A population-based study of microinvasive disease of the cervix--a colposcopic and cytologic analysis

Role of FoxP3-positive regulatory T-cells in regressive and progressive cervical dysplasia

PURPOSE

Forkhead Box Protein 3 (FoxP3) is known as a key mediator in the immunosuppressive function of regulatory T-cells (Tregs). The aim of our study was to investigate whether FoxP3-positive Tregs have the potential to act as an independent predictor in progression as well as in regression of cervical intraepithelial neoplasia, especially in patients with intermediate cervical intraepithelial neoplasia (CIN II).

METHODS

Nuclear FoxP3 expression was immunohistochemically analysed in 169 patient samples (CIN I, CIN II with regressive course, CIN II with progressive course, CIN III). The median numbers were calculated for each slide and correlated with the histological CIN grade. Statistical analysis was performed by SPSS 26 (Mann-Whitney U test, Spearman's rank correlation).

RESULTS

An increased FoxP3 expression in CIN II with progression could be detected in comparison to CIN II with regression (p = 0.003). Total FoxP3 expression (epithelium and dysplasia-connected stroma) was higher in more advanced CIN grades (p < 0.001 for CIN I vs. CIN II; p = 0.227 for CIN II vs. CIN III). A positive correlation could be detected between FoxP3-positive cells in epithelium and total FoxP3 expression (Spearman's Rho: 0,565; p < 0.01).

CONCLUSION

Expression of FoxP3 could be a helpful predictive factor to assess the risks of CIN II progression. As a prognosticator for regression and progression in cervical intraepithelial lesions it might thereby help in the decision process regarding surgical treatment vs. watchful waiting strategy to prevent conisation-associated risks for patients in child-bearing age. In addition, the findings support the potential of Tregs as a target for immune therapy in cervical cancer patients.

A randomized trial comparing limited-excision conisation to Large Loop Excision of the Transformation Zone (LLETZ) in cervical dysplasia patients

Objective

To show noninferiority of a limited-excision (resection of the dysplastic lesion only) vs. classical Large Loop Excision of the Transformation Zone (LLETZ).

Methods

In this prospective, randomized, multicenter trial, women with human papillomavirus (HPV) positive cervical intraepithelial neoplasia grade 3 were randomized into two groups (1:1). Primary outcome was the rate of negative HPV tests after 6 months, secondary outcomes included cone size, complete resection rates as well as cytological and histological results after 6 and 12 months. A sample size of 1,000 was calculated to show noninferiority of the limited-excision compared to the LLETZ group using a noninferiority margin of 5%. Enrollment was stopped after 100 patients due to slow accrual.

Results

Patients in the limited-excision group did not show a lower number of negative HPV tests (78% [LLETZ]−80% [limited-excision]=−2%; 90% confidence interval=−15%, 12%). The limited-excision resulted in a substantially lower cone size (LLETZ: 1.97 mL vs. limited-excision: 1.02 mL; p<0.001) but higher numbers of involved margins (LLETZ: 8% vs. limited-excision: 20%). Although postoperative cytological results slightly differed, histological results were similar in both groups. One limited-excision patient received immediate re-conisation, whereas one patient in each group was scheduled for re-conisation after 6 months.

Conclusion

The limited-excision could represent a promising option to reduce the surgical extent of conisations while maintaining oncological safety. The trial was not sufficiently powered to reach statistical significance due to early termination. Nevertheless, the study provides important insights in the feasibility of a limited-excision and could serve as a pilot study for future trials.

Trial Registration

German Clinical Trials Register Identifier: DRKS00006169

Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease

BACKGROUND

The mean age of women undergoing local treatment for pre-invasive cervical disease (cervical intra-epithelial neoplasia; CIN) or early cervical cancer (stage IA1) is around their 30s and similar to the age of women having their first child. Local cervical treatment has been correlated to adverse reproductive morbidity in a subsequent pregnancy, however, published studies and meta-analyses have reached contradictory conclusions.

