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PubMed1980

Effects of dilute acetic acid on cancer cytology. I. Effects on normal tissue.

The simultaneous use of exfoliative cytology and colposcopy is occasionally indicated in the detection of cervical cancer. When there is a fragile epithelium in the perimenopausal or postmenopausal woman, the taking of a cytology preparation may cause sufficient vascular injury so that subsequent colposcopy is not possible. A series of patients was subjected to primary colposcopy followed by cytologic testing in order to evaluate the effect of dilute acetic acid on the Papanicolaou preparation. The minimal alterations caused by dilute acetic acid are easily recognized and do not impair the validity of the cytologic technique for cancer detection.

Acetates↗
PubMed1995

Towards a rational cervical cytology screening strategy. Case study of a peri-urban settlement.

OBJECTIVES: To assess cervical cytology screening activity in a peri-urban settlement near Cape Town, with a view to informing rational policy development. METHOD: Total and age-specific prevalence rates of women who had been screened, relative prevalence by age group of women who had not been screened, and yield of screening were estimated from cytopathology laboratory records and available demographic data. Age-specific prevalence rates among women who had been screened were compared with age at presentation with cervical cancer at the referral hospital. Attendance for colposcopy follow-up was assessed from colposcopy clinic records. RESULTS: The number of smears taken and the prevalence of women who had been screened peaked in the 20 - 24-year age group, and declined to low levels in those over the age of 40 years. The relative prevalence of those who had not had a smear exceeded 9 in all age groups over 39 years, compared with women of 20 - 24 years. Smears which showed signs of CIN III, malignancy or possible malignancy comprised 0.13%. Thirty-six per cent of women booked for colposcopy did not attend. CONCLUSIONS: Efficiency of screening could be improved by emphasising coverage of higher-risk age groups, e.g. women over the age of 30 years, and better follow-up.

Adolescent↗
PubMedDate not supplied

Management of suboptimal cytologic smears. Persistent inflammatory smears.

In this study, cytologic smears from 161 women presenting with persistent inflammation were reviewed and the cytologic diagnoses compared with the colposcopic and biopsy findings. When colposcopy was performed and information was available for evaluation (102 cases), 62.7% (64 cases) had abnormal colposcopic findings requiring treatment. The similar figure for biopsy was 76.2% (64 of 84 cases). Of significance was the proportion of major advanced abnormalities requiring immediate treatment. Colposcopy and biopsy, respectively, revealed 7.9% and 19.1% of cases with high grade squamous intraepithelial lesions (CIN 2) or worse. These striking data reinforce the importance of recommending colposcopy as a means of managing persistent inflammation in cytologic smears.

Adolescent↗
PubMed1993

[Current indications for colposcopic examination].

OBJECTIVE: It has become necessary to set out exactly the indications for colposcopic examination and to improve out-patient therapy. A response has been made to the ever increasing pre-cancerous pathological conditions of the lower genital tract. TYPE OF STUDY: A review of the pathological conditions of the lower genital tract has led to colposcopic examinations being carried out to work out how far grounded its indications are. The authors particularly lead to the future for colposcopy and histology of so called "atypical" cytology. MATERIAL: A review of the literature and a retrospective study of the agreement between the cytology and the histology in 1,454 patients who were examined and followed up at the centre for laparoscopy and colposcopy between 1.1.1987 and 31.12.1991. THE PRINCIPLE: A study of the information is being gathered about the cytological, colposcopic and histological diagnoses. PRINCIPLES RESULTS: Dysplasias diagnosed cytologically were confirmed in 95% of cases by colposcopic examination and by the results of directed biopsy. In over 90% cases of smears showing "atypical" cells the colposcopy confirmed the pathology that was found and in more than 85% of cases the histological examination confirmed a papillomavirus lesion or a dysplasia of the cervix or elsewhere in the lower genital tract. CONCLUSION: Over and above the indication for colposcopic examination, cytological dysplasias were found and to were condylomata of the lower genital tract or leukoplakia of the vulva, and one has to add "atypical" smears. Furthermore repeating a smear in cases of atypical cytology is useless, and can be deceptive. Systemic control of the vulva and vagina has to be carried out when the cervix is examined because there is a frequent association of dysplasic lesions and there is a possible presence of isolated extracervical lesions when cytologically pathological smears are found.

