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

Human Papillomavirus Infection and Cytological Atypia in Female Allogeneic Hematopoietic Stem Cell Transplantation Recipients

BACKGROUND

Female recipients of allogeneic hematopoietic stem cell transplantation are at high risk of developing human papillomavirus (HPV)-associated lesions and (pre)cancer. We describe the results of a cervical cancer screening program in these women.

METHODS

From 2010 to 2022, 70 female recipients of allogeneic hematopoietic stem cell transplantation in our institution entered a standardized protocol of gynecological evaluation. HPV testing, Papanicolaou smear, and thorough gynecological examinations were conducted in all the women.

RESULTS

The cumulative prevalence of HPV infection was 21.4% (15/70). Ten of 70 women (14.3%) had a positive HPV test result in the first gynecological evaluation and 5 additional women (7.1%) became positive during follow-up. Thirteen women (18.5%) presented cytohistological lesions (3 high-grade lesions and 10 low-grade lesions). Twenty-nine women (41.4%) showed HPV-negative reactive atypical abnormalities related to the conditioning treatment, which closely mimicked HPV-associated lesions, which spontaneously disappeared during follow-up.

CONCLUSIONS

Gynecological evaluation should be maintained over time, as a significant proportion of these women may become HPV positive during follow-up. Reactive benign, atypical changes related to the treatment, which closely mimic HPV-associated lesions, are a frequent finding in these women. HPV testing is a key tool for the evaluation of these patients, as it allows for identifying women at risk and excluding cytological mimickers.

Role of DNA ploidy in diagnosis and prognosis of high-grade cervical intraepithelial neoplasia: A prospective cohort study

OBJECTIVE

To compare the sensitivity and specificity of DNA ploidy with cytology, human papillomavirus (HPV) testing and colposcopy in diagnosis of high-grade cervical intraepithelial neoplasia (CIN) and to assess the role of aneuploidy in cervical lesions with the worst prognosis. A prospective observational cohort study was conducted on 254 women with altered colpocytology.

METHODS

Colposcopy, biopsy, DNA-ICM and HPV examinations were applied to cervical cytological and histological samples. Participants were evaluated every 6 months and divided into two groups: 'Harm' and 'No-harm'. Logistic regression and multivariate COX model were used to identify independent risk factors for diagnosis and prognosis of high-grade CIN, and ROC curve to assess the sensitivity and specificity of methods.

RESULTS

Variables 'age greater than or equal to 30 years', 'lesion size greater than 20%', 'aneuploidy' and 'HPV 16' were associated with diagnosis of high-grade CIN and 'aneuploidy' and 'women living with HIV', with a worse prognosis. Agreement for colposcopy was good, with a sensitivity of 79.3% and specificity of 94.4%; DNA-ICM and cytology were moderate, with sensitivity of 74.6% and 72.3% and specificity of 85.3% and 76.1%, respectively. High-risk HPV and HPV 16 tests were weak, with sensitivity of 75.0% and 43.75% and specificity of 50.0% and 88.64%, respectively.

CONCLUSIONS

In relation to high-grade CIN diagnosis, DNA-ICM presented similar sensitivity and specificity to cytology and high-risk HPV test when associated with HPV 16. Regarding prognosis, this research certifies that aneuploidy is considered a predictor of more severe cervical injury.

Distribution of cervical intraepithelial neoplasia is closely associated with HPV status and uterine position

