Prediction of cervical histologic results using an abbreviated Reid Colposcopic Index during ALTS

Lugol's Solution Reduces Positive Margins and Residual Disease After the Large Loop Excision of Transformation Zone

OBJECTIVE

This study aimed to examine whether the intraoperative use of Lugol's solution reduces the proportion of positive resection margins (RMs) using the data of women who underwent large loop excision of the transformation zone (LLETZ).

MATERIALS AND METHODS

A total of 1,751 consecutive women with cervical intraepithelial neoplasia (CIN) who underwent LLETZ with or without Lugol's solution were retrospectively retrieved from each database of 3 university hospitals in South Korea. Outcomes included positive RMs and residual disease pathologically confirmed within 6 months after LLETZ.

RESULTS

Positive RMs were noted in 345 cases (19.7%). Among 1,507 women followed up, residual disease was diagnosed in 100 cases (6.6%) (69/308 cases with positive RMs; 31/1,199 cases with negative RMs). The Lugol's solution group was less likely to have positive RMs (11.8% vs 25.5%, p < .01), to require additional surgical intervention (5.4% vs 10.2%, p < .01), and to have residual disease (4.9% vs 8.0%, p = .02). On multiple logistic regression analysis, Lugol's solution reduced the proportion of positive RMs (adjusted odds ratio [aOR], 0.31). Age (50 years or older; aOR, 1.64), preconization cervical cytology (aOR, 1.53), high-risk human papillomavirus (aOR, 1.75), and CIN 2 or 3 (aOR, 2.65) were independent risk factors for margin positivity ( p < .01 for all except high-risk human papillomavirus of p = .05).

CONCLUSIONS

Lugol's solution optimizes CIN treatment by reducing the proportion of positive RMs and residual disease after LLETZ.

Underdiagnosis of cervical intraepithelial neoplasia by colposcopy and its association with thin high‑grade squamous intraepithelial lesions

The relationship between the thickness of the epithelium and the colposcopic diagnosis is controversial. The present study was conducted to determine whether colposcopic underdiagnosis of cervical intraepithelial neoplasia (CIN) is associated with thin high-grade squamous intraepithelial lesions (HSILs) of the cervix. A total of 136 cases of HSIL verified by pathological biopsy at Peking University People's Hospital between June and October 2021 were retrospectively analyzed; 79 cases were CIN2 and 57 cases were CIN3. The number and thickness of epithelial layers were analyzed using colposcopic impressions. In the low-grade colposcopic impression group, the number of epithelial layers (12.8±4.2 vs. 17.8±4.2) and epithelial thickness (105.2±41.9 µm vs. 150.3±50.0 µm) of CIN2 lesions were significantly lower compared with the high-grade colposcopic impression group; however, the differences for CIN3 were not statistically significant. CIN2 lesions had significantly fewer (12.8±4.2 vs. 17.2±5.4) and thinner (105.2±41.9 µm vs. 140.4±48.6 µm) epithelial layers than CIN3 lesions in the low-grade colposcopic impression groups. In the high-grade colposcopic impression group, however, there were no significant differences in the number or thickness of epithelial layers between CIN2 and CIN3. In 12 cases of thin HSILs, 91.6% of the colposcopic impressions were low-grade. Thin HSILs are likely associated with underdiagnosed colposcopic findings, particularly for CIN2. Thin HSILs usually present with small to minute lesions and lack the typical colposcopic appearance of classic HSIL, which may help to explain why thin HSILs are easily underestimated under colposcopy.

Clinical application of the 2011 IFCPC colposcope terminology

BACKGROUND

Colposcopy offers an accurate way to the diagnose of cervical precancerous lesions. However, the diagnostic accuracy of colposcopy is unsatisfied. This study was to evaluate colposcopic accuracy according to the 2011 International Federation of Cervical Pathology and Colposcopy (IFCPC) terminology.

METHODS

A retrospective cohort study was performed in 1,838 patients who underwent colposcopy in Shandong Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University from October 2013 to April 2018. Using conization or cervical biopsy pathology as the gold standard, the agreement between colposcopic diagnosis and pathologic diagnosis was calculated, and correlations between variables were analyzed.

RESULTS

As an authoritative and widely used terminology for colposcopy diagnosis, the 2011 IFCPC terminology has certain clinical practicality and diagnostic accuracy. However, some signs such as mosaic, punctation, sharp border, inner border sign and ridge sign had high specificity but unsatisfactory sensitivity, which limited the diagnostic value. Therefore, we discussed the Lugol's staining, a very common sign in colposcopy, and analyzed the diagnostic significance of bright yellow staining in low-grade squamous intraepithelial lesion (LSIL) and mustard yellow staining in high-grade squamous intraepithelial lesion (HSIL). The results showed that mustard yellow may be a valuable indicator in the diagnosis of HSIL.

CONCLUSION

The 2011 IFCPC colposcope terminology has standardized interpretations of the colposcopic findings and improved the accuracy of colposcopy diagnosis. The aceto-white epithelium still has important diagnostic value; however, the value of a few signs is needed to be discussed and new signs are expected to be discovered. Although the significance of Lugol's staining was diminishing, mustard yellow might be a valuable indicator for the diagnosis of HSIL.

100 years of iodine testing of the cervix: A critical review and implications for the future

OBJECTIVES

We aim to describe the history of iodine testing of the cervix and identify areas where further work is required.

STUDY DESIGN

We conducted a search of PubMed and Google Scholar. Full article texts were reviewed. Reference lists were screened for additional articles and books. 37 basic articles in journals including ones written in German and three basic articles in books were identified.

RESULTS

Glycogen staining of the ectocervical squamous epithelium with iodine goes back to Paul Ehrlich (1854-1915). Walter Schiller (1887-1960) examined nearly 200 different dyes and found that vital staining of the cervical squamous epithelium was best achieved with Lugol's iodine solution, which was indicated by Jean Guillaume Lugol (1786-1851) for disinfection of the vagina. In 1928 W. Lahm observed that the glycogen content of a squamous epithelium cell decreases as anaplasia increases. From the outset, H. Hinselmann included the iodine test in the minimum requirements for colposcopy. In 1946 H. J. Wespi first mentioned the finding of an "uncharacteristic iodine negative area." The first international colposcopic terminology from Graz in 1975 lists the "iodine light area" among the different colposcopy findings. The IFCPC nomenclatures from Rome 1990, Barcelona 2002, and Rio de Janeiro 2011 have evaluated the iodine test and classified their findings differently. A breakthrough to effective cervical cancer screening in resource-limited settings in Africa, India, and Latin America was achieved with R. Sankaranarayanan's publication on naked-eye visual inspection of the cervix after application of Lugol's iodine.