Ambulatory Care↗
PubMed1993

[Accuracy of pretherapeutic diagnosis of early invasive cervical carcinoma].

In 114 women treated at the First Department of Gynecology Medical Academy in Cracow, between the years 1967-1985 there was compared the agreement of the histological examination of a colposcopy directed biopsy specimen with the histological examination of the operative specimen in cervical carcinoma with early invasion. In 103 cases (90.4%) histological examination of a guided biopsy specimen of early invasive carcinoma confirmed the results of the operative specimen. In 1 case the operative specimen confirmed severe dysplasia as in the guided biopsy specimen early invasive carcinoma. In 10 cases the guided biopsy specimen confirmed CIN 3 (6 cases severe dysplasia and 4 cases ca in situ), the results of operative specimen confirmed early invasive carcinoma. In 5 out the above 10 cases, the results were altered due to a 3-8 mouth delay of surgery. The divergence regards to the remaining 5 cases (4.4%). This high agreement of histological examination of a colposcopy guided biopsy specimen and operative specimen shows a significant accurate meaning of colposcopy in confirming early lesions of cervical carcinoma.

Adult↗
PubMed1993

Evaluation of the cervical canal with the endocervical brush.

OBJECTIVE: To evaluate and compare the cytologic information obtained from the endocervical brush and the histologic information obtained from the standard endocervical curettage (ECC) used to evaluate the endocervical canal in patients with an abnormal Papanicolaou test. METHODS: Three hundred eighty-eight patients underwent evaluation of an abnormal Papanicolaou test with a repeat Papanicolaou test, a separate endocervical brush test, colposcopy, directed biopsies, and ECC. The study group comprised 101 patients who subsequently underwent conization and/or hysterectomy. The brush and ECC results were evaluated against the final pathologic findings. RESULTS: Sixty-five patients had a satisfactory colposcopy and 36 had an unsatisfactory colposcopy. Results for these two groups are reported separately. For the total group, the sensitivities of the ECC and brush were 49 and 93%, respectively (P < .001); the specificities were 82 and 26% (P < .001), the positive predictive values were 69 and 52% (P = .99), and the negative predictive values were 65 and 82% (P = .004). CONCLUSION: The endocervical brush appears to be a sensitive test for disease in the endocervical canal but yields a high false-positive rate. The role of the brush in this setting will require further study. The ECC is more specific but is also a suboptimal test for identifying disease in the endocervical canal.

Adolescent↗
PubMed1993

The adequacy of management of women with CIN 2 and CIN 3 Pap smear abnormalities.

OBJECTIVE: To assess the adequacy of management of Sydney women with Papanicolaou (Pap) smears showing cervical intraepithelial neoplasia (CIN) grades two and three. DESIGN: A prospective descriptive study of patient management. METHOD: All 206 general practitioners (GPs) who sent Pap smears which were reported as CIN 2 or CIN 3 to three Sydney laboratories between January and June 1990 were included in the sample. The GPs were contacted and management details for the women collected. The adequacy of management was evaluated by comparing it with management guidelines constructed for the study. Management steps were: notification of results, referral for colposcopy, biopsy, treatment and follow-up. The number of women reaching each step, expressed as a proportion of those women who should have reached that step according to the management guidelines, was calculated. The points where management was inadequate were established and the reasons explored. RESULTS: All GPs provided management information about their patients. Ninety-nine per cent of women (95% confidence intervals [CI], 98%-100%) were informed of their Pap smear result and 94% (CI, 90%-97%) of the total sample subsequently underwent colposcopy. Ninety-three per cent (CI, 88%-97%) of the 160 women definitely requiring histological diagnosis had this and 98% (CI, 94%-100%) of the 140 women definitely needing treatment were treated. Following treatment (or equivalent if not indicated) 80% of women (CI, 74%-86%) were known to have had a follow-up Pap smear but only 31% (CI, 24-38%) of women needing follow-up colposcopy were known to have had it. At the time of the study (on average, 17 months after the index Pap smear) only 60% (CI, 54%-67%) of women were still being followed up. CONCLUSIONS: Virtually all women with the more severe cytological abnormalities are being referred by their GPs for further investigation and treatment. However, follow-up after treatment is often inadequate. The responsibility for this follow-up needs to be clarified, as well as communication about it between women, their GPs and gynaecologists. A cytology registry could increase the proportion of Sydney women known to be receiving follow-up.