Although cervical intraepithelial neoplasia (CIN) lesions are considered to be not randomly distributed across the cervix, but predominantly in the anterior wall, the clinicopathological etiology remains unknown. Herein, we aimed to elucidate the relationship between quantitatively measured area of CIN2/3 and cervical cancer associated factors by retrospective cohort study. We analyzed 235 consecutive therapeutic conization specimens dissected as a single intact section to determine CIN2/3 area and its correlation with both clinical risk factors including human papillomavirus (HPV) status (single or multiple infection) and uterine position defined by transvaginal ultrasound. Cervical wall was classified into three groups: anterior: (11, 12, 1, and 2 o'clock), posterior (5, 6, 7, and 8 o'clock) and lateral (3, 4, 9, and 10 o'clock). Multiple regression revealed that younger age and HPV16 status were significantly correlated with CIN2/3 area (p = 0.0224 and p = 0.0075, respectively). The Jonckheere-Terpstra test showed a significant trend: CIN2/3 area was highest in the single HPV16 group, followed by the multiple HPV16 group and the non-HPV16 group (p < 0.0001). CIN2/3 area in the anterior wall was statistically significantly larger than the posterior and lateral wall (p = 0.0059 and p = 0.0107, respectively). CIN2/3 area in the anterior wall was significantly greater with anteversion-anteflexion than retroversion-retroflexion (p = 0.0485), whereas CIN2/3 area in the posterior wall was significantly larger with retroversion-retroflexion than anteversion-anteflexion (p = 0.0394). In conclusion, the topographical distribution of CIN2/3 area is closely associated with patient age, high-risk HPV status, especially single HPV16 infection and uterine position.

Colposcopic accuracy in diagnosing squamous intraepithelial lesions: a systematic review and meta-analysis of the International Federation of Cervical Pathology and Colposcopy 2011 terminology

BACKGROUND

Colposcopy is an important tool in diagnosing cervical cancer, and the International Federation of Cervical Pathology and Colposcopy (IFCPC) issued the latest version of the guidelines in 2011. This study aims to systematically assess the accuracy of colposcopy in predicting low-grade squamous intraepithelial lesions or worse (LSIL+) / high-grade squamous intraepithelial lesions or worse (HSIL+) under the 2011 IFCPC terminology.

METHODS

We performed a systematic review and meta-analysis, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched for studies about the performance of colposcopy in diagnosing cervical intraepithelial neoplasia under the new IFCPC colposcopy terminology from PubMed, Embase, Web of Science and the Cochrane database. Data were independently extracted by two authors and an overall diagnostic performance index was calculated under two colposcopic thresholds.

RESULTS

Totally, fifteen articles with 22,764 participants in compliance with the criteria were included in meta-analysis. When colposcopy was used to detect LSIL+, the combined sensitivity and specificity were 0.92 (95% CI 0.88-0.95) and 0.51 (0.43-0.59), respectively. When colposcopy was used to detect HSIL+, the combined sensitivity and specificity were 0.68 (0.58-0.76) and 0.93 (0.88-0.96), respectively.

CONCLUSION

In accordance with the 2011 IFCPC terminology, the accuracy of colposcopy has improved in terms of both sensitivity and specificity. Colposcopy is now more sensitive with LSIL+ taken as the cut-off value and is more specific to HSIL+. These findings suggest we are avoiding under- or overdiagnosis both of which impact on patients' well-being.

Transfer learning supported accurate assessment of multiclass cervix type images

Cervical cancer predominately affects women compared to lung, breast and endometrial cancer. Premature stage identification and proper treatment of this cancer may lead to 100% survival rate. The cervix type is very prominent in the detailed diagnosis of cervical cancer. High expertise and experienced gynecologist are required for an accurate diagnosis of cervical cancer. To reduce their burden, a model is proposed, based on deep learning that automatically classifies the cervix types. This paper presents Modified Deep Convolutional Neural Networks namely Modified VGG16 (MVGG16), Modified VGG19 (MVGG19), Modified ResNet50 (MRN50), Modified InceptionV3 (MIV3), and Modified InceptionResNetV2 (MIRNV2) for the classification of cervix type images. These modified networks are implemented using a Multiclass Support Vector Machine classifier. The performance metrics are tabulated and compared with pre-trained models. The simulation results show that MIRNV2 achieves the best performance compared to other models with an overall Accuracy of 92.91% and a Kappa score of 0.88. MIRNV2 model also gives better classification accuracy of 96.62% for type 1, 93.58% for type 2, and 95.61% for type 3 cervix images. Hence, this facilitates the application of MIRNV2 as a diagnostic tool to assist the gynecologist in the classification of cervix type images.

Inter- and intra-observer agreement in the assessment of the cervical transformation zone (TZ) by visual inspection with acetic acid (VIA) and its implications for a screen and treat approach: a reliability study

BACKGROUND

In low-resource countries, interpretation of the transformation zone (TZ) using the classification of the International Federation for Cervical Pathology and Colposcopy (IFCPC), adopted by the World Health Organization, is critical for determining if visual inspection with acetic acid (VIA) screening and thermal ablation treatment are possible. We aim to assess inter- and intra-observer agreement in TZ interpretation.