CONCLUSIONS

This paper is a step toward a better understanding of what we think and do today with iodine testing and what problems and upcoming tasks will arise in future.

Performance of colposcopic scoring by modified International Federation of Cervical Pathology and Colposcopy terminology for diagnosing cervical intraepithelial neoplasia in a low-resource setting

Introduction:

Colposcopy is a tool to evaluate women with cervical pre-cancer and cancer. To interpret the colposcopic findings, various scoring systems are used but with inter observer variations. To improve the quality of colposcopy, International Federation of Cervical Pathology and Colposcopy (IFCPC) has introduced a colposcopic nomenclature in 2011. Colposcopic scoring helps to select patients who need treatment for cervical intraepithelial neoplasia.

Aim of the Study:

The study aimed to evaluate the agreement between colposcopic diagnosis with the modified IFCPC terminology and cervical pathology in patients with abnormal screening tests and to assess the utility of this colposcopic scoring system in low resource settings.

Methodology:

Patients with abnormal screening tests who underwent colposcopic assessment in the department of Gynaecological oncology were included in the study. Colposcopic scoring was done by the modified IFCPC nomenclature. The results were compared with cytology and the final histopathology.

Results:

56 patients were included in the study. The colposcopic scoring when compared to histopathology showed agreement in 65.7% which indicated the agreement was substantial and was statistically significant (P = 0.0001). With cytology the colposcopic score showed agreement in 35.6% indicating a fair agreement and this was also statistically significant (P = 0.001).

Conclusion:

Colposcopic scoring by modified IFCPC 2011 criteria showed substantial agreement with cervical histopathology. Compared to traditional methods, 2011 international terminology of colposcopy could improve colposcopic accuracy.

Replacing Iodine Staining with Size of Lesion: The Performance of Modified Reid Colposcopic Index

AIM

This study of diagnostic accuracy aimed to assess the performance of authors' proposing colposcopic index for detecting histological diagnosis of cervical intraepithelial neoplasia grade 2 or worse (CIN2 or worse).

METHODS

Retrospective analysis of data was carried out on medical records of women who underwent colposcopy in Rajavithi hospital from January 2007 to December 2014. The authors' proposed score included the first 3 criteria of RCI (margin, color, vascular pattern) and replacing the last RCI criterion (iodine staining) with the detail of size and location of a lesion which was retrospectively retrieved from medical records. Total score for detecting any lesion was ranged from 0-8, similar to the RCI. Performance of the score was assessed for sensitivity, specificity, and positive and negative predictive values at every cut-off level.

RESULTS

Among 207 eligible women, 87 (42%) had CIN2 or worse. Cut-off level of score ≥ 6 had a sensitivity, specificity, and positive and negative predictive values of 54.0%,97.5%,94.0%,74.5%, respectively while cut-off value ≥ 2 had sensitivity , specificity, positive and negative predictive values of 94.2% ,55.8% ,60.7%, and 93.0%, respectively, for histological diagnosis of CIN 2 or worse. The area under ROC curve was 0.88. In women with type 3 T-zone, the area under ROC curve was 0.94 which was excellent.

CONCLUSION

The performance of the colposcopic score that replaces iodine staining with the size and location of the lesion is good and practical. High cut-off level can be used in see and treat approach for high-grade squamous intraepithelial lesions. Low cut-off level may be used for omitting biopsy in case of low grade impression. This scoring system seems to have greater performance in womens with type 3 T- zone.

Combined dynamic spectral imaging and routine colposcopy strategy for the diagnosis of pre-cancerous cervical lesions

The present study aimed to investigate the sensitivity and specificity of combined dynamic spectral imaging (DySI) and routine colposcopy in diagnosing pre-cancerous lesions in subjects with abnormal cytological results. The retrospective study included 146 patients diagnosed with cervical lesions and atypical squamous cells of undetermined significance according to a colposcopy examination. Data from colposcopy clinics were used to evaluate performance of DySI in different histological types. The present study evaluated the clinical performance of two different referral strategies (single diagnosis or combined diagnosis) in combination with a smear test. The sensitivity of DySI and routine colposcopy for detecting severe pre-cancerous cervical disease in patients referred with a borderline histology or mild dyskaryosis was 69% [95% confidence interval (CI): 56-82%] and 43% (95% CI: 28-57%), respectively (P=0.01). However, for the HSIL group, the sensitivity of DySI and routine colposcopy was 64 and 61%, respectively. In the HSIL group, the sensitivity was as high as 85% when the DySI method was combined with routine colposcopy. When the conditions of new screening strategies were applied to remove those patients with a negligible risk, DySI had a higher sensitivity to detect severe pre-cancerous cervical disease than conventional colposcopy. In conclusion, the combined DySI and routine colposcopy strategy had a higher diagnostic sensitivity in subjects with low or high abnormalities on cytological examination, compared with either method separately. The present study suggests that the baseline colposcopy sensitivity may be enhanced with the adjunctive use of DySI, irrespective of the cytology result for referral.

Digital Cervicography by Simply Portable Device as an Alternative Test for Cervical Cancer Screening in Rural Area of Thailand

Objective:

Various screening methods for cervical cancer are proved to be effective in reducing such type of cancer. We aims to introduce a new portable device as an alternative method for cervical cancer screening. The performance of device was tested on the assessment of cervical lesions using cervicograph score with the cervical cytology.

Methods:

325 non-pregnant women were tested from March 2013 to August 2015. The cervical and vaginal cells from the sample were collected for cytology, then all of them received the digital cervicography conducted with our new device and scored using cervicograph score. Small pieces of cervical tissues were also collected for histologic examination. SPSS software version 18.0 was used for the statistical analysis.