OBJECTIVES

To assess the effect of local cervical treatment for CIN and early cervical cancer on obstetric outcomes (after 24 weeks of gestation) and to correlate these to the cone depth and comparison group used.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, 2017, Issue 5), MEDLINE (up to June week 4, 2017) and Embase (up to week 26, 2017). In an attempt to identify articles missed by the search or unpublished data, we contacted experts in the field and we handsearched the references of the retrieved articles and conference proceedings.

SELECTION CRITERIA

We included all studies reporting on obstetric outcomes (more than 24 weeks of gestation) in women with or without a previous local cervical treatment for any grade of CIN or early cervical cancer (stage IA1). Treatment included both excisional and ablative methods. We excluded studies that had no untreated reference population, reported outcomes in women who had undergone treatment during pregnancy or had a high-risk treated or comparison group, or both DATA COLLECTION AND ANALYSIS: We classified studies according to the type of treatment and the obstetric endpoint. Studies were classified according to method and obstetric endpoint. Pooled risk ratios (RR) and 95% confidence intervals (CIs) were calculated using a random-effects model and inverse variance. Inter-study heterogeneity was assessed with I2 statistics. We assessed maternal outcomes that included preterm birth (PTB) (spontaneous and threatened), preterm premature rupture of the membranes (pPROM), chorioamnionitis, mode of delivery, length of labour, induction of delivery, oxytocin use, haemorrhage, analgesia, cervical cerclage and cervical stenosis. The neonatal outcomes included low birth weight (LBW), neonatal intensive care unit (NICU) admission, stillbirth, perinatal mortality and Apgar scores.

MAIN RESULTS

We included 69 studies (6,357,823 pregnancies: 65,098 pregnancies of treated and 6,292,725 pregnancies of untreated women). Many of the studies included only small numbers of women, were of heterogenous design and in their majority retrospective and therefore at high risk of bias. Many outcomes were assessed to be of low or very low quality (GRADE assessment) and therefore results should be interpreted with caution. Women who had treatment were at increased overall risk of preterm birth (PTB) (less than 37 weeks) (10.7% versus 5.4%, RR 1.75, 95% CI 1.57 to 1.96, 59 studies, 5,242,917 participants, very low quality), severe (less than 32 to 34 weeks) (3.5% versus 1.4%, RR 2.25, 95% CI 1.79 to 2.82), 24 studies, 3,793,874 participants, very low quality), and extreme prematurity (less than 28 to 30 weeks) (1.0% versus 0.3%, (RR 2.23, 95% CI 1.55 to 3.22, 8 studies, 3,910,629 participants, very low quality), as compared to women who had no treatment.The risk of overall prematurity was higher for excisional (excision versus no treatment: 11.2% versus 5.5%, RR 1.87, 95% CI 1.64 to 2.12, 53 studies, 4,599,416 participants) than ablative (ablation versus no treatment: 7.7% versus 4.6%, RR 1.35, 95% CI 1.20 to 1.52, 14 studies, 602,370 participants) treatments and the effect was higher for more radical excisional techniques (less than 37 weeks: cold knife conisation (CKC) (RR 2.70, 95% CI 2.14 to 3.40, 12 studies, 39,102 participants), laser conisation (LC) (RR 2.11, 95% CI 1.26 to 3.54, 9 studies, 1509 participants), large loop excision of the transformation zone (LLETZ) (RR 1.58, 95% CI 1.37 to 1.81, 25 studies, 1,445,104 participants). Repeat treatment multiplied the risk of overall prematurity (repeat versus no treatment: 13.2% versus 4.1%, RR 3.78, 95% CI 2.65 to 5.39, 11 studies, 1,317,284 participants, very low quality). The risk of overall prematurity increased with increasing cone depth (less than 10 mm to 12 mm versus no treatment: 7.1% versus 3.4%, RR 1.54, 95% CI 1.09 to 2.18, 8 studies, 550,929 participants, very low quality; more than 10 mm to 12 mm versus no treatment: 9.8% versus 3.4%, RR 1.93, 95% CI 1.62 to 2.31, 8 studies, 552,711 participants, low quality; more than 15 mm to 17 mm versus no treatment: 10.1 versus 3.4%, RR 2.77, 95% CI 1.95 to 3.93, 4 studies, 544,986 participants, very low quality; 20 mm or more versus no treatment: 10.2% versus 3.4%, RR 4.91, 95% CI 2.06 to 11.68, 3 studies, 543,750 participants, very low quality). The comparison group affected the magnitude of effect that was higher for external, followed by internal comparators and ultimately women with disease, but no treatment. Untreated women with disease and the pre-treatment pregnancies of the women who were treated subsequently had higher risk of overall prematurity than the general population (5.9% versus 5.6%, RR 1.24, 95% CI 1.14 to 1.34, 15 studies, 4,357,998 participants, very low quality).pPROM (6.1% versus 3.4%, RR 2.36, 95% CI 1.76 to 3.17, 21 studies, 477,011 participants, very low quality), low birth weight (7.9% versus 3.7%, RR 1.81, 95% CI 1.58 to 2.07, 30 studies, 1,348,206 participants, very low quality), NICU admission rate (12.6% versus 8.9%, RR 1.45, 95% CI 1.16 to 1.81, 8 studies, 2557 participants, low quality) and perinatal mortality (0.9% versus 0.7%, RR 1.51, 95% CI 1.13 to 2.03, 23 studies, 1,659,433 participants, low quality) were also increased after treatment.