Adult↗
PubMed1993

The use of large-loop excision of the transformation zone in an inner-city population.

OBJECTIVE: To determine whether large-loop excision of the transformation zone (LLETZ) can be used in our population to treat patients in a routine colposcopy clinic without diminishing the capability to see the large number of patients who require care, and to compare these results to our previous experience with laser surgery. METHODS: Patients found to have squamous intraepithelial lesions on colposcopically directed biopsies were offered treatment with LLETZ during counseling regarding their biopsy findings. Procedures included "ablation equivalents" and "cone biopsy equivalents" using local anesthesia. Follow-up examinations were used to determine cure and included cytology, colposcopy, and directed biopsies when indicated. The cure rate was compared to our previous experience with laser surgery. RESULTS: Two hundred thirty-six patients were treated in the colposcopy clinic without diminishing the capability to see all patients requiring care. Complications were few. The mean (+/- standard deviation) follow-up period was 50.7 +/- 25.3 weeks. The overall cure rate of 91.3% (95% confidence interval [CI] 87.1-95.5) was not influenced by the severity of the disease, but positive endocervical margins significantly lowered the cure rate to 69.2% compared with those who had negative margins. Before this series, only 73.1% of our patients scheduled for laser surgery returned for treatment. Assuming a 90% cure rate among those who returned, this means that the actual cure rate was only 65.8%. The likelihood of cure was 1.37 times greater (95% CI 1.27-1.52; P < .0001) using LLETZ in the clinic at the time the patient was counseled regarding her biopsy findings than using laser at a later date. In 33 patients, the LLETZ specimen showed no evidence of disease. The relative risk of negative histology was 3.31 (95% CI 1.78-6.13; P < .001) when LLETZ was done for a discrepancy between cytology and histology as opposed to any other indication. Cancer was found on the LLETZ specimen in four patients (two microinvasive, two frankly invasive), but was not suspected preoperatively in any of the patients. CONCLUSION: In our inner-city clinic, treatment with LLETZ at the time the patient was counseled regarding her biopsy findings improved the actual cure rate. The LLETZ procedure can be done safely in a clinic setting without diminishing the capability to care for a large number of patients.

Adolescent↗
PubMed1993

Acetic acid visualization of the cervix to detect cervical dysplasia.

OBJECTIVE: To determine whether acetic acid visualization of the cervix can identify cervical dysplasia and improve detection of lesions missed by Papanicolaou test screening. METHODS: During a 2-year period, patients attending family planning clinics for regular gynecologic examinations had acetic acid applied to the cervix, followed by gross visualization without magnification. Patients with suspicious acetowhite lesions and normal Papanicolaou tests were referred for colposcopic evaluation. Findings from these examinations and corresponding biopsy results were analyzed retrospectively. RESULTS: Eighty-five women were referred for colposcopy because of abnormal acetowhite areas on the cervix. Thirteen patients (15%) had cervical intraepithelial neoplasia (CIN) (nine CIN I, four CIN II), 22 (26%) had koilocytosis, and 16 (19%) had benign histologic findings. In total, 51 patients had suspicious lesions at colposcopy for which biopsies were performed, and 34 (40%) had normal colposcopic examinations. CONCLUSIONS: Acetic acid visualization of the cervix can detect dysplasia otherwise missed by Papanicolaou test screening. However, further refinements in technique are required to decrease false-positive findings and unnecessary referrals for colposcopy.

Acetates↗
PubMed1993

Abnormal cervical cytology in pregnancy: a 17-year experience.