Results:

We grouped cytology results and cervicograph scores to 2 subgroups, ≤ ASC-US and ≥ LSIL, and 0-3 points and 4-6 points, respectively. The data then correlated with histology results which sub-grouped to ≤ CIN 1 and ≥ CIN 2. The accuracy, sensitivity, specificity, and positive predictive value (PPV) of cervicograph scores 4-6 points to detect CIN 2+ were 92%, 72.41%, 97%, and 84%, respectively which were not inferior to Pap smear did.

Conclusion:

The digital cervicography device provides similar accuracy to Pap cytology screening and is suitable to use in the area that lacks cytoscreeners. Large scale use and generalization are required for this new device.

Closer to a Uniform Language in Colposcopy: Study on the Potential Application of 2011 International Federation for Cervical Pathology and Colposcopy Terminology in Clinical Practice

As the newest colposcopic terminology, the 2011 International Federation for Cervical Pathology and Colposcopy (IFCPC) classification provides standardized interpretation of colposcopic findings. In this study, we analyzed the colposcopic accuracy and the significance of individual findings according to the 2011 IFCPC classification in 525 patients, reviewed by 13 trained colposcopists. Results show that colposcopic diagnoses are in 64.95% perfect agreement with cervical pathology, with 63.64% sensitivity and 96.01% specificity for high-grade squamous intraepithelial lesion (HSIL+). And the accuracy is reproducible across different experienced examiners. Many individual findings, especially the two new signs, inner border sign and ridge sign, are proved to have good predictive accuracy, while iodine negativity demonstrates an inferior performance. However, the distribution of three cervical transformation zone (TZ) types is heterogeneous in examiners. A comparison was also made of the findings of another two colposcopists without nomenclature training according to the Reid Colposcopic Index (RCI), modified RCI, and Swede Score. Results show that colposcopic accuracies in them are lower than in those nomenclature trained colposcopists. The 2011 IFCPC nomenclature improves colposcopic accuracy in trained colposcopists, like speaking the same language. However, the reproducibility of TZ and the predictive value of a few signs remain to be discussed.

International Image Concordance Study to Compare a Point-of-Care Tampon Colposcope With a Standard-of-Care Colposcope

OBJECTIVE

Barriers to cervical cancer screening in low-resource settings include lack of accessible, high-quality services, high cost, and the need for multiple visits. To address these challenges, we developed a low-cost, intravaginal, optical cervical imaging device, the point-of-care tampon (POCkeT) colposcope and evaluated whether its performance is comparable with a standard-of-care colposcope.

MATERIALS AND METHODS

There were 2 protocols, which included 44 and 18 patients. For the first protocol, white-light cervical images were collected in vivo, blinded by device, and sent electronically to 8 physicians from high-, middle-, and low-income countries. For the second protocol, green-light images were also collected and sent electronically to the highest performing physician from the first protocol who has experience in both a high- and low-income country. For each image, physicians completed a survey assessing cervix characteristics and severity of precancerous lesions. Corresponding pathology was obtained for all image pairs.

RESULTS

For the first protocol, average percent agreement between devices was 70% across all physicians. The POCkeT and standard-of-care colposcope images had 37% and 51% agreement with pathology for high-grade squamous intraepithelial lesions (HSILs), respectively. Investigation of HSIL POCkeT images revealed decreased visibility of vascularization and lack of contrast in lesion margins. After changes were made for the second protocol, the 2 devices achieved similar agreement to pathology for HSIL lesions (55%).

CONCLUSIONS

Based on the exploratory study, physician interpretation of cervix images acquired using a portable, low-cost POCkeT colposcope was comparable to a standard-of-care colposcope.

Comparison of Colposcopic Impression Based on Live Colposcopy and Evaluation of Static Digital Images

OBJECTIVE

The aim of the study was to evaluate the agreement and compare diagnostic accuracy of colposcopic impressions from live colposcopy versus evaluation of static digital images.

MATERIALS AND METHODS

Live impressions and corresponding static images obtained during colposcopy of 690 women were independently compared. Diagnostic accuracy was calculated for colposcopic impressions from both methods, varying hypothetical thresholds for colposcopically directed cervical biopsies (acetowhitening or worse, low grade or worse, high grade or worse). Stratified analyses investigated the impact of referral cytology, human papillomavirus 16 infection, and age on colposcopic impression.

RESULTS

Overall agreement between live and static colposcopic visualization was 43.0% (κ = 0.20; 95% CI = 0.14-0.26) over normal, acetowhitening, low-grade, and high-grade impressions. Classification of acetowhitening or worse impressions showed the highest agreement (92.2%; κ = 0.39; 95% CI = 0.21-0.57); both methods achieved more than 95% sensitivity for CIN 2+. Agreement between live and static colposcopic visualization was 69.3% for rating low-grade or worse impressions (κ = 0.23; 95% CI = 0.14-0.33) and 71% when rating high-grade impressions (κ = 0.33; 95% CI = 0.24-0.42). Live colposcopic impressions were more likely to be rated low grade or worse (p < .01; odds ratio = 3.5; 95% CI = 2.4-5.0), yielding higher sensitivity for CIN 2+ at this threshold than static image assessment (95.4% vs 79.8%, p < .01). Overall, colposcopic impressions were more likely rated high grade on live assessment among women referred with high-grade cytology (odds ratio = 3.3; 95% CI = 1.8-6.4), significantly improving the sensitivity for CIN 2+ (66.3% vs 48.5%, p < .01).

CONCLUSIONS

Colposcopic impressions of acetowhitening or worse are highly sensitive for identifying cervical precancers and reproducible on static image-based pattern recognition.

Performance of the abbreviated Reid colposcopic index in prediction of high-grade lesions

OBJECTIVE

To assess the diagnostic performance of the Reid colposcopic index (RCI) and establish the optimal cutoff value to predict a histology of cervical intraepithelial neoplasia grade 2 or worse (CIN2+).

METHODS

A retrospective analysis was undertaken of the medical records of women who underwent colposcopy with RCI scoring at a center in Bangkok, Thailand, between 2003 and 2014. Only patients for whom histology reports were available were included. Cases had been scored according to three criteria: margin, color, and vascular pattern. The performance of this three-criterion score (abbreviated RCI) was assessed for sensitivity, specificity, and positive and negative predictive values at every cutoff level. Receiver operation characteristics (ROC) curve analysis was performed to determine the optimal cutoff value to distinguish between women with CIN2+ and others.

