showing "inflammatory atypia" (IA), a study was conducted to correlate the initial cytologic diagnosis of IA with the follow-up findings in colposcopically directed cervical biopsies and smears. From March 1988 through June 1989, 70 women had two consecutive smears reported as IA; all underwent colposcopy and cervical biopsy. In 58 patients (83%) the biopsies and smears obtained during colposcopy were negative for condyloma and/or cervical intraepithelial neoplasia (CIN). Ten patients (14%) had condylomas, and two (3%) had condylomas with CIN (one CIN I and one II). The initial IA smears from those 12 patients were reviewed retrospectively: 2 showed condylomas (they had been undercalled), 5 were "suggestive of condyloma" (the atypical cells were too few or poorly preserved for a definitive diagnosis), and 5 showed IA. None showed cytologic evidence of CIN, most probably because of sampling error. Our results suggest that colposcopy is warranted after two consecutive diagnoses of IA on cervical smears, considering that 17% of the patients in our study showed underlying intraepithelial lesions of the cervix.

Adolescent↗
PubMed1991

Genital human papillomavirus infection in men. Diagnosis and treatment with a laser and 5-fluorouracil.

One hundred twenty-eight consecutive men, sexual partners (for more than six months) of women treated for genital condylomata acuminata, were evaluated with colposcopy to assess the percentage of infected men among the couples. Ninety-three (73%) of the men were found to have a genital human papillomavirus infection on colposcopically directed biopsies. All but one patient were treated with outpatient colposcopically guided laser vaporization under local anesthesia (one patient with extensive condylomata required general anesthesia). Two weeks after laser surgery, 5% 5-fluorouracil cream, used in the genital area, was initiated on a weekly basis for two months and every other week for two more months. Patients were followed in the clinic with colposcopy performed every eight weeks for six months to evaluate the regimen's results. Thirty-seven (40%) of the 93 men had "clinically" apparent genital HPV infection, and 56 (60%) of the 93 had "subclinical" disease (as determined with colposcopy). The majority of the patients (87 of 93, or 94%) responded to one laser treatment followed by 5-fluorouracil cream and had no visible lesions at six months. Colposcopic evaluation of the male partners of infected women and laser surgery followed by topical 5-fluorouracil therapy appear to be safe and effective in controlling genital HPV infection.

Acetates↗
PubMed1990

[Diagnosis and follow-up study of human papillomavirus infection in benign epithelium and mild dysplasia of the uterine cervix].

In this study, we evaluated the sensitivity of cytology, colposcopy and the dot blot method (Vira Pap, Vira Type) for the screening of HPV infection in benign epithelium and mild dysplasia of the uterine cervix, and then investigated subsequent changes in HPV DNA in the lesion. The HPV infection detection rates for cytology, colposcopy and the dot blot method were 14/46 (30.4%), 30/46 (65.2%) and 35/46 (76.1%), respectively. Cases where HPV DNA was negative with the dot blot method but HPV infection was suspected with cytologic and colposcopic examination were 3/6 (50.0%) in the undigestive type except for HPV types 6, 11, 16, 18, 31, 33 and 35. HPV DNA disappeared after 3-6 months in persistent cases with histologically benign epithelium in the one year follow-up. In persistent cases of mild dysplasia followed up histologically for one year from the time of the first visit showed differences between negative and positive cases of HPV DNA after 1 year. In 2 progressive cases (HPV 31 and 16 types) HPV DNA in the cervix was detected continuously. We consider that the dot blot technique is a valuable method for identifying human papillomavirus infection. However, detection of undigestive HPV types by the dot blot method was poor. Therefore, the joint use of cytology, colposcopy and the dot blot method seems to be a valuable screening technique. Individual variations in the clinical course of the high risk group appear to reflect profound differences in the effectiveness of host responses. Therefore, cases where continuous HPV DNA was observed in the high risk groups should be followed up for a long period.

Adult↗
PubMedDate not supplied

Routine colposcopic survey of patients with squamous atypia. A method for identifying cases with false-negative smears.