METHODS

We performed a prospective multi-observer reliability study. One hundred cervical digital images of Human papillomavirus positive women (30-49 years) were consecutively selected from a Cameroonian cervical cancer screening trial. Images of the native cervix and after VIA were obtained. The images were evaluated for the TZ type at two time points (rounds one and two) by five VIA experts from four countries (Côte d'Ivoire, Cameroon, Peru, and Zambia) according to the IFCPC classification (TZ1 = ectocervical fully visible; TZ2 = endocervical fully visible; TZ3 = not fully visible). Intra- and inter-observer agreement were measured by Fleiss' kappa.

RESULTS

Overall, 37.0% of images were interpreted as TZ1, 36.4% as TZ2, and 26.6% as TZ3. Global inter-observer reliability indicated fair agreement in both rounds (kappa 0.313 and 0.288). The inter-observer agreement was moderate for TZ1 interpretation (0.460), slight for TZ2 (0.153), and fair for TZ3 (0.329). Intra-observer analysis showed fair agreement for two observers (0.356 and 0.345), moderate agreement for two other (0.562 and 0.549), and one with substantial agreement (0.728).

CONCLUSION

Interpretation of the TZ using the IFCPC classification, adopted by the World Health Organization, is critical for determining if VIA screening and thermal ablation treatment are possible. However, the low inter- and intra-observer agreement suggest that the reliability of the referred classification is limited in the context of VIA. It's integration in treatment recommendations should be used with caution since TZ3 interpretation could lead to an important referral rate for further evaluation. Trial registration Cantonal Ethics Board of Geneva, Switzerland: N°2017-0110. Cameroonian National Ethics Committee for Human Health Research N°2018/07/1083/CE/CNERSH/SP.

Risk Factors Associated with CIN2+ in Spanish Patients with L-SIL/ASCUS Cytology Collected from a Madrid Hospital

The management of patients with L-SIL/ASCUS cytology is controversial and not clearly standardized.

OBJECTIVE

To analyze the risk factors associated with H-SIL/CIN2+ in a cohort of patients with ASCUS or L-SIL in a Pap smear.

METHODS

Between 2012 and 2022, 1259 eligible women with ASCUS/L-SIL were referred for colposcopy. The risk factors associated with H-SIL/CIN2+ were analyzed. The colposcopic study, conventional or assisted with dynamic spectral imaging (DSI), was performed in all cases. Guided biopsies were performed in cases of abnormal examination or random biopsies when no lesions were found. A LEEP was performed in H-SIL/CIN2+ results or persistent LSIL/CIN.

RESULTS

A normal or metaplastic specimen was found in 750 women (63.2%), LSIL/CIN1 in 346 (29.1%), and H-SIL/CIN2+ in 92 (7.7%). The presence of HR-HPV (OR = 2.1; IC 95% = 1.4-3.2), smoking habits (OR = 2.2; IC 95% = 1.4-3.5), and the performance of DSI combined with colposcopy (OR = 0.6; IC 95% = 0.37-0.83) were the factors associated with the detection of H-SIL/CIN2+. A summative effect of HR-HPV and smoking habit (OR = 2.9; IC 95% = 1.7-5.0) was observed in the detection of H-SIL/CIN2+. In multivariate analysis, the presence of HPV 16/18 was the unique independent factor associated with H-SIL/CIN2+.

CONCLUSION

In women carrying an ASCUS/LSIL in the Pap smear, the unique independent factor predictive of H-SIL/CIN2+ is the presence of the HPV 16/18 genotype. Smoking women carrying ASCUS/LSIL with HR-HPV should be targeted for stricter follow-up to avoid an unsuspected H-SIL/CIN2+.

Endocervical Margins Status in Excision for Preventing Cervical Cancer According to the Transformation Zone Type

OBJECTIVE

The aim of this study is to assess the outcomes of 610 excision types I and II in a referral facility as a function of transformation zone (TZ) types.