OBJECTIVE: To evaluate the safety and accuracy of colposcopy and colposcopically directed biopsy in pregnant women with abnormal cervical cytology. METHODS: A retrospective analysis of 612 gravidas with abnormal cervical cytology was conducted. Colposcopy and directed biopsy were performed using standard techniques. Two patients underwent diagnostic conization during the second trimester. One hundred twelve patients had procedures that provided a final specimen. Endocervical curettage was omitted. The transformation zone was fully visualized in all patients by the 20th week of gestation. Directed cervical biopsy was performed on the following patients: 1) with colposcopic evidence of invasion or cervical intraepithelial neoplasia (CIN) III, 2) with discordancy between colposcopy and cytology, 3) electing termination of pregnancy, and 4) whose anticipated reliability was even remotely questioned. RESULTS: A colposcopically directed biopsy was performed in 449 patients (73%). Ninety-one patients (15%) did not have biopsies because of normal colposcopic findings, and the remaining 72 patients (12%) had either CIN I or II. Thirty-nine of these patients (6%) were lost to follow-up. Colposcopically directed biopsy and colposcopic impression had a 95% concordancy within one degree of severity; however, 14% of CIN I colposcopic impressions and 54% of normal colposcopic findings turned out to be CIN III and CIN I or II, respectively. Ninety-five percent of the biopsy diagnoses correlated with the final pathology to within one degree of severity. CONCLUSION: The data confirm previous findings that colposcopically directed biopsy is a safe and reliable method of evaluating pregnant patients with abnormal cervical cytology.

Adolescent↗
PubMed1996

[Role of the histologic examination in the diagnosis of cervical intraepithelial cancer].

AIM: Retrospective analysis of preoperative histology examinations in patients with intra-epithelial cancer of the cervix. PATIENTS AND METHODS: Histological examination in 501 cases of cervical dysplasia leading to excision therapy. CONCLUSION: The major contribution of the histological examination is to confirm dysplasia suspected on the basis of cytology and/or colposcopy examinations. It also gives the stage of the dysplasia to orient treatment. However, the choice of a therapy cannot be based on the results of the preoperative histology examination alone. Decisions must be made after comparing all the colposcopy and histology findings. In advanced stage intra-epithelial cancer of the cervix or when the cytology and colposcopy examination give conflicting results, excision would be the preferred choice. These observations confirm the importance of the colposcopic examination.

Algorithms↗
PubMed1996

Evaluation of colposcopic accuracy in diagnosis of cervical neoplasia.

OBJECTIVE: To evaluate the accuracy of colposcopy in the diagnosis of cervical neoplasia. STUDY DESIGN: A four year retrospective study from May, 1991 to May 1995 was conducted in 309 patients with abnormal cervical cytology who had undergone colposcopic examination at the Mc Cormick Hospital. The correlation between cervical cytology and colposcopically directed biopsy (CDB), colposcopic impression and CDB, CDB and subsequent conization or hysterectomy specimens were analyzed. The correlation was accepted as accurate when both reports were either the same or within one-step disparity of pathologic diagnosis and no invasive cancer was missed. RESULTS: In comparison of cervical cytology and CDB, the correlation was accurate in 212 of 241 cases (88%). The CDB was found to be less and more severe than cytology in 16 cases (6.6%) and 13 cases (5.4%) respectively. Colposcopic impression was accurate in 221 of 241 patients (91.7%) when compared to the CDB results. Sixty nine patients had undergone conization. The results of the CDB were comparable with those of the conization specimens in all but 8 patients, giving a total accuracy of 88.4 per cent. Four cases of invasive cancer were missed at the time of colposcopy and biopsy but subsequently diagnosed by conization. Of 67 patients who underwent hysterectomy, the surgical specimens were found to be more advanced than CDB in 4 patients, giving a total accuracy of 94 per cent. Two cases of minimally microinvasive cancer were missed. CONCLUSION: This study confirms the diagnostic value of colposcopy in the management of patients with abnormal cervical cytology.

Adolescent↗
PubMed1997

Vaginal intraepithelial neoplasia (VAIN) following hysterectomy in patients treated for carcinoma in situ of the cervix.