RESULTS

Among 349 included patients, 158 (45.3%) had CIN2+. The most appropriate cutoff score was 3, which had a sensitivity of 72.7%, a specificity of 86.9%, and positive and negative predictive values of 82.1% and 79.4%, respectively. The area under ROC curve was 0.857 (95% confidence interval 0.815-0.898).

CONCLUSION

The performance of the abbreviated RCI seems satisfactory. The optimal cutoff value was 3.

Polarized Light Colposcopy Compared With Standard Colposcopy

OBJECTIVE

The objective of this study was to determine the potential benefits of polarized light colposcopy compared with standard colposcopy examinations in the evaluation of women with abnormal cervical cytology.

MATERIALS AND METHODS

Polarized and standard colposcopy examinations were performed on 330 subjects. Respective images and biopsy annotations were obtained. Sensitivity and specificity; differences in the severity of cervical neoplasia; agreement of colposcopy impression, biopsy intent, and biopsy site; and differences in the number of biopsies were determined using the ROC, Bowker's test of symmetry, kappa statistic, and paired t test, respectively.

RESULTS

The sensitivity and specificity for a lesion being seen with nonpolarized light and polarized light colposcopy were 96.8% and 64.5%, and 96.8% and 64.9%, respectively. There was no statistically significant difference in the ROC of the lesion being seen between nonpolarized (80.7) and polarized (80.9) colposcopy. Likewise, there was no statistically significant difference in the ROC of intent to biopsy between nonpolarized (80.2) and polarized colposcopy (78.8). The agreement of cervical histopathology and colposcopy impression for nonpolarized and polarized colposcopy were 0.986 and 0.952, respectively. There was no significant difference between nonpolarized and polarized colposcopy in the mean number of lesions seen or number of sites intended to biopsy.

CONCLUSIONS

Polarized light colposcopy was not useful as an adjunct to conventional colposcopy in this study. Further research needs to be performed to determine the overall utility of polarized light colposcopy in clinical practice.

Is cervical punch biopsy enough for the management of low-grade cervical intraepithelial neoplasia?

OBJECTIVE

This study aimed to analyze the correlation between the histopathologic results of excisional procedure and cervical punch biopsy and to investigate the accuracy rates of colposcopic punch biopsy and cervical cytology to detect cervical intraepithelial neoplasia (CIN) grade 2 and/or more severe lesions (CIN 2+).

MATERIALS AND METHODS

Two hundred six patients who underwent excisional procedure in the gynecologic oncology clinic of the Zeynep Kamil Women and Children Diseases Education and Research Hospital between 2004 and 2011 were enrolled in a retrospective study.

RESULTS

The correlation between the pathologic findings gained by excisional procedure and punch biopsy was weak ( p = .0001, κ = 0.03). The overall concordance rate between the pathologic findings of cervical biopsy and excisional procedure was 57.29%. The rates of detecting more severe lesions by excisional procedure when compared to biopsies (biopsy underestimation) were 71.42%, 22.91%, 37.03%, and 12.72% for biopsy results with negative, CIN 1, CIN 2, and CIN 3/adenocarcinoma in situ lesions, respectively. Similarly, the rates of less severe lesions diagnosed by excisional procedure when compared to biopsies (biopsy overestimation) were 29.16%, 40.74%, and 15.45% for biopsy results with CIN 1, CIN 2, and CIN 3/adenocarcinoma in situ lesions, respectively. The rate of CIN 2+ lesions after excisional procedure in cases with previous biopsy results with either negative or CIN 1 was 27.27%.

CONCLUSIONS

Our results suggested that colposcopy-directed biopsy was neither a good diagnostic nor a reliable management method. We think that the indications of conization should be enlarged to avoid overlooking high-grade lesions.

Clinical application of DNA ploidy to cervical cancer screening: A review

Screening for cervical cancer with DNA ploidy assessment by automated quantitative image cytometry has spread throughout China over the past decade and now an estimated 1 million tests per year are done there. Compared to conventional liquid based cytology, DNA ploidy has competitive accuracy with much higher throughput per technician. DNA ploidy has the enormous advantage that it is an objective technology that can be taught in typically 2 or 3 wk, unlike qualitative cytology, and so it can enable screening in places that lack sufficient qualified cytotechnologists and cytopathologists for conventional cytology. Most papers on experience with application of the technology to cervical cancer screening over the past decade were published in the Chinese language. This review aims to provide a consistent framework for analysis of screening data and to summarize some of the work published from 2005 to the end of 2013. Of particular interest are a few studies comparing DNA ploidy with testing for high risk human papilloma virus (hrHPV) which suggest that DNA ploidy is at least equivalent, easier and less expensive than hrHPV testing. There may also be patient management benefits to combining hrHPV testing with DNA ploidy. Some knowledge gaps are identified and some suggestions are made for future research directions.

Women's Preferences of Dynamic Spectral Imaging Colposcopy

BACKGROUND

The focus of testing the dynamic spectral imaging (DSI) colposcope has been on the technical characteristics and clinical performance. However, aspects from a patient's perspective are just as important.

METHODS

This study was designed as a substudy of the DSI validation study, a prospective comparative, multicenter clinical trial to assess the clinical performance of DSI colposcopy. All women included in this study were asked to complete two questionnaires: a patient characteristics questionnaire and a patient satisfaction questionnaire.

RESULTS

In the initial study a total of 239 women were included in the intention-to-treat cohort. Of these, 230 women (96.2%) completed both questionnaires. When assessing the women's preferences for some of the possible uses of DSI colposcopy, a high level of agreement was noted for all potential implementations. In general, women found the additional time DSI colposcopy took acceptable: just 15 women (6.5%) thought the time DSI colposcopy took made them feel uncomfortable. Furthermore, women ranked test accuracy as the most important characteristic, followed by (more) rapid testing and comfort. Quick notification of the results and costs were considered the least important characteristics.

CONCLUSION

Women are willing to accept discomfort in the form of an additional or longer test if there is clinical benefit.