AUTHORS' CONCLUSIONS

Women with CIN have a higher baseline risk for prematurity. Excisional and ablative treatment appears to further increases that risk. The frequency and severity of adverse sequelae increases with increasing cone depth and is higher for excision than it is for ablation. However, the results should be interpreted with caution as they were based on low or very low quality (GRADE assessment) observational studies, most of which were retrospective.

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

BACKGROUND

The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact.

METHODS

Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research.

RESULTS

We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.

Comparison of two surgical methods for the treatment of CIN: classical LLETZ (large-loop excision of the transformation zone) versus isolated resection of the colposcopic apparent lesion - study protocol for a randomized controlled trial

Background

In compliance with national and international guidelines, non-pregnant women with cervical intraepithelial neoplasia grade 3 should be treated by cervical conization. According to the definition of the large loop excision of the transformation zone (LLETZ) operation, the lesion needs to be resected, including the transformation zone. It is well known from the literature that the cone size directly correlates with the risk of preterm delivery in the course of a future pregnancy. Thus, it would be highly desirable to keep the cone dimension as small as possible while maintaining the same level of oncological safety.

Methods/Design

The aim of this study is to analyze whether resection of the lesion only, without additional excision of the transformation zone, is equally as effective as the classical LLETZ operation regarding oncological outcome. We are performing this prospective, patient-blinded multicenter trial by randomly assigning women who need to undergo a LLETZ operation for cervical intraepithelial neoplasia grade 3 to either of the following two groups at a ratio of 1:1: (1) additional resection of the transformation zone or (2) resection of the lesion only. To evaluate equal oncological outcome, we are performing human papillomavirus (HPV) tests 6 and 12 months postoperatively. The study is designed to consider the lesion-only operation as oncologically not inferior if the rate of HPV high-risk test results is not higher than 5 % compared with the HPV high-risk rate of women undergoing the classical LLETZ operation.

Discussion

In case that non-inferiority of the “lesion-only” method can be demonstrated, this operation should eventually become standard treatment for all women at childbearing age due to the reduction in risk of preterm delivery.

Trial registration

German Clinical Trials Register (DRKS) Identifier: DRKS00006169. Date of registration: 30 July 2014.

Pregnancy outcome after electrosurgical cervical cone biopsy using Fischer cone biopsy excisor

OBJECTIVE

To evaluate the pregnancy outcomes of all patients who underwent electrosurgical cone biopsy of the cervix between January 2000 and December 2011 and subsequently became pregnant.

STUDY DESIGN

Retrospective cohort study.

SETTINGS

District General Hospital in the North East of England.

METHODS

Patients were identified from the local colposcopy electronic data, Hospital Episode Statistics and Maternity electronic data. Data were collected on a pro forma with two sections: (1) treatment section and (2) pregnancy section. In the treatment section, year and indication for treatment, volume of cervix removed, histological results and marginal status of specimen were documented. In the pregnancy section, time interval between treatment and pregnancy, pre-treatment obstetric history, cervical length measurements, cervical suture, gestation and mode of delivery and neonatal outcome were documented. Data were analysed using SPSS.