Routine colposcopy was performed on 376 women with cervical squamous atypia (originally reported as "inflammatory atypia"). Colposcopy showed no abnormalities in 240 cases and a lesion in 136 cases; the latter were sampled by colposcopy-guided biopsy. The biopsy samples showed evidence of human papillomavirus (HPV) infection and/or grade I cervical intraepithelial neoplasia (CIN I) in 42 cases (11.1%), CIN II in 4 cases (1.1%) and CIN III in 5 cases (1.3%); the other 85 biopsied cases were histologically negative. Most cases of HPV/CIN I (35 of 42) and all of the cases of CIN II-III occurred in women under the age of 40. The detection rates were 4.4% for CIN II-III in women under the age of 40, 4.0% for HPV/CIN I in women 40 and older and 17.2% for HPV/CIN I in women under the age of 40 (P less than .001). It thus appears that women under the age of 40 who show cytologic evidence of squamous atypia would benefit from colposcopic examination.

Adult↗
PubMedDate not supplied

Improving the sensitivity of cervical cytologic screening. A comparison of duplicate smears and colposcopic examination of patients with cytologic inflammatory epithelial changes.

During a ten-month period, 264 cervical cytologic specimens were submitted in duplicate to two separate cytology laboratories. An attempt was made to perform colposcopy on all 45 patients reported as having an abnormality by either laboratory. All but one patient with a cytologic diagnosis of cervical intraepithelial neoplasia (CIN) underwent colposcopy, as did 68% of the patients with a diagnosis of nondysplastic atypia (inflammatory epithelial changes [IEC]). Five cases of histologically verified CIN were found by colposcopic study of patients with a cytologic diagnosis of CIN; two additional cases were found by colposcopic study of patients with a cytologic diagnosis of IEC. On the assumption that patients not colposcoped were not systematically different from the others with IEC, the screening sensitivities for both laboratories and for cytology followed by colposcopy of IEC cases were estimated. A statistically significant improvement in screening sensitivity was achieved by colposcopic examination of patients with IEC. This conclusion was tempered by a Bayesian analysis that suggested that some of the apparent improved sensitivity could be due to falsely positive biopsy reports. Despite potential benefits, it is premature to recommend universal colposcopic examination of patients with cytologic reports of inflammatory epithelial changes.

Cervix Uteri↗
PubMed1989

Squamous atypia on cytology. The influence of age.

The optimal management of squamous atypia on cytology has not been determined. Colposcopy has been recommended because of the high false-negative rate of cytology. To evaluate colposcopy, 1,074 consecutive, nonpregnant women presenting with squamous atypia on cytology were examined prospectively with colposcopy and simultaneous repeat cytology. No specific treatment was given prior to evaluation. Biopsy and endocervical curettage were performed when clinically indicated. Two hundred two women (18.8%) had abnormal cervical or vaginal biopsies, 74 had human papillomavirus, and 128 had cervical intraepithelial neoplasia with or without associated papillomavirus infection. Invasive cancer was not detected. Repeat cytology suggested intraepithelial neoplasia in 60 women, 37 (61%) of whom had positive biopsy findings. Such biopsy findings were obtained in 89 of 306 women (29.1%) with repeat squamous atypia on cytology and in 76 of 708 women (10.8%) with repeat negative cytology. When the data were stratified in terms of age, 184/787 (19.6%) abnormal biopsies occurred in women less than or equal to 40 years of age and 18/287 (6.3%) in women greater than or equal to 41. Squamous atypia on cytology should not be ignored. However, women greater than or equal to 41 are at lower risk of having colposcopically detectable abnormalities and can be followed more conservatively.

Adolescent↗
PubMed1988

The significance of atypical cervical smears.

The significance of and approach to cervical smears showing cytologic atypia without dyskaryosis remains controversial. A review of 139 colposcopies performed for atypical cytology revealed cervical intraepithelial neoplasia (CIN) in 25%. Of the CIN found, 85% was CIN I and 15%, II. No case of more advanced disease was found. The type and severity of the cytologic atypia correlated with the presence of CIN. However, all degrees of atypia were found to have a significant association with CIN, and the degree of cytologic atypia therefore cannot be used to exclude colposcopy in any women with atypical smears. This study suggested that cytologic atypia is an expression of early CIN, and the results support our endorsement of routine colposcopy in the evaluation of women with persistent atypia.