METHODS

This is a retrospective cohort study of women with cervical precursor lesions who underwent loop electrocautery excision procedure from 2017 to 2019 at the University of Campinas. The primary outcome was endocervical margin status, negative or positive. Other variables were excision type (I/II), TZ (1/2/3), age, menopausal status, hormonal contraceptives, smoking, and sexual debut. Tests used were chi-square or Fisher exact, Mann-Whitney, and simple and multiple logistic regression.

RESULTS

The most frequent was TZ 1 (62.5%). Excision II was the most frequent: 54.1% in TZ 1, 67.2% in TZ 2, and 82.1% in TZ 3. A negative margin was observed in TZ 1, 76.0% when excision I and 86.4% when excision II ( p = .009); TZ 2, 86.4% when excision I and 88.9% when excision II ( p = .672); and TZ 3, 76.5% when excision I and 78.9% when excision II ( p = .672). Multivariate analysis revealed in TZ 1 a 2.12 (1.23-3.65) higher risk of obtaining a negative margin in excision type II. In TZ 2 and 3, none of the variables predicted the chance of a negative margin.

CONCLUSIONS

The endocervical margin was negative in 3 in every 4 women who underwent loop electrocautery excision procedure, regardless of excision type. Age, menopausal status, smoking, and hormonal contraception did not predict margin status.

Usefulness of E7 mRNA in HPV16-Positive Women to Predict the Risk of Progression to HSIL/CIN2

Objective: To evaluate whether E7 mRNA can predict the risk of progression in women with HPV16 infection. Design: A prospective observational study. Setting: A tertiary university hospital. Population: A cohort of 139 women referred to colposcopy for an abnormal screening result fulfilling the following inclusion criteria: (1) a positive test result confirming HPV16 infection; (2) a biopsy sample with a histological diagnosis of an absence of lesion or low-grade SIL/CIN grade1 (LSIL/CIN1); (3) no previous HPV vaccination; (4) no pregnancy; and (5) no previous cervical treatments; and (6) no immunosuppression. Methods: At the first visit, all women underwent a cervical sample for liquid-based cytology, HPV testing and genotyping, and HPV16 E7 mRNA analysis and a colposcopy with at least one colposcopy-guided biopsy. Follow-up visits were scheduled every six months. In each control, a liquid-based Pap smear, HPV testing, as well as a colposcopy examination with biopsy if necessary were performed. Main outcome measures: Histological diagnosis of HSIL/CIN2+ at any time during follow-up. Results: E7 mRNA expression was positive in 55/127 (43.3%) women included in the study and seven (12.7%) progressed to HSIL/CIN2+. In contrast, only 1/72 (1.4%) women with no HPV16 E7 mRNA expression progressed (p = 0.027). HPV16 E7 mRNA expression was associated with a 10-fold increased risk of progression (HR 10.0; 95% CI 1.2–81.4). Conclusions: HPV16 E7 mRNA could be useful for risk stratification of women with HPV16 infection in whom a HSIL/CIN2+ has been ruled out. Funding: Instituto de Salud Carlos III (ICSIII)-Fondo de Investigación Sanitaria and ERDF ‘One Way to Europe’ (PI17/00772).

Colposcopic Impression Has a Key Role in the Estimation of the Risk of HSIL/CIN3

Simple Summary

Colposcopy impression could provide valuable information for risk estimation. We aimed to analyze the value of adding colposcopy impression to screening tests for the diagnosis of high-grade squamous intraepithelial lesion/grade 3 cervical intraepithelial neoplasia (HSIL/CIN3) in 302 women referred for colposcopy due to abnormal screening results. At least 30% of the women with grade 2 colposcopy findings had HSIL/CIN3, independent of the screening test results. Among women with an HSIL Pap smear and grade 2 colposcopy findings, 53.3% had HSIL/CIN3 independently of the hrHPV genotype. The prevalence of HSIL/CIN3 in women with <HSIL Pap smear, non-HPV 16/18 infection, and normal colposcopy or with grade 1 findings was 2.9% and 8.1%, respectively. In conclusion, a colposcopic impression provides essential information to identify women at risk of HSIL/CIN3.

