Positive cervical smear with subsequent normal colposcopy and histology--frequency of CIN in a long-term follow-up

Use of the HPV MLPA assay in cervical cytology for the prediction of high grade lesions

Current screening methods for uterine cervical cancer such as Papanicolaou smears and/or high risk human Papillomavirus (HR-HPV) detection have a high negative predictive value but a low positive predictive value for the presence of high grade cervical lesions. Therefore, new parameters are needed to reduce the rate of unnecessary referrals for colposcopy. The predictive value of the HPV multiplex ligation-dependent probe amplification (MLPA) assay, which can assess simultaneously HPV16/18 viral load and viral integration, was evaluated. The assay was applied to 170 cervical cytological samples, and the results were correlated with the matching histological follow-up. The GP5+/6+ assay and qPCR were used as a control for HR-HPV typing. The MLPA assay classified a higher percentage of cases as high-risk (high-viral load and/or viral integration) with higher grades of dysplasia. There was a high correlation between the HPV MLPA assay and qPCR for viral load and HPV genotyping, and between the MLPA assay and the GP5+/6+ assay for HPV genotyping. The sensitivity and specificity of the HPV MLPA assay for the detection of high-grade lesions were 44% and 93%, respectively. This study demonstrates that the HPV MLPA assay can reliably detect HPV 16/18, viral load, and viral integration in cytological samples. Also, high-risk classification correlated well with the presence of high-grade dysplasia. However, for the implementation of the MLPA assay into clinical practice, additional HR-HPV types need to be included to increase the sensitivity of the assay, and thereby increase its negative predictive value.

Is it clinically useful to repeat a pap smear at colposcopy?

OBJECTIVE

To assess the role of repeating a Pap smear at the time of colposcopy performed within 6 months of a referent Pap smear.

MATERIALS AND METHODS

A clinical database was queried to identify colposcopies performed within 6 months of a referent abnormal squamous Pap smear at which time a repeat Pap smear was obtained. All Pap smears and cervical biopsy specimens were interpreted at an affiliated hospital laboratory. Referent Pap smears, repeat Pap smears, colposcopic cervical biopsy results, patient age and ethnicity, and the interval since the referent Pap smear were tabulated. A hierarchy of Pap smear results was defined a priori to characterize the relative differences between the referent and repeat Pap smears. Results of repeat smears and cervical biopsies were contrasted with the referent Pap smears. An assessment was made of the clinical usefulness of the repeat Pap smear.

RESULTS

Four hundred ninety-eight patients contributed 536 colposcopies with repeat Pap smears within 6 months of the referent smear. Pap smears obtained at colposcopy predominantly were either of lower severity (52.2%) or unchanged (42%). Management of 8 of 498 patients (1.6%) was influenced by the results of the repeat Pap smear. The outcomes for six recommendations for a loop electrosurgical excision procedure included three cases of diagnoses of potentially reversible conditions.

CONCLUSIONS

The evidence for the clinical usefulness of repeating a Pap smear at colposcopy for a squamous cytologic abnormality under the defined study parameters is noncompelling. Continued surveillance is a critical component of management.

Outcome After Negative Colposcopy Among Human Immunodeficiency Virus–Infected Women With Borderline Cytologic Abnormalities

OBJECTIVE

To estimate the risk of and risk factors for progression among human immunodeficiency virus (HIV)-seropositive women with abnormal cervical cytology but negative colposcopy.

METHODS

In a prospective cohort study, 391 HIV-seropositive and 103 seronegative women with cervical cytology read as atypical squamous cells (ASC) or low-grade squamous intraepithelial lesion (LSIL) but negative colposcopy were followed up for a mean of 4.0 years with cytology at 6-month intervals. Colposcopy was prescribed for any epithelial abnormality.

RESULTS

Progression to CIN2, CIN3, high-grade SIL/severe dysplasia, or cancer occurred in 47 (12%) HIV-seropositive women and 4 (4%) HIV-seronegative women (P = .02). Progression to CIN1 was seen in an additional 12 HIV-seropositive women and 1 seronegative woman. In multivariate analysis, high-risk but not low-risk HPV detection (hazard ratio [HR] 2.46-95% confidence interval [CI] 1.18-5.12, P = .02 for high risk, HR 1.41, 95% CI 0.62-3.21, P = .42 for low risk), satisfactory colposcopy (HR 2.01, 95% CI 1.11-3.65, P = .02), and non-Hispanic African-American ethnicity (HR 5.08, 95% CI 1.72-14.98, P = .003) were the only factors associated with progression, while HIV serostatus was marginally significant (HR 2.53, 95% CI 0.85-7.50, P = .09).

CONCLUSION

Human immunodeficiency virus-seropositive women with negative colposcopy after borderline cytology face a higher risk of progression than seronegative women, but the absolute risk is low and becomes nonsignificant after controlling for HPV risk type, ethnicity, and colposcopic findings. Observation is appropriate.

LEVEL OF EVIDENCE

II-2.