RESULTS

25 women achieved 47 pregnancies after electrosurgical cone biopsy treatment. Most common indication for cone biopsy was glandular neoplasia accounting for nearly half of the procedures; 21.2% of pregnancies ended in first-trimester miscarriages. The preterm delivery rate (<37 weeks) was 19.4%. Volume of cervix excised was significantly greater in women who delivered preterm compared to women who delivered at term (p = 0.028). The rate of preterm delivery was significantly higher in post treatment pregnancies when compared to pregnancies before treatment in the same women (p = 0.02). The preterm delivery in post-treatment pregnancies was not related to the time interval between treatment and pregnancy (p = 0.54). There was no significant difference in miscarriage rates in pre- and post-treatment pregnancies (p = 0.98).

CONCLUSION

Electrosurgical cone biopsy of cervix is associated with increased risk of preterm labour that is related to the volume of cervix excised.

Risk of preterm delivery associated with prior treatment of cervical precancerous lesion according to the depth of the cone

The aim of this study was to evaluate the impact of the surgical excisional procedures for cervical intraepithelial neoplasia (CIN) treatment both on subsequent fertility (cervical factor) and pregnancy complication (risk of spontaneous preterm delivery). We retrospectively analyzed 236 fertile women who underwent conization for CIN. We included in the study 47 patients who carried on pregnancy and delivered a viable fetus. Patients were asked about postconization pregnancies, obstetrical outcomes, and a possible diagnosis of secondary infertility caused by cervical stenosis. We evaluated the depth of surgical excision, the timing between cervical conization and subsequent pregnancies, surgical technique, and maternal age at delivery. We recorded 47 deliveries, 10 cases of preterm delivery; 8 of them were spontaneous. The depth of surgical excision showed a statistically significant inverse correlation with gestational age at birth. The risk of spontaneous preterm delivery increased when conization depth exceeded a cut-off value of 1.5 cm. Our data do not demonstrated a relation between conization and infertility due to cervical stenosis.

Pregnancy outcome following loop electrosurgical excision procedure (LEEP) a systematic review and meta-analysis

OBJECTIVE

This study aimed at assessing the association of the relative risk (RR) of adverse pregnancy outcomes with previous treatment of loop electrosurgical excision procedure (LEEP) for the management of cervical intraepithelial neoplasia (CIN).

METHODS

Data sources were from MEDLINE, EMBASE, and SCI citation tracking.

SELECTION CRITERIA

The eligible studies had data on pregnancy outcomes of women with or without previous treatment for CIN. Considered outcomes were severe preterm delivery (<34/32 weeks), extreme preterm delivery (<28 weeks), low birth weight (<2,500 g), stillbirth, preterm spontaneous rupture of membranes, perinatal mortality, and neonatal mortality and induction.

RESULTS

36,954 cases and 1,794,174 controls in 4 prospective cohort and 22 retrospective studies were included in this meta-analysis. LEEP was associated with a higher risk of severe preterm delivery (<32 weeks, relative risk 1.98, 95% CI [1.31, 2.98] 159/11,337 vs. 7,830/860,883), extreme preterm delivery (<28 weeks, RR, 2.33, 95% CI [1.84, 2.94] 97/9,611 vs. 1,559/618,332), preterm premature rupture of the membranes (RR, 1.88, 95% CI [1.54, 2.29] 126/2,837 vs. 7,899/313,094), and low birth weight (<2,500 g, RR, 2.48, 95% CI [1.75, 3.51] 110/1,451 vs. 55/1,742). A cervical length of less than 3 cm was significantly increased in LEEP as compared with that of control group (RR, 4.88, 95% CI [1.56, 15.25]), but increasing LEEP volume or depth was not associated with an increased rate of preterm birth <37 weeks. And LEEP was not associated with a significantly increased risk of perinatal mortality, cesarean section, stillbirth mortality, neonatal mortality, induction, and neonatal intensive care unit admission.