Abstract

Recently published guidelines stratify the risk of high-grade squamous intraepithelial lesion/grade 3 cervical intraepithelial neoplasia (HSIL/CIN3) based on hrHPV detection and Pap smear results. However, colposcopic impression could also provide valuable information for risk estimation. We aimed to analyze the value of adding colposcopic impression to screening tests for the diagnosis of HSIL/CIN3 in 302 women referred for colposcopy due to an abnormal Pap smear. All women underwent hrHPV detection and genotyping (HPV 16/18 vs. non-16/18 hrHPV), Pap smear, and colposcopy with at least one biopsy. HSIL Pap smear, HPV 16/18, and grade 2 colposcopy findings increased the risk of HSIL/CIN3 in the univariate analysis but only colposcopy retained significance in the multivariate model. At least 30% of the women with grade 2 colposcopy findings had HSIL/CIN3, independent of the screening test results. Among women with an HSIL Pap smear and grade 2 colposcopy findings, 53.3% had HSIL/CIN3 independently of the hrHPV genotype. Contrarily, the prevalence of HSIL/CIN3 in women with <HSIL Pap smear, non-HPV 16/18 infection, and normal colposcopy or with grade 1 findings was 2.9% and 8.1%, respectively. In conclusion, colposcopy impression provides essential information to identify women at risk of HSIL/CIN3.

The application of deep learning based diagnostic system to cervical squamous intraepithelial lesions recognition in colposcopy images

Background Deep learning has presented considerable potential and is gaining more importance in computer assisted diagnosis. As the gold standard for pathologically diagnosing cervical intraepithelial lesions and invasive cervical cancer, colposcopy-guided biopsy faces challenges in improving accuracy and efficiency worldwide, especially in developing countries. To ease the heavy burden of cervical cancer screening, it is urgent to establish a scientific, accurate and efficient method for assisting diagnosis and biopsy. Methods The data were collected to establish three deep-learning-based models. For every case, one saline image, one acetic image, one iodine image and the corresponding clinical information, including age, the results of human papillomavirus testing and cytology, type of transformation zone, and pathologic diagnosis, were collected. The dataset was proportionally divided into three subsets including the training set, the test set and the validation set, at a ratio of 8:1:1. The validation set was used to evaluate model performance. After model establishment, an independent dataset of high-definition images was collected to further evaluate the model performance. In addition, the comparison of diagnostic accuracy between colposcopists and models weas performed. Results The sensitivity, specificity and accuracy of the classification model to differentiate negative cases from positive cases were 85.38%, 82.62% and 84.10% respectively, with an AUC of 0.93. The recall and DICE of the segmentation model to segment suspicious lesions in acetic images were 84.73% and 61.64%, with an average accuracy of 95.59%. Furthermore, 84.67% of high-grade lesions were detected by the acetic detection model. Compared to colposcopists, the diagnostic system performed better in ordinary colposcopy images but slightly unsatisfactory in high-definition images. Implications The deep learning-based diagnostic system could help assist colposcopy diagnosis and biopsy for HSILs.

Cervical Digital Photography: An Alternative Method to Colposcopy

OBJECTIVE

This study sought to evaluate the performance of cervical digital photography as an alternative to colposcopy.

METHODS

Colposcopy and cervical digital photography were performed on 228 women. The cervical digital photographs were evaluated through the Internet by three colposcopy experts. The agreement between methods was calculated with kappa and percentages of agreement. Next, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were calculated for colposcopy and cervical digital photography. Histology was used as the gold standard (Canadian Task Force Classification II-2).

RESULTS

Cervical digital photography and colposcopy were in agreement in 89.9% of the cases (κ = 0.588). Cervical digital photography had higher sensitivity (52.5%) and positive predictive value (60%) than colposcopy (35% and 48.28%, respectively). There were no other significant differences between cervical digital photography and colposcopy: specificity was 91.86% and 91.28%, negative predictive value was 89.3% and 85.8%, and diagnostic accuracy was 84.4% and 80.7%, respectively.

CONCLUSION

Cervical digital photography is a promising alternative method to colposcopy.