OBJECTIVE: To determine the number of patients with carcinoma in situ of the cervix treated by hysterectomy who proceeded to develop vaginal intraepithelial neoplasia (VAIN) and define whether the subsequent development of VAIN justifies intensive cytology and colposcopy follow-up. MATERIALS AND METHODS: Nine hundred and ninety-three women who were subjected to hysterectomy with CIN, (793 patients had completed 10 years of cytology and colposcopy follow-up) were identified. RESULTS: Forty-one patients with VAIN presented with CIN 3 after hysterectomy. The upper one half of the vagina was the area more affected. The middle age group developed VAIN in the shortest time. Atypical Cells (ASCUS) were found in 42% of these patients. Colposcopy revealed VAIN involving the vault angles of the suture line in 54% of the cases. In 51% of the cases the grade of vaginal abnormality was the same as that of the original lesion in the cervix. CONCLUSION: With such data we would propose screening over a 5-year period. Follow-up should also include colposcopic review during every examination.

Adult↗
PubMed1997

[The detection of papillomavirus by in situ hybridization. Clinico-pathological and virological correlation in patients with squamous intraepithelial lesions of the uterine cervix].

BACKGROUND: Clinical usefulness of human papillomavirus (HPV) detection by molecular techniques is not well established. The aim of the study is to determine, by in situ hybridization, HPV DNA in patients with cervical intraepithelial neoplasia (CIN), assessing the prevalence rate, the association with epidemiologic factors and the correlation with classic diagnostic procedures (cytology, colposcopy and histology). PATIENTS AND METHODS: Among 138 patients diagnosed with CIN, HPV was determined in 75 treated by excisional procedures. All cases underwent pap-smear, colposcopy, and colposcopically directed biopsy. RESULTS: Histologic diagnosis was as follows: 1 cervical condyloma (1.3%); 31 CIN-I (41.3%); 23 CIN II (30.7%), and 20 CIN-III (26.7%). HPV was detected in 31 cases (41.3%), being more frequent in higher histologic grades (35.5%) CIN-I, 43.5% CIN-II and 45% CIN-III). No association between cytologic, colposcopic and histologic diagnoses and HPV positivity was observed. HPV detection in patients with false negative cytologies was lower than in positive ones (p = 0.021). Smoking was the only epidemiologic factor significantly associated to HPV presence (chi 2 for trend = 4.022; p = 0.045). CONCLUSIONS: Clinical usefulness of in situ hybridization for HPV detection remains controversial because of its low sensitivity, and the scarce relationship between its results and those obtained by cytology, colposcopy and histology. Smoking is associated with a higher detection rate of HPV in patients with squamous intraepithelial lesions of the uterine cervix.

Adult↗
PubMed1997

[Value of screening for cervical intraepithelial neoplasia in women treated for adnexitis].

OBJECTIVE: To demonstrate that women treated for PID constitute a population with a specially high incidence of cervical intraepithelial neoplasia (CIN) and who should be screened for CIN. POPULATIONS AND METHODS: Retrospective, non-comparative study of 260 patients treated for PID in the Gynecology-Obstetrics Department of Hôtel-Dieu hospital in Rennes (France) from December 1st, 1989 to May 31st, 1996. CIN screening was performed by smear tests and colposcopy. RESULTS: Cervical lesions were detected in 39 patients (15%): five CIN 3 (including one early-stage microinvasion), twelve CIN 2 and 22 CIN 1 and/or condylomas, i.e., 6.5% high grade and 8.5% low grade lesions. Colposcopy in this case proved to be more effective than smears for screening. DISCUSSION: According to epidemiological studies, sexual behavior is a major risk factor of CIN, due to the role played by sexually transmissible human papillomavirus in their pathogenesis. Because the main risk factor of PID is sexual activity, it is likely that CIN are more frequent in women with PID. Our study clearly established that fact because the prevalence of CIN in the general population is only 0.5 to 4% according to literature reports. CONCLUSION: We are in favor of CIN screening in women treated for PID, and in our view colposcopy is the preferred method.

Adolescent↗
PubMed1998

The cancer registry in the monitoring of cervical screening practice: the neglected value of the Pap smear in patients diagnosed with CIN3 on biopsy.