Adolescent↗
PubMed1985

Colposcopic accuracy in the diagnosis of microinvasive and occult invasive carcinoma of the cervix.

One hundred eighty patients with microinvasive and occult invasive squamous cell carcinoma of the cervix who were examined by colposcopy during a ten-year period are reviewed. Forty-two percent of patients with microinvasive carcinoma and 28% of patients with occult invasive carcinoma had an unsatisfactory colposcopic examination. Colposcopy led to the correct management in 90% of patients with occult invasive cancer and in 84% of patients with microinvasive carcinoma. Colposcopy appeared to be less sensitive in detecting microinvasive lesions than in detecting occult carcinoma. Two-thirds of the errors made were colposcopist-related, either failure of interpretation or protocol violation. A small but definite group of patients will have lesions whose colposcopic appearance is not sufficiently distinct or characteristic to permit a diagnosis of early invasion.

Adult↗
PubMed1985

The value of endocervical curettage as part of the standard colposcopic evaluation.

Whether to perform endocervical curettage (ECC) as part of a routine colposcopic examination in patients with an abnormal Papanicolaou smear remains controversial. Some studies consider ECC an essential part of a colposcopic examination regardless of the level of the squamocolumnar junction (SCJ); others consider it superfluous in cases where the SCJ can be visualized. Between January 1980 and December 1982, 278 new patients with abnormal Papanicolaou smears underwent colposcopy. Directed biopsies established the degree of cervical intraepithelial neoplasia (CIN) and ruled out invasive disease. ECC was done on every patient. A total of 51 patients (18%) had a positive ECC. Seven patients could not be evaluated because their records were incomplete. Of the 44 evaluable patients, 32 (73%) had satisfactory colposcopy. In the remaining 12 (27%) the upper limit of the transformation zone could not be seen clearly; in that group the degrees of CIN on colposcopic biopsy and ECC were in agreement in two cases; ECC revealed the degree to be less severe in four cases and more severe in six (50%). In the group with satisfactory examinations, 15 had the same degree of CIN on colposcopic biopsy and ECC; ten had less severe and seven (22%), more severe degrees of CIN on ECC. Of greatest clinical importance was that, overall, 11.5% had a positive ECC despite a satisfactory colposcopic examination. This study indicated that ECC provides unique and important information, justifying its inclusion as part of the standard evaluation of every patient undergoing colposcopy for abnormal cervical cytology.

Biopsy↗
PubMed1979

Development of DES-associated clear-cell carcinoma: the importance of regular screening.

Because the rate of malignancies in young women exposed in utero to diethylstilbesterol (DES) is low, appropriate population screening methods have not been established. A case is presented that is believed to represent the first reported instance of a DES-exposed daughter who developed clear cell adenocarcinoma of the vagina after initially negative examinations. The patient was followed with Papanicolaou smears, pelvic examinations, and colposcopy every 6 months for 2 years prior to the discovery of malignancy. Initially negative, Papanicolaou smears successfully predicted the presence of an early adenocarcinoma. Palpation aided by colposcopy allowed directed biopsy of the small asymptomatic lesion. This case underscores the necessity for frequent vaginal cytologic smears and pelvic examinations at intervals no greater than 6 months. Colposcopy is indicated to direct biopsies when an abnormal cytologic smears is reported or when abnormal bleeding or discharge occurs. Biopsy of any palpable lesion is mandatory.

Adenocarcinoma↗
PubMed1983

[Comparison between colposcopic and cytologic findings in relation to clinical and histologic diagnoses in carcinoma in situ].

From 1977 to 1979 95 cases of carcinoma in situ had been detected at the Gynaecological Department of the Medical Academy of Erfurt. In 81 of these women there was a cytological examination before treatment. The accuracy of cytology and colposcopy was opposed the histological diagnosis in these selected cases. An agreement of colposcopy, cytology and histological findings could be found in 70 cases. In 6 cases colposcopy and in 4 cases cytology was wrong. Only in one case both examination methods failed.

Carcinoma in Situ↗