Value of HPV 16/18 Genotyping and p16/Ki-67 Dual Staining to Predict Progression to HSIL/CIN2+ in Negative Cytologies From a Colposcopy Referral Population

OBJECTIVES

To assess the prognostic value of human papillomavirus (HPV) 16/18 genotyping and p16/Ki-67 dual staining cytology in high-risk HPV (hrHPV)-positive women with no lesion or minor abnormalities.

METHODS

We evaluated progression to high-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia grades 2 to 3 or cervical cancer (HSIL/CIN2+), persistence/regression of hrHPV infection in women referred to colposcopy showing hrHPV infection, histology diagnosis different from HSIL/CIN2+, and negative cytology. HPV 16/18 genotyping and dual staining were performed in liquid-based cytologic specimens obtained on the first visit.

RESULTS

Progression was observed in 16 (8.0%) of 200 women. Those with HPV 16/18 infection had an increased risk of progression compared with women infected by other hrHPV types, and they also showed more persistence. However, no association was observed between progression or persistence and the result of the dual staining.

CONCLUSIONS

HPV 16/18-positive women with no lesions or minor abnormalities are at high risk of progression to HSIL/CIN2+ and hrHPV persistence.

Cross-sectional study of anal intraepithelial lesions in women with cervical neoplasia without HIV

OBJECTIVE

To evaluate the prevalence of anal intraepithelial lesions and associated risk factors in women with cervical neoplasia.

METHODS

The present cross-sectional study enrolled patients with intraepithelial or invasive cervical neoplasia who had been referred to the lower genital tract pathology outpatient department of the Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brazil, between December 1, 2008, and December 31, 2009; patients with HIV infections were excluded. All participants underwent anal cytology and high-resolution anoscopy; sociodemographic and clinical risk factors were identified using multivariate analysis.

RESULTS

There were 324 patients included and 37 (11.4%) had anal intraepithelial neoplasia. Factors associated with anal intraepithelial neoplasia in the multivariate analysis were being older than 35 years of age (P=0.002), having completed no more than 4 years of education (P=0.012), anomalous anal cytology (P=0.003), and anomalous high-resolution anoscopy findings (P<0.001); subclinical HPV lesions on vulvoscopy (P=0.057) were not associated with anal intraepithelial neoplasia.

CONCLUSION

The prevalence of anal intraepithelial neoplasia was high among patients with cervical neoplasia who did not have HIV, particularly patients older than 35 years.

Complication and recurrence rate in laser CO2 versus traditional surgery in the treatment of Bartholin's gland cyst

PURPOSE

The treatment of Bartholin's gland cysts by traditional surgery is characterized by some disadvantages and complications such as hemorrhage, postoperative dyspareunia, infections, necessity for a general anesthesia. Contrarily, CO2 laser surgery might be less invasive and more effective as it solves many problems of traditional surgery. The aim of our study is to describe CO2 laser technique evaluating its feasibility, complication rate and results vs traditional surgery.

METHODS

Among patients treated for Bartholin's gland cyst, we enrolled 62 patients comparing traditional surgical excision vs CO2 laser surgery of whom 27 patients underwent traditional surgery, whereas 35 patients underwent CO2 laser surgery. Mean operative time, complication rate, recurrence rate and short- and long-term outcomes were assessed.

RESULTS

The procedures required a mean operative time of 9 ± 5.3 min for CO2 laser surgery and 42.2 ± 13.8 for traditional surgery. Two patients (5.7 %) needed an hemostatic suture for intraoperative bleeding in the laser CO2 laser technique against 14.8 % for traditional surgery. Carbon dioxide allows a complete healing in a mean time of 22 days without scarring, hematomas or wound infections and a return to daily living in a mean time of 2 days. Instead, patients undergone traditional surgery required a mean time of 14 days to return to daily life with a healing mean time completed in 28 days.

CONCLUSIONS

The minimum rate of intra- and post-operative complications, the ability to perform it under local anesthesia in an outpatient setting make CO2 laser surgery more cost-effective than traditional surgery.

Distribution of cervical intraepithelial neoplasia on the cervix in Chinese women: pooled analysis of 19 population based screening studies

Background

Controversy remains whether a pattern of cervical intraepithelial neoplasia exists on the cervix. Our study aims at determining if the prevalence of histologically proven lesions differs by cervical four-quadrant location or by 12 o'clock surface locations of diagnosis.