Advances in colposcopy: new technologies to challenge current practice

Colposcopy has a poor sensitivity to detect precancerous abnormalities of the cervix. These abnormalities will become less common after HPV vaccinated girls enter the screened population. However HPV-based screening is likely to result in more colposcopic referrals. Both these changes to cervical screening programs will reduce the incidence of high grade CIN and cervical cancer as well as the prevalence of high grade CIN presenting to the colposcopist. As a consequence the diagnostic performance of conventional colposcopy will be further challenged. This review aims to discuss leading technologies which are currently available as an alternative or in addition to colposcopy and may serve to improve the current colposcopic assessment of precancerous cervical abnormalities.

Colposcopy: a global perspective: introduction of the new IFCPC colposcopy terminology

This article describes the current nomenclature of colposcopic findings in the lower genital tract as defined by the International Federation for Cervical Pathology and Colposcopy (IFCPC) and agreed at their Triennial General Meeting in July 2012 in Rio de Janeiro. It builds on previous nomenclature published by the IFCPC over the last two decades and introduces for the first time the concept of transformation zone excision types. Vulval and vaginal colposcopic terminology is described.

Correlation discrepancies between high-grade squamous intraepithelial lesions and high-grade cervical intraepithelial neoplasia: a cytological/histological correlation study from a single-institution experience

OBJECTIVE

Previous studies have demonstrated diagnostic discrepancies for the detection of high-grade cervical intraepithelial neoplasia (CIN 2/3) from previously confirmed cytological high-grade squamous intraepithelial lesions (HSILs). The goal of this study is to investigate the possible factors which may be responsible for this diagnostic discrepancy.

STUDY DESIGN

The study included all the cytological specimens diagnosed with a HSIL by the Papanicolaou (Pap) test at Temple University Hospital (2000-2010) as well as timely follow-up cervical biopsies. The biopsy tissue types and diagnoses were subsequently categorized and analyzed.

RESULTS

Of the total 842 Pap tests with HSIL diagnosis, 96 cases (11.4%) showed non-CIN 2/3 in follow-up cervical biopsies. Among those cases, the most common biopsy diagnoses were cervicitis (27.9%) and CIN 1 (25%). Endocervical curettage (ECC) samples showed a high percentage of inadequacy for diagnosis (43.7%). Thirty-seven cases had subsequent follow-up biopsy, and CIN 2/3 was found in 15 cases. However, none of the CIN 2/3 cases was detected by ECC sampling.

CONCLUSIONS

Our study indicated that the discrepant correlation between HSIL and CIN 2/3 was most likely due to tissue sampling issues during colposcopic examination. The diagnostic value of ECC remains poor for the detection and grading of cervical intraepithelial dysplasia.

Quality improvement opportunities in gynecologic cytologic-histologic correlations: findings from the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference working group 4

CONTEXT

Cytopathology experts, interested stakeholders, and representatives from the College of American Pathologists, the Centers for Disease Control and Prevention, the American Society of Cytopathology, the Papanicolaou Society of Cytopathology, the American Society for Clinical Pathology, and the American Society of Cytotechnology convened the Gynecologic Cytopathology Quality Consensus Conference to present preliminary consensus statements developed by working groups, including the Cytologic-Histologic Correlations Working Group 4, using results from surveys and literature review. Conference participants voted on statements, suggested changes where consensus was not achieved, and voted on proposed changes.

OBJECTIVES

To document existing practices in gynecologic cytologic-histologic correlation, to develop consensus statements on appropriate practices, to explore standardization, and to suggest improvement in these practices.

DATA SOURCES

The material is based on survey results from 546 US laboratories, review of the literature from 1988 to 2011, and the College of American Pathologists Web site for consensus comments and additional survey questions.

CONCLUSIONS

Cytologic-histologic correlations can be performed retrospectively, during initial case review, or both. At minimum, all available slides should be reviewed for a high-grade squamous intraepithelial lesion Papanicolaou test with negative biopsies. The preferred monitor for correlations is the positive predictive value of a Papanicolaou test. Laboratories should design cytologic-histologic correlation programs to explore existing or perceived quality deficiencies.

Accuracy of detection of high-grade cervical intraepithelial neoplasia using electrical impedance spectroscopy with colposcopy

Objective

To determine if electrical impedance spectroscopy (EIS) improves the diagnostic accuracy of colposcopy when used as an adjunct.

Design

Prospective, comparative, multi-centre clinical study.

Setting

Three colposcopy clinics: two in England and one in Ireland.

Population

Women referred with abnormal cytology.

Methods

In phase 1, EIS was assessed against colposcopic impression and histopathology of the biopsies taken. In phase 2, a probability index and cut-off value for the detection of high-grade cervical intraepithelial neoplasia (HG–CIN, i.e. grade CIN2+) was derived to indicate sites for biopsy. EIS data collection and analyses were performed in real time and blinded to the clinician. The phase-2 data were analysed using different cut-off values to assess performance of EIS as an adjunct.

Main outcome measure

Histologically confirmed HG–CIN (CIN2+).

Results

A total of 474 women were recruited: 214 were eligible for analysis in phase 1, and 215 were eligible in phase 2. The average age was 33.2 years (median age 30.3 years, range 20–64 years) and 48.5% (208/429) had high-grade cytology. Using the cut-off from phase 1 the accuracy of colposcopic impression to detect HG–CIN when using EIS as an adjunct at the time of examination improved the positive predictive value (PPV) from 78.1% (95% CI 67.5–86.4) to 91.5%. Specificity was also increased from 83.5% (95% CI 75.2–89.9) to 95.4%, but sensitivity was significantly reduced from 73.6% (95% CI 63.0–82.5) to 62.1%, and the negative predictive value (NPV) was unchanged. The positive likelihood ratio for colposcopic impression alone was 4.46. This increased to 13.5 when EIS was used as an adjunct. The overall accuracy of colposcopy when used with EIS as an adjunct was assessed by varying the cut-off applied to a combined test index. Using a cut-off set to give the same sensitivity as colposcopy in phase 2, EIS increased the PPV to detect HG–CIN from 53.5% (95% CI 45.0–61.8) to 67%, and specificity increased from 38.5% (95% CI 29.4–48.3) to 65.1%. NPV was not significantly increased. Alternatively, applying a cut-off to give the same specificity as colposcopy alone increased EIS sensitivity from 88.5% (95% CI 79.9–94.4) to 96.6%, and NPV from 80.8% (95% CI 67.5–90.4) to 93.3%. PPV was not significantly increased. The receiver operator characteristic (ROC) to detect HG–CIN had an area under the curve (AUC) of 0.887 (95% CI 0.840–0.934).