Patients diagnosed with CIN3 on biopsy without a Pap smear are an inevitable correlate of the extensive utilization of colposcopy as a basic screening test. In a series of 248 CIN3 cases diagnosed on biopsy and notified to the Romagna Cancer Registry between 1986 and 1993, we evaluated the independent association between the Pap smear result and (1) the final histology diagnosis, (2) the first choice treatment, and (3) the appropriateness of hysterectomy. The patients were grouped into the following categories: (1) no smear, ie colposcopy only (n = 40 or 16%), (2) CIN1, CIN2, LGSIL, and minor changes, (3) CIN3 and HGSIL, and (4) carcinoma. In multiple logistic regression analysis, patients without a Pap smear were used as a reference category. Patients with smears reported as CIN1-2/LGSIL or less as well as CIN3/HGSIL had a significantly lower probability of invasive squamous carcinoma (odds ratio = 0.26 for both categories) compared with those not undergoing cytology. The Pap smear result was not a determinant of the first choice treatment. Hysterectomy had a greater probability of being unnecessary if performed in patients with smears reported as showing CIN3/HGSIL (odds ratio = 5.05) or less. In conclusion, this registry-based study demonstrated that the Pap smear had an independent but neglected value in the assessment of cases reported as CIN3 on colposcopy-guided biopsy.

Colposcopy↗
PubMed1998

Visual inspection of the uterine cervix after the application of acetic acid in the detection of cervical carcinoma and its precursors.

BACKGROUND: Organized cervical cytology screening programs are not feasible in many developing countries where cervical carcinoma is an important cause of mortality among adult women. This study compared visual inspection of the cervix after application of 3-4% acetic acid (VIA, or cervicoscopy) with cytology as methods for the detection of cervical carcinoma and its precursors. METHODS: Three thousand women were examined by both VIA and cytology. Those positive on one or both of the screening tests (n = 423) or those who had clinically suspicious lesions even if the tests were negative (n = 215) were invited for colposcopy. Directed biopsies were obtained from 277 of 573 women at colposcopy. Those with moderate dysplasia or worse lesions diagnosed by histology were considered true-positives. Those with no lesions or with reactive or reparative changes at colposcopy and those for whom histology revealed no pathology, reactive or reparative changes, atypia, or mild dysplasia were considered false-positives. The detection rate of true-positive cases and the approximate specificity of the two tests were compared. RESULTS: VIA was positive in 298 women (9.8%), and cytology was positive (for atypia or worse lesions) in 307 women (10.2%). Of the 51 true-positive cases (20 cases of moderate dysplasia, 7 of severe dysplasia, 12 of carcinoma in situ, and 12 of invasive carcinoma), VIA detected 46 (90.1%) and cytology 44 (86.2%), yielding a sensitivity ratio of 1.05. VIA detected five lesions missed by cytology, and cytology detected three missed by VIA; both missed two lesions. The approximate specificities were 92.2% for VIA and 91.3% for cytology. The positive predictive value of VIA was 17.0%, and that of cytology was 17.2%. CONCLUSIONS: These results indicate that VIA and cytology had very similar performance in detecting moderate dysplasia or more severe lesions in this study. VIA merits further evaluation as a primary screening test in low-resource settings.

Acetic Acid↗
PubMedDate not supplied

Improving the follow-up of patients with abnormal Papanicolaou smear results.

A review of the literature on adherence with recommended follow-up after an abnormal screening Papanicolaou smear result reveals that many women do not receive adequate follow-up. Primary care providers can influence the number of women who undergo timely colposcopy or a subsequent Papanicolaou smear by addressing common barriers to follow-up. Physicians should anticipate fears commonly experienced by women when they learn of abnormal Papanicolaou smear results, including fear of cancer, fear of pain during colposcopy, and fear of loss of sexual or reproductive function. An awareness that certain populations are at especially high risk of inadequate follow-up, including black and Hispanic women, women with less than a high school education, and women of low socioeconomic status, can help physicians target their efforts. Practical strategies for improving follow-up include speaking directly with the patient about results, emphasizing the precancerous nature of most lesions, actively preparing the patient for colposcopy by describing the procedure and its complications, and addressing fears about the common treatment options for cervical intraepithelial neoplasia. Office-based reminder systems and educational materials may also be used as adjuncts to personal contact.

Family Practice↗