CONCLUSIONS

LEEP is associated with an increased risk of subsequent preterm delivery (<32/34, <28 weeks) and other serious pregnancy outcomes. But increasing LEEP volume or depth is not associated with an increased rate of preterm birth.

[Colposcopy in the diagnosis of early cervical cancer]

Cervical intraepithelial neoplasia and early cervical cancer are characterized by colposcopic minor and major changes and vessel abnormalities. In minor changes check-ups in most cases are sufficient. To avoid R1-resection and conization associated premature birth, conization should be performed under colposcopic visualization. In the USA and UK evidence based colposcopic guidelines were issued based on cytologic and colposcopic classifications. The German Society of Colposcopy (AG-CPC) published recommendations for the daily practice for all findings. For screening purposes there is no evidence to recommend colposcopy. In these cases, cytology is at the forefront, whereas colposcopy is only indicated in cases of conspicuous or unclear cytological results.

Microinvasive squamous carcinoma (FIGO stage IA1) of the cervix: are there colposcopic criteria for the diagnosis?

OBJECTIVE

The purpose of this study was to evaluate colposcopic sensitivity in the diagnosis of microinvasive squamous carcinoma of the cervix.

STUDY DESIGN

We conducted a cross-sectional study in 151 patients from 1991-2008. The colposcopic findings of microinvasion suspicion were described by the International Federation for Cervical Pathology and Colposcopy in 2003.

RESULTS

There has been colposcopic suspicion of invasion in 35 patients, which represents a sensitivity of 23%. The major colposcopic findings that were observed in the transformation zone included acetowhite epithelium in 21% (32/151 patients), coarse punctuation in 19% (29/151 patients), coarse mosaic in 17% (26/151 patients), and atypical vessels in 3.9% (6/151 patients). Suspicion of microinvasion was found in 14.5% of unsatisfactory colposcopy and in 8.6% of satisfactory colposcopy.

CONCLUSION

The sensitivity of colposcopy in the diagnosis of microinvasive carcinoma of the cervix was low. Colposcopy plays an important role in directing the biopsy to the most suspicious area. The definitive diagnosis of microinvasive squamous carcinoma is established only by histologic study.

Microinvasive cervical carcinoma: a retrospective study of cases presenting to the Oxford Colposcopy Unit between 1989 and 1996

This a retrospective analysis of 65 cases of microinvasive disease and 5-8 years of follow-up (mean 6.2 years), evaluating the effectiveness of cytology and colposcopy in the diagnosis of microinvasive disease and the role of conservative surgery in its management. Cervical cytology reports indicated disease more severe than CIN III in 23% of cases. A further 7% at colposcopy were thought to have possible invasive disease despite no indication from the smear report, this impression correlated with increasing depth of invasion (>1.40 mm).

Feasibility and outcome of laser CO2conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2conization of the cervix forin situand minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinomain situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.

Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis

BACKGROUND

Conservative methods to treat cervical intraepithelial neoplasia and microinvasive cervical cancer are commonly used in young women because of the advent of effective screening programmes. In a meta-analysis, we investigated the effect of these procedures on subsequent fertility and pregnancy outcomes.

METHODS

We searched for studies in MEDLINE and EMBASE and classified them by the conservative method used and the outcome measure studied regarding both fertility and pregnancy. Pooled relative risks and 95% CIs were calculated with a random-effects model and interstudy heterogeneity was assessed with Cochrane's Q test.

FINDINGS

We identified 27 studies. Cold knife conisation was significantly associated with preterm delivery (<37 weeks; relative risk 2.59, 95% CI 1.80-3.72, 100/704 [14%] vs 1494/27 674 [5%]), low birthweight (<2500 g; 2.53, 1.19-5.36, 32/261 [12%] vs 905/13 229 [7%]), and caesarean section (3.17, 1.07-9.40, 31/350 [9%] vs 22/670 [3%]). Large loop excision of the transformation zone (LLETZ) was also significantly associated with preterm delivery (1.70, 1.24-2.35, 156/1402 [11%] vs 120/1739 [7%]), low birthweight (1.82, 1.09-3.06, 77/996 [8%] vs 49/1192 [4%]), and premature rupture of the membranes (2.69, 1.62-4.46, 48/905 [5%] vs 22/1038 [2%]). Similar but marginally non-significant adverse effects were recorded for laser conisation (preterm delivery 1.71, 0.93-3.14). We did not detect significantly increased risks for obstetric outcomes after laser ablation. Although severe outcomes such as admission to a neonatal intensive care unit or perinatal mortality showed adverse trends, these changes were not significant.