Conclusions

EIS used as an adjunct to colposcopy improves colposcopic performance. The addition of EIS could lead to more appropriate patient management with lower intervention rates.

[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.

New technologies and advances in colposcopic assessment

To have a good grasp of clinical colposcopy, it is necessary to understand the histopathologic structure of the normal and dysplastic cervical epithelium. Previous meta-analyses had indicated high overall sensitivity of colposcopy in detecting dysplastic lesions, but recent studies have suggested that the technique has much lower sensitivity in detecting high-grade intraepithelial neoplasia. The best practice in colposcopy relies on accurately taking a biopsy from the correct (i.e. most morphological abnormal) site, and by taking more than one biopsy, the sensitivity for detection of high-grade cervical intraepithelial neoplasia can be increased. Cytological screening programmes of proven and maintained high quality will enhance the predictive colposcopic accuracy for high-grade cervical intraepithelial neoplasia after referral. With the advent of computerised colposcopy and the Internet, digital imaging can be transmitted in real-time for instant viewing, facilitating distant consultation and education. This form of 'telemedicine' will allow family practice and remote areas to have access to colposcopy expertise. Of all the currently available technological adjuncts to colposcopy, spectroscopy devices have demonstrated relatively high sensitivities, and seem to have the best potential to become the technique of choice in future routine clinical practice in developed countries following the human papillomavirus vaccination. Other alternatives may need to be used in parts of the globe with high disease incidence and without organised screening or vaccination programmes. Opportunities remain for global collaboration in research, education and training to promote more effective and affordable cervical screening, and to enhance the skills of colposcopists worldwide.

The accuracy of colposcopic biopsy: analyses from the placebo arm of the Gardasil clinical trials

We evaluated the overall agreement between colposcopically directed biopsies and the definitive excisional specimens within the context of three clinical trials. A total of 737 women aged 16-45 who had a cervical biopsy taken within 6 months before their definitive therapy were included. Per-protocol, colposcopists were to also obtain a representative cervical biopsy immediately before definitive therapy. Using adjudicated histological diagnoses, the initial biopsies and the same day biopsies were correlated with the surgically excised specimens. The overall agreement between the biopsies taken within 6 months of definitive therapy, and the definitive therapy diagnoses was 42% (weighted kappa = 0.34) (95% CI: 0.29-0.39). The overall underestimation of cervical intraepithelial neoplasia grade 2/3 or adenocarcinoma in situ (CIN2-3/AIS) and CIN3/AIS was 26 and 42%, respectively. When allowing for one degree of variance in the correlation, the overall agreement was 92% for CIN2-3/AIS. The overall agreement between the same day biopsy and definitive therapy specimen was 56% (weighted kappa = 0.41) (95% CI: 0.36-0.47), and the underestimation of CIN2-3/AIS was 57%. There were significant associations in the agreement between biopsies and excisional specimen diagnoses when patients were stratified by age, number of biopsies, lesion size, presence of human papillomavirus (HPV)16/18 and region. Of 178 diagnostic endocervical curettages performed, 14 (7.9%) found any HPV disease. Colposcopic accuracy improved when CIN2 and CIN3/AIS were grouped as a single predictive measure of high-grade disease. Colposcopy functioned well when allowed a one-degree difference between the biopsy and the surgical histologic interpretations, as done in clinical practice. Taking more than one biopsy improved colposcopic accuracy and could improve patient management.

Population-based frequency assessment of HPV-induced lesions in patients with borderline Pap tests in the Emilia-Romagna Region: the PATER study

BACKGROUND

The PATER study assessed the frequency of high-risk (HR) and low-risk (LR) human papillomavirus (HPV) in HPV-induced lesions in patients with borderline cytology.

METHODS

This retrospective observational cohort study was designed to evaluate ASCUS patients detected through a local cervical cancer screening programme and referred to the Department of Gynaecology and Obstetrics at the S. Orsola-Malpighi University Hospital in Bologna, in the period between January 2000 and December 2007.

RESULTS

In 1047 patients aged 38.4 ± 9.6 years (range 23-65 years), 34.8% (n = 364) was positive for HR- or LR-HPV DNA. The mean age of women with HPV infection was significantly lower compared with the negative group (36.8 ± 9.4 versus 39.3 ± 9.6 years; p < 0.001). Overall, 357 (34.1%) women had cervical lesions: 279 (26.6%) had CIN1, 18 (1.7%) CIN2, and 60 (5.7%) CIN3+. HR-HPV genotype was detected in 83.3%, and 91.5% of patients with CIN2 and CIN3+ respectively. Among the 124 CIN1 HPV-positive women, 8.9% harboured LR-HPV genotypes, 80.6% HR-HPV and 10.5% a combination of HR- and LR-HPV. HPV-6 and 11 accounted for 19.4% of all HPV-positive CIN1 lesions.

CONCLUSION

Our study suggest that: in ASCUS patients over 40 years there is a low risk of positivity for HPV infection; the HPV DNA testing in patients with CIN3+ and a mean age close to 40 years is highly sensitive (98.3%) and acceptably specific (75.5%); the frequency of LR-HPV (alone or in combination with HR) in ASCUS cytology is not negligible. A tetravalent-based HPV vaccination alongside the screening programme would provide considerable clinical, organizational, and economic benefits.

Random biopsy after colposcopy-directed biopsy improves the diagnosis of cervical intraepithelial neoplasia grade 2 or worse

OBJECTIVES

To evaluate the usefulness of additional random biopsies in the diagnosis of cervical intraepithelial neoplasia grade 2 (CIN 2) or worse (CIN 2+) after colposcopy-directed biopsy.

MATERIALS AND METHODS

A retrospective chart review was performed in 107 women with satisfactory colposcopy results after colposcopy-directed biopsy with random biopsy for abnormal cervical cytological evaluation at Soonchunhyang University Hospital between April 2008 and November 2009. Random biopsies were performed at the cervical squamocolumnar junction in lesion-free quadrants of the cervix. Loop electrosurgical excision procedure conizations were performed in 59 women. Age, referral cytology, lesion size, human papilloma virus (HPV) viral load, and HPV type were analyzed as possible indicators of lesion severity detected using random biopsy.