Methods

We conducted a retrospective, histopathological study of 19 different population based cervical cancer screening studies from 1999 to 2010 by Cancer Hospital of Chinese Academy of Medical Sciences. The Institutional Review Board for human research subjects at CHCAMS approved all of the studies. During the colposcopy procedure, participant received either 4-quadrant biopsy or directed biopsy with/without endocervical curettage. Data of all samples were stratified by the methods of sampling. Kruskal-Wallis test was used to determine overall distribution of normal/CIN1, CIN2 and CIN3+ on the cervix.

Results

In total, 53,088 cervical samples were included in distribution analysis. 66.9 % samples were obtained by random biopsy, 16.1 % were by directed biopsy, and 17.0 % were by endocervical curettage. 95.9%of the biopsied samples were diagnosed as normal/CIN1, 2.0 % were CIN2, and 2.1 % were CIN3 + . CIN2 and CIN3+ were most often found in quadrants 2 and 3 (χ_KW² = 46.6540, p < 0.0001) and at the 4- and 7-o'clock positions by directed biopsy (OR_CIN2 = 2.572, 1.689, OR_CIN3+ = 3.481, 1.678, respectively), and at the 5-, 6-, 7-, 9- and 12-o’clock positions by random biopsy. CIN3+ was least often found at the 11-o’clock position by directed biopsy (OR = 0.608).

Conclusions

Our results suggest a predisposition of specific locations on the cervix to CIN occurrence. Quadrants 2 and 3, especially the 4- and 7-o’clock positions should be preferentially targeted during biopsy. The decision for random biopsy should be reconsidered in future studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1494-4) contains supplementary material, which is available to authorized users.

A comparison between type 3 excision of the transformation zone by straight wire excision of the transformation zone (SWETZ) and large loop excision of the transformation zone (LLETZ): a randomized study

BACKGROUND

The management of preinvasive cervical lesions has the objective to ensure the absence of invasive lesions and to prevent progression to cancer. Excisional procedures have been preferred to treat these lesions as they report the presence of unsuspected invasive lesions and the status of surgical margins, allowing inferring full excision when such are free of disease. The purpose of this study is to determine whether Straight Wire Excision of the Transformation Zone (SWETZ) is a better alternative than Large Loop Excision of the Transformation Zone (LLETZ-cone) as a type 3 excision of the Transformation Zone (TZ) to reduce incomplete excision and concerning other outcomes of surgical interest.

METHOD

Randomized controlled trial including women who needed type 3 excision of the TZ referred to a colposcopy clinic after cytological screening between January 2008 thru December 2011. The interventions were performed using local anesthesia and sedation in an inpatient basis by different experienced surgeons. The study enrolled and randomized 164 women, of which 82 were allocated to each group. After exclusions, 78 remained in SWETZ and 76 in LLETZ-cone groups for the analysis of outcomes of surgical interest and 52 and 54, respectively, for the margins analysis.

RESULTS

There was an even distribution between the groups after randomization and exclusions, concerning mean age, parity, current smoking, prior cytological diagnosis and histopathological diagnosis obtained in cone specimen even after exclusions. We observed significantly higher risk of compromised or damaged endocervical margin in specimens resulting from the LLETZ-cone in relation to SWETZ (RR 1.72, 95% CI: 1.14 to 2.6), with an absolute risk reduction (ARR) of 26.4% (95% CI: 8.1 to 44.8) for patients operated by SWETZ. The specimens obtained by SWETZ showed less fragmentation (ARR = 19.8%, 95% CI: 10.3 - 29.3%), but the procedure took longer. There were complications in 5.6% of the procedures, with no significant differences between the groups.

CONCLUSION

This study showed a lower proportion of compromised or damaged endocervical surgical margin in specimens resulting from SWETZ in relation to LLETZ-cone. SWETZ demonstrated to be more efficient than LLETZ-cone concerning less fragmentation of the specimen obtained. However, it accounted for longer surgical time. Both techniques showed morbidity

TRIAL REGISTRATION

Number at ClinicalTrials.gov: NCT01929993 (June 10, 2012).