INTERPRETATION

All the excisional procedures to treat cervical intraepithelial neoplasia present similar pregnancy-related morbidity without apparent neonatal morbidity. Caution in the treatment of young women with mild cervical abnormalities should be recommended. Clinicians now have the evidence base to counsel women appropriately.

Does regular cervical screening protect women from microinvasive squamous cell carcinoma of the cervix? A retrospective case-control study

OBJECTIVES

To compare the smear histories of women with microinvasive squamous cell carcinoma (SCC) of the cervix to those of women with cervical intraepithelial neoplasia grade 3 (CIN3).

DESIGN

Retrospective case-control study.

SETTING

A large public hospital gynaecology unit. Sample Twenty-nine consecutive women with microinvasive SCC FIGO stage 1A1 (cases). Fifty-five age-matched controls with histologically confirmed CIN3 (controls).

METHODS

The cases and controls were selected from institutional databases; smear histories and other information was retrieved from hospital notes or following consent from other records.

MAIN OUTCOME MEASURES

The time from index smear to prior screening smear and participation in the National Screening Programme (NCSP).

RESULTS

Only 35% of cases compared with 78% controls had a smear in the last 3 years (P = 0.00008.) Cases had a longer median interval between the abnormal smear that resulted in diagnosis and the previous screening smear (4 years) compared with controls (2 years). Cases were less likely to be enrolled in the NCSP (65%) prior to their index smear than controls (85%).

CONCLUSION

Delayed interval screening was more frequent in women with 1A1 SCC than CIN3.

Independent determinants of inaccuracy of colposcopically directed punch biopsy of the cervix

OBJECTIVE

The goal of this study was to determine the clinical factors independently associated with inaccuracy of colposcopically directed punch biopsy in defining extent and severity of epithelial lesions of the cervix.

METHODS

The study was conducted in a colposcopy clinic devoted to the management of patients with abnormal Pap smear and/or histology diagnosis of cervical intraepithelial neoplasia (CIN) on punch biopsy or endocervical curettage. Seven hundred and thirty-nine patients (median age, 33 years; range, 18-83 years) referred with a punch biopsy diagnosis of CIN2-3 and treated with electrosurgical conization were evaluated. Cone histology diagnosis was assumed to supply the correct diagnosis. Two types of deviation of biopsy diagnosis were considered: (1). unconfirmed high-grade CIN diagnosis, defined as a cone diagnosis of CIN1 and reactive/reparative changes, and (2). nondiagnosis of carcinoma, defined as a cone diagnosis of microinvasive and invasive squamous carcinoma. Multinomial logistic regression analysis was used to assess the determinants of the probability of each type of deviation.

RESULTS

The probability of unconfirmed high-grade CIN diagnosis (n = 190, 25.7%) was inversely related to number of quadrants involved, severity of referral Pap smear, and grade of biopsy. The probability of nondiagnosis of carcinoma (n = 43, 5.8%) was positively related to patient age, invisibility of the squamocolumnar junction, number of quadrants involved, and cone width. Endo-ectocervical location, cone depth, and time period had no effect whatsoever.

CONCLUSIONS

The study confirmed previous observations regarding the positive association of patient age and invisibility of squamocolumnar junction with the probability of nondiagnosis of carcinoma. The concomitant positive effects of number of quadrants involved and cone width were suggested to mirror the effect of circumferential development and, respectively, surface area of CIN. Severity of referral Pap smear and grade of biopsy were shown to be inversely related to the probability of a cone diagnosis of CIN1 and benign changes.