Clinical perception of disease probability associated with Bethesda System diagnoses

The degree to which clinical perceptions of Papanicolaou smear sensitivity contribute to patient mismanagement is uncertain. A voluntary, anonymous questionnaire was mailed to 350 obstetricians/gynecologists (OGYNs) and 350 other primary care providers (PCPs) located in Pennsylvania or Ohio. The clinicians estimated the probability of no disease, dysplasia, and invasive carcinoma for 1 of 7 Bethesda System diagnoses. Differences in probability estimates between provider types and between the clinicians and medical literature data were measured. The response rate was 22.7%. Compared with published values, clinicians estimated similar disease probabilities for many diagnoses. However, for some diagnoses, the probability estimates differed considerably from published values (e.g., overestimation of dysplasia and invasive carcinoma for benign diagnoses and underestimation of dysplasia for some dysplasia diagnoses), and such errors could contribute to patient mismanagement. OGYNs generally were more accurate in probability estimates than PCPs. Methods to convey more accurately these diagnostic disease probabilities should be examined.

Prognostic implications of cervical intraepithelial neoplasia in a single cervical smear. an age-matched case-control study of women with negative smear histories

Our aim was to investigate the prognostic implications of a single cervical smear showing cervical intraepithelial neoplasia (CIN) in a group of women with a previous series of negative smears, and to estimate their risk of developing histologically confirmed CIN 3. A retrospective case-control study was set up. It consisted of 171 cases and 513 age-matched controls, all with at least 3 negative and no positive smears between 1981 and 1988 inclusive. In all cases CIN had been diagnosed on cytology in 1989, while the controls had remained negative. The women were followed up to the end of 1995. The outcome was recorded in terms of regression, progression, persistence or surgical treatment. In women with a single smear showing CIN 1 or 2, the risk of developing histologically proven CIN 3 was 14 and 26 times that in women with negative smears. Negative control smears in the short term did not exclude subsequent progression. Thus women with a single cervical smear indicating CIN 1 had a greatly enhanced risk of producing a lesion that demanded intervention. Such cases should be observed closely with repeat smears over a period of at least 6 years.

Clinical role of HPV testing

The subjectivity of morphologic methods contributes to a "swamping" of colposcopic services, excessive costs, overdiagnosis, and overtreatment. HPV DNA testing provides the objectivity required to clarify difficult patient management issues, including follow-up, for low-grade cytologic abnormalities (ASCUS and LSIL), noncorrelating (nonconfirmed) Pap smears, evaluation of nondiagnostic lower genital tract lesions, and cytology and histology laboratory quality assurance. Additionally, favorable preliminary data on HPV testing as a primary screen raise the exciting prospect of potentially lowering costs of cervical cancer-screening programs, while further decreasing the incidence of cervical cancer.

Screening for cervical cancer

It is well accepted that conscientious and widespread use of cervical cytology will significantly decrease the incidence and mortality rates of cervical cancer. The Papanicolaou smear for cervical cytology fulfills all the criteria for an ideal screening test. Not only is it cost effective, acceptable to most patients, and adaptable to widespread screening, it is sensitive enough to detect preinvasive disease resulting in decreased morbidity and mortality. Nevertheless, in developing countries cervical cancer still occurs at epidemic proportions, where an estimated 460,000 new cases per annum will be diagnosed, a significant proportion of which will be in advanced stages. First world notions pertaining to screening have proved unrealistic for the developing health care system of third world nations. This article provides an overview of screening for cervical cancer and considers cytological smearing, cervicography and direct visualization of the cervix, be it without or with the application of 4 percent acetic acid.

Spontaneous evolution of intraepithelial lesions according to the grade and type of the implicated human papillomavirus (HPV)

Because of the fact that any meaningful classification should bear a close relationship to the biological behavior of the lesions, the usefulness of all new classifications of cervical precancer lesions can only be established by well controlled prospective follow-up studies. However, several methodological and conceptual problems are encountered in the natural history studies conducted during the past several decades. While reviewing the available prospective follow-up studies on cervical intraepithelial neoplasia (CIN), Ostör (1993) found 3529 cases of CIN 1, of which 57% showed regression, persistence was found in 32%, progression to CIN III in 11%, and progression to invasive cancer in 1% of cases. The corresponding figures for CIN II were 43%, 35%, 22%, and 5%, respectively. The recognition of the association between human papillomavirus (HPV) and CIN has further complicated the assessment of the natural history of cervical precancer lesions. Results from the early prospective follow-up studies are remarkably consistent, however. Progression from HPV-NCIN (i.e., koilocytosis without CIN) to CIN I or greater was reported for 18 (8%) of 232 women followed by Syrjänen et al. for an average of 25 months, for 26 (8%) of 314 women followed by de Brux et al. (1981) for 15 to 18 months, and for 113 (13%) of 846 women followed for up to six years by Mitchell et al. During a 42-month follow-up period, 10% progression rate was found in 1269 women with HPV-CIN I, and in 17% of 762 women with HPV-CIN II by de Brux et al. (1983). The spontaneous regression rates were 53% and 39% in these cohorts, respectively. This is fully consonant with our experience from an almost 14-year follow-up of 530 women in Kuopio, where the spontaneous regression rate seems to increase in parallel with the extent of the follow-up time, currently being 66.7% for HPV-NCIN and 55.7% for HPV-CIN I. The figures for progression are 6.3% and 14.2%, respectively. It is obvious that the probability of a cervical precancer lesion to progress into an invasive disease increases with the severity of the atypia. Another distinct prognostic factor is HPV type, HPV 16 lesions possessing a significantly higher risk for progression than infections by other HPV types. The follow-up data also indicate, however, that even the high grade lesions may spontaneously regress, which should have important implications in therapy. The continuous problem still remains; these natural history observations only apply to a large series of women but are of little help in predicting the disease outcome in individual women.