RESULTS

The mean age was 39.3 years (range = 21-72 y), and 96 (89.7%) women were premenopausal. Sixty-three women had CIN 2+; of those, 8 (12.7%) were diagnosed using random biopsies: 6 had high-grade squamous intraepithelial lesions; 1 had low-grade squamous intraepithelial lesions; and 1 had atypical squamous cells of undetermined significance. Lesions diagnosed as CIN 2+ using random biopsies were significantly correlated with high-grade cytology (p <.001) and lesion size (p <.001) but not age (cutoff = 40 years), HPV viral load (cutoff = 300 relative light units; Hybrid Capture 2), or HPV genotype. Of 59 patients who underwent loop electrosurgical excision procedure conization, the disease severity of 9 (15.3%) cases was upgraded 1 or more grades, compared with the punch biopsy results.

CONCLUSIONS

The detection of CIN 2+, particularly high-grade cytological abnormalities and large lesion size, can be increased by additional random biopsies after satisfactory colposcopy. Loop electrosurgical excision procedure conization can detect lesions not detected by punch biopsy.

Evaluation of 'see-see and treat' strategy and role of HIV on cervical cancer prevention in Uganda

Background

There is scant information on whether Human Immunodeficiency Virus (HIV) seropositivity has an influence on the outcome of treatment of precancerous cervical lesions using cryotherapy. We studied the prevalence of cervical abnormalities detectable by visual inspection and cervical lesions diagnosed by colposcopy according to HIV serostatus and described the outcomes of cryotherapy treatment.

Methods

Trained nurses examined women not previously screened for cervical cancer using visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) in two family planning/post natal clinics in Kampala, Uganda, from February 2007 to August 2008. Women with abnormal visual inspection findings were referred for colposcopic evaluation and HIV testing. Women with precancerous cervical lesions detected at colposcopy were treated mainly by cryotherapy, and were evaluated for treatment outcome after 3 months by a second colposcopy.

Results

Of the 5 105 women screened, 834 presented a positive screening test and were referred for colposcopy. Of these 625 (75%) returned for the colposcopic evaluation and were tested for HIV. For the 608 (97.5%) women in the age range 20-60 years, colposcopy revealed 169 women with cervical lesions: 128 had inflammation, 19 had low grade squamous intraepithelial lesion (LGSIL), 13 had high grade squamous intraepithelial lesion (HGSIL), 9 had invasive cervical cancer and 2 had inconclusive findings. Detection rates per 1 000 women screened were higher among the older women (41-60 years) compared to women aged 20-40 years. They were accordingly 55% and 20% for inflammation, 10% and 2% for LGSIL, 5% and 2% for HGSIL, 6% and 1% for invasive cervical cancer.

Of the 608 women, 103 (16%) were HIV positive. HIV positivity was associated with higher likelihood of inflammation (RR = 1.7; 95% CI: 1.2-2.4).

Conclusions

Detection rates were higher among older women 41-60 years. Visual inspection of the cervix uteri with acetic acid (VIA) and Lugol's iodine (VILI) used as a sole method for cervical cancer screening would entail significant false positive results. HIV seropositivity was associated with a higher prevalence of inflammatory cervical lesions. In view of the small numbers and the relatively short follow up time of 3 months, we could not make an emphatic conclusion about the effect of HIV serostatus on cryotherapy treatment outcome.

The accuracy of colposcopic grading for detection of high-grade cervical intraepithelial neoplasia

OBJECTIVE

To relate aspects of online colposcopic image assessment to the diagnosis of grades 2 and 3 cervical intraepithelial neoplasia (CIN 2+).

METHODS

To simulate colposcopic assessment, we obtained digitized cervical images at enrollment after acetic acid application from 919 women referred for equivocal or minor cytologic abnormalities into the ASCUS-LSIL Triage Study. For each, 2 randomly assigned evaluators from a pool of 20 colposcopists assessed images using a standardized tool online. We calculated the accuracy of these assessments for predicting histologic CIN 2+ over the 2 years of study. For validation, a subset of online results was compared with same-day enrollment colposcopic assessments.

RESULTS

Identifying any acetowhite lesion in images yielded high sensitivity: 93% of women with CIN 2+ had at least 1 acetowhite lesion. However, 74% of women without CIN 2+ also had acetowhitening, regardless of human papillomavirus status. The sensitivity for CIN 2+ of an online colpophotographic assessment of high-grade disease was 39%. The sensitivity for CIN 2+ of a high-grade diagnosis by Reid Index scoring was 30%, and individual Reid Index component scores had similar levels of sensitivity and specificity. The performance of online assessment was not meaningfully different from that of same-day enrollment colposcopy, suggesting that these approaches have similar utility.

CONCLUSIONS

Finding acetowhite lesions identifies women with CIN 2+, but using subtler colposcopic characteristics to grade lesions is insensitive. All acetowhite lesions should be assessed with biopsy to maximize sensitivity of colposcopic diagnosis with good specificity.

The role of deeper levels and ancillary studies (p16(Ink4a) and ProExC) in reducing the discordance rate of Papanicolaou findings of high-grade squamous intraepithelial lesion and follow-up cervical biopsies

BACKGROUND

Discordant results of cervical biopsy histology after a cytologic diagnosis of high-grade squamous intraepithelial lesion (HSIL) are often attributed to sampling variation. The purpose of the current study was to determine whether deeper levels and ancillary staining (p16(Ink4a) and ProExC) reduce the discordant rate.

METHODS

A total of 246 cases of HSIL were retrieved from the computerized database from 2005 and 2006. Of these cases, 151 were followed by cervical biopsy. There was cytologic-histologic correlation in 87 cases, as defined by the presence of high-grade (2 or 3) cervical intraepithelial neoplasia (HGCIN). For each discordant biopsy (n = 64), 2 deeper levels for hematoxylin and eosin (H&E) were taken at 30-micro and 90-micro depths, and 4 sections for p16(Ink4a) and ProExC staining were taken at a 60-micro depth. All cytologic and histologic material from these 64 cases was reviewed by 3 cytopathologists. In 2 cases, the original HSIL diagnoses were downgraded and the cases censored from the study.