Cervical cytology in an urban population in Lagos, Nigeria

Eight hundred and eighty-four consecutive women had cervical smears in a clinic in Lagos, Nigeria between September 1998 and 31 August 1999. Mean age was 36.6 - 11.6 years (range 16-81 years); 93.7% were first-time screening. Three hundred and twenty-five (36.5%) smears were normal, inflammatory smears 52.7%, mild dyskaryosis 2.4%, moderate dyskaryosis 1.5%, severe dyskaryosis 0.3% and probable malignancy (malignant cells) 0.8%. Abnormal smears were higher in symptomatic cases compared with asymptomatic cases (chi2=15.3, P< 0.01); 6.1% and 2.1% of symptomatic cases had dyskaryosis and carcinoma, respectively, compared with 3.4% and 0.1% for asymptomatic cases. In postcoital bleeding 9.3% and 1.9% had dyskaryosis and carcinoma, respectively. Fifty-six of 62 cases of cervical erosion had abnormal smears. In postmenopausal bleeding 13.0% and 4.3% had dyskaryosis and carcinoma, respectively. Prevalence of abnormal cervical smears is high in women who have genital tract disease. In places with no national screening programmes every effort should be made to screen such women.

Delivery outcomes following loop electrosurgical excision procedure for microinvasive (FIGO stage IA1) cervical cancer

OBJECTIVE

The goal of this study was to report the delivery outcomes in women who had loop electrosurgical excision procedure (LEEP) for microinvasive cervical cancer (stage IA1 without lymphovascular invasion) and became pregnant and progressed beyond 24 weeks.

METHODS

A case-control study was performed. Twenty-eight women who were managed exclusively with LEEP for microinvasive cervical carcinoma had at least one pregnancy beyond 24 weeks and were the cases. Each case was matched with one woman who delivered at the same department without prior treatment of her cervix (controls) and their delivery outcomes were compared with those of the cases. Known risk factors for preterm delivery were used as matching factors.

RESULTS

There was no statistically significant difference (P > 0.05) between cases and controls in the duration of pregnancy (37.6-38.4 weeks respectively), birth weight (3212-3315 g), cesarean section rate (17.8-32.1%), neonatal unit admission rate (21.4-10.7%), and precipitate labor rate (13-10.5%). The duration of labor was significantly shorter in cases (5.5-7.1 h, P = 0.032). After LEEP the relative risk for preterm delivery is 3.67 (95% confidence interval, 0.97-20.27), for low birth weight infant 0.67 (0.06-5.8), for precipitate labor 1 (0.05-3.88), and for delivery by cesarean section 0.5 (0.17-4.46).

CONCLUSIONS

Women treated for microinvasive cancer with LEEP did not have significantly more delivery complications compared with controls apart from shorter duration of labor. There was a possible non-statistically significant trend toward shorter duration of pregnancy in cases. While caution should be advised when selecting and treating women with microinvasive carcinoma by LEEP, the apparent safety of the management and the satisfactory delivery outcome seem to justify this approach in many cases.

Triage of the abnormal Papanicolaou smear in pregnancy

Triage of the abnormal Papanicolaou smear in pregnancy requires colposcopic evaluation and directed biopsy. If histologic cervical intraepithelial neoplasia is confirmed, the patient can be managed with observations and can be re-evaluated in the postpartum period. If evidence of microinvasion is present, conization must be performed. For patients with invasive disease, a delay in therapy until fetal maturity is achieved does not compromise survival.

Positive predictive rate of colposcopic examination of the cervix uteri: an overview of literature

Study of literature revealed that the positive predictive rate of the colposcopic impression is better as the cervical lesion is more severe. When directed biopsies are taken, the positive predictive rate of colposcopy increases considerably. For microinvasive disease, the positive predictive rate is quite poor, probably because of the absence of characteristic features. Large loop biopsies diagnosed all cases of microinvasive disease missed by directed biopsies, but this technique has the disadvantage of considerable "overtreatment" when integrated in the management of all patients with abnormal cytology. The restrictions of colposcopy are the invisibility of the squamocolumnar junction and observer variability in the assessment of the impression. The levels of agreement among experienced colposcopists are in the same range as those in cytological and histopathological diagnosis. It is concluded that colposcopy is an indispensable tool in the management of premalignant cervical disease, as long as the restrictions of the technique are kept in mind by the colposcopist.

The case for stopping cervical screening at age 50

OBJECTIVE

To determine the pattern of abnormal cervical cytology in women aged 50 to 60 years and to determine whether the development of cervical neoplasia in this age group is confined to women who have been inadequately screened.

DESIGN

Retrospective case analysis study.

POPULATION

An 11-year birth cohort of women in Grampian Region born between 2/10/33 and 1/10/44, and those who had significant cytological abnormalities in the 5 year period 1/10/89 to 30/9/94.

MAIN OUTCOME MEASURES

Cytological and histological outcome for women with significant cytological abnormalities between 50 to 60 years of age and the interval between three consecutive smears taken up to 50 years of age for those women.

RESULTS

Of 23,440 women aged 50 to 60 years ever screened in Grampian Region, 229 (1%) had significant cytological abnormalities. Seventy had CIN 3 and 15 had invasive disease of the cervix. Among approximately 9000 women with adequate smear histories prior to age 50, one case of CIN 3 and one case of invasion were detected. The prevalence of invasive disease in the whole cohort during this five year period was 59/100,000. Among the previously well screened women the prevalence was 11/100,000.

CONCLUSION

The incidence of preinvasive disease of the cervix is low over the age of 50 and is seen almost exclusively in inadequately screened women. There would appear to be little benefit in continuing cervical screening over the age of 50 in women who have had regular negative smears. The release of this low risk group from the cervical screening programme could alleviate anxiety and could enable reallocation of resources to target better high risk women who default from regular screening and to reduce screening intervals where necessary to three years.

T lymphocytes infiltrating advanced grades of cervical neoplasia. CD8-positive cells are recruited to invasion

BACKGROUND

Impaired cellular immunity appears to be a risk factor for progression of cervical neoplasia, but the immunobiology of neoplastic progression is poorly understood. The objective of this study was to characterize the subpopulations of T lymphocytes that infiltrate various grades of cervical neoplasia including metaplasia to invasive cancer in immunocompetent women.

METHOD

In 65 patients with a spectrum of cervical disease ranging from normal cytology to carcinoma, the relative proportions of total T lymphocytes and CD4- or CD8-expressing (helper or cytotoxic) T lymphocyte subsets were determined by immunohistochemistry.

RESULTS

When the invasive carcinoma stromal infiltrate was compared with the infiltrate of preinvasive lesions, the numbers of total T cells and the CD8-positive subset increased significantly in the invasive cancers (P < 0.005). Although immunocyte infiltrates were highly concentrated in focal clusters beneath the preinvasive squamous lesions, the CD8-positive immunocytes diffusely infiltrated the invading tumor.

CONCLUSIONS

The CD8-positive T cell infiltrate far exceeded the CD4-positive cells in the invasive, but not in the preinvasive lesions, a finding that suggests that CD8 cells are recruited preferentially to cervical lesions with progression to invasion.

Colposcopy and directed biopsy reliability during pregnancy: a cohort study

The reliability of cytology, colposcopy, and directed biopsy were assessed in pregnancy and compared with that observed in a matched non-pregnant control group in order to evaluate the influence of pregnancy. One hundred and seventeen gravidas in which the final pathology could be ascertained and 234 control patients were examined by the same colposcopist. Concordance between cytology and final diagnosis was complete or within one degree of severity in 55.6% and 77.8% of patients, respectively. Unsatisfactory colposcopy was significantly less frequent in pregnant patients than in controls (12.8% vs. 23.1%, P = 0.023). In pregnant patients, colposcopy provided concordance, overestimation and underestimation of the final diagnosis in 72.6%, 17.6% and 9.8%, respectively. In the same group, the concordance between the histologic findings of directed biopsy and final diagnosis was complete or within one degree of severity in 83.7% and 95.9%, respectively. The reliability of cytology, colposcopy and directed biopsy was not related to pregnancy. These data show that the physiological changes which occur in pregnancy do not significantly alter the reliability of colposcopy and directed biopsy, if the colposcopist is aware of the peculiar difficulties and does not overreact to the accentuated patterns that may occur during pregnancy.