RESULTS

Fifty-seven of the 62 discordant cases had sufficient tissue for deeper levels and ancillary staining. Two of 57 cases were reclassified to HGCIN. In both of these cases, reclassification was suggested by results of immunostains; however, the H&E sections were necessary for definitive interpretation of the immunostain results.

CONCLUSIONS

In the current study, deeper levels and ancillary staining with p16(Ink4a) and ProExC did not significantly reduce the discordance rate. Although there are many known causes of sampling variation, including factors related to colposcopic technique, regression of infection, and insufficient histologic sectioning, sampling variation remains a valid justification of noncorrelation in women with HSIL followed up by cervical biopsy alone.

A tissue basis for colposcopic findings

Colposcopic changes are related to the variable degrees of white light that are absorbed and reflected by the cervix. The interface between the surface and the underlying vascular stroma consists of cells with variable amounts of nuclei and cytoplasm. Changes in the cell microanatomy, as well as microvessel growth related to different normal and abnormal cervical environments will dictate the color and vascular appearance of the colposcopically viewed cervix.

New approaches to cervical cancer screening in Latin America and the Caribbean

Cervical cancer remains an important public health problem in the Latin America and Caribbean region (LAC), with an expected significant increase in disease burden in the next decades as a result of population ageing. Prophylactic human papillomavirus (HPV) vaccine is currently unaffordable in LAC countries. However, even if vaccination was implemented, an additional two decades will be required to observe its impact on HPV related disease and cancer. With some exceptions, cytology-based screening programs have been largely ineffective to control the problem in the region, and there is a need for new approaches to the organization of screening and for use of newly developed techniques. Several research groups in LAC have conducted research on new screening methods, some of which are summarized in this paper. A recommendation to reorganize screening programs is presented considering visual inspection for very low resource areas, improvement of cytology where it is operating successfully and HPV DNA testing followed by visual inspection with acetic acid (VIA) or cytology as soon as this method becomes technically and economically sustainable. This could be facilitated by the incorporation of new, low-cost HPV DNA testing methods and the use of self-collected vaginal specimens for selected groups of the population. An important requisite for screening based on HPV testing will be the quality assurance of the laboratory and the technique by validation and certification measures.

Advances in treatment options of endometriosis

Endometriosis, defined as the presence of endometrial tissue outside the uterus, is a challenging condition associated with substantial morbidity. Management of endometriosis must be individualized according to the desired treatment outcome, whether it is relief of pain, improvement of fertility, or the prevention of recurrence. For alleviation of endometriosis-associated pain, medical treatment is generally successful, with no medical agent being more efficacious than another in spite of significantly differing side-effect profiles. Surgical therapy has also been demonstrated to reduce pain scores in comparison with expectant management, although conservative surgery has been frequently associated with recurrence. The efficacy of combination therapies still remains to be clarified. For treatment of endometriosis-associated infertility, suppressive medical treatment has been proven to be detrimental to fertility and should be discouraged, while surgery is probably efficacious for all stages. Controlled ovarian hyperstimulation with intrauterine insemination is recommended in early-stage and surgically corrected endometriosis. Combined surgery with GnRH analog treatment has been proposed to be first-line therapy, followed by IVF as second-line therapy in advanced cases. More rigorously designed randomized clinical trials focusing on the endocrinological, immunological, and genetic aspects of endometriosis are necessary to refine conclusions regarding the etiopathogenesis and therapeutic innovations of this perplexing disease.

Use of compact digital cervicography: an adjuvant screening tool for precancerous cervical lesions

OBJECTIVE

In an attempt to develop a new model to screen for cervical cancer, we set up a digital camera mounted with a macro lens for cervicography. This digitalized compact form of cervicography with the Reid colposcopic index (RCI) can be applied as an adjuvant tool to screen for abnormal Papanicolaou (Pap) smears.

MATERIALS AND METHODS

Among 21,532 cases screened with a Pap smear, we enrolled 125 cases with precancerous smears for this prospective study. An 8-megapixel Canon digital camera with a macro lens and a light source comprised the compact digital cervicographic system. The results of compact digital cervicography were reported using the RCI scoring system. Cases with high-grade squamous intraepithelial lesion or atypical glandular cells of undetermined significance were transferred to medical centers for further confirmation and management. In total, 119 cases underwent compact digital cervicography. The data were analyzed with the McNemar test.

RESULTS

With the digitized results of compact digital cervicography, we were able to show patients with precancerous Pap smears their cervix and help them understand its status. For patients with an abnormal Pap smear, the results of performing compact digital cervicography combined with the RCI scoring system were statistically significant (p < 0.05).

CONCLUSION

The use of compact digital cervicography with the RCI scoring system is a significant device for screening abnormal Pap cases. It helps to improve patient care. Further research is required to understand the discrepancies among diagnostic results of Pap smears (the Bethesda system), cervicography with RCI, and histopathology.

Interobserver agreement in the assessment of components of colposcopic grading

OBJECTIVE

To estimate the reproducibility of the assessment of visual characteristics of cervical lesions used to judge lesion grade from colposcopy.

METHODS

Digitized cervical images from 862 women enrolled in the ASCUS-LSIL Triage Study were obtained after application of 5% acetic acid. Each image was later assessed online by two randomly assigned evaluators from a pool of 20 experienced colposcopists. Interobserver agreement beyond chance was assessed by kappa statistics.

RESULTS

Of 862 evaluable images with paired assessments, 607 were considered to have an acetowhite lesion by both evaluators, 171 by one, and 84 by neither. Kappa values (95% confidence intervals) for agreement were 0.22 (0.17-0.27) for color, 0.24 (0.18-0.30) for margins, 0.22 (0.16-0.29) for mosaicism, 0.17 (0.11-0.23) for punctation, 0.11 (0.00-0.22) for atypical vessels, and 0.26 (0.22-0.31) for modified Reid Index score.

CONCLUSION

Characteristics used to assign colposcopic grade are poorly reproducible when used to assess static cervical images from women with borderline cytology results.

LEVEL OF EVIDENCE

II.