Colposcopic diagnosis and treatment of cervical dysplasia at a single clinic visit. Experience of low-voltage diathermy loop in 1000 patients

Clinical practice variation and overtreatment risk in women with abnormal cervical cytology in the Netherlands: two-step versus see-and-treat approach

BACKGROUND

Only a few small studies have compared the 2-step method (biopsy followed by treatment) with a see-and-treat (immediate treatment) approach in women both low-grade or high-grade referral cytology. The clinical practice variation in the Netherlands has not been reviewed before.

OBJECTIVES

To determine overtreatment rates in the 2-step versus see-and-treat approach in women referred for colposcopy because of abnormal cytology results, and to evaluate clinical practice variation in the Netherlands.

MATERIALS AND METHODS

This was a population-based retrospective cohort study including 36,581 women with a histologic result of the cervix identified from the Dutch Pathology Registry (PALGA) between 2016 and 2017. Odds ratios for overtreatment, defined primarily as cervical intraepithelial neoplasia grade 1 or less, were determined for the 2-step and see-and-treat approach in relation to age, high-risk human papillomavirus status, and referral cytology.

RESULTS

Of the included women 10,713 women (29.3%) received the 2-step method; 6,851 women (18.7%) underwent see-and-treat; and 19,017 women (52.0%) received conservative management after colposcopy with histologic assessment with cytologic follow-up or another type of treatment. Despite the existence of a national guideline advising see-and-treat only in case of suspected high-grade disease in women who have completed their childbearing, there is a wide practice variation between the 2 strategies in the Netherlands, with 7.0-88.3% of the women receiving see-and-treat per laboratory. The median time between cytology and treatment was 1-2 months (range, 0-12 months) in women receiving see-and-treat and the 2-step method, respectively. A total of 4119 women (23.5%) were overtreated, with older women, high-risk human papillomavirus-negative women, and women with low-grade cytology results being more likely to be overtreated. Women with low-grade cytology results and see-and-treat were associated with a higher overtreatment rate than women receiving the 2-step method (65.0% [1414 of 2174] versus 32.1% [1161 of 3613], respectively; odds ratio, 3.34; 95% confidence interval, 2.92-3.82). However, in women with high-grade cytology results, see-and-treat was inversely associated with overtreatment (11.3% [529 of 4677] versus 14.3% [1015 of 7100], respectively; odds ratio, 0.68; 95% confidence interval, 0.58-0.81).

CONCLUSION

A see-and-treat approach is justified only in women with high-grade cytology results who have completed their childbearing. There is a wide practice variation between the 2 strategies in the Netherlands, and gynecologists should adhere to the guideline to prevent overtreatment.

Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the American Society of Transplantation Infectious Diseases Community of Practice update the epidemiology and management of human papillomavirus (HPV) infections in organ transplant recipients. HPV is one of the most common sexually transmitted infections and is associated with cancers of the anogenital region. Increasing evidence suggests an association with head and neck cancers as well. Solid organ transplant recipients have a higher risk of HPV infection than the general population. Infection manifests as premalignant lesions, warts, or cancer of the cervix, penis, vulva, scrotum, and anal canal. Most are asymptomatic initially, so diagnosis can be difficult without screening. A vaccine is available though not effective in preventing all cancer-causing strains. Organ transplant recipients should be screened for HPV-associated cancers and appropriate therapy initiated in a timely manner. Further studies are warranted to delineate the most effective screening methods and therapeutic modalities, including whether changes in immunosuppression are effective in attenuating disease.

Recurrence after Treatment by Loop Electrosurgical Excision Procedure (LEEP) of High-Grade Cervical Intraepithelial Neoplasia

Purpose

To evaluate the recurrence rate of high-grade CIN treated by loop electrosurgical excision procedure (LEEP) and the optimal follow-up schedule.

Method

622 cases of CIN2/3 consecutively treated by LEEP in the Florence screening program, with 66.5 months average follow-up (range, 6–195 months), were evaluated. Recurrence was defined as histological evidence of high-grade CIN.

Results

The average recurrence rate was 9.1% (52 cases). Recurrence was significantly associated to increasing age (χ2 = 12.73, df = 3, P < 001), CIN grade (10.5 vs 6.1%, χ2 = 3.37, df = 1, P = 0.067), and time interval, with the risk of developing a recurrence highest in the first year (7.4%, 95% confidence interval, 5.3–9.5%.), and rare beyond the third year. Multivariate analysis confirmed a significant independent association of age (particularly over age 40) and CIN grade to the risk of recurrence.

Conclusions

LEEP is an effective procedure for the treatment of high-grade CIN. Most recurrences after LEEP occur in the first 3 years, and non-recurrent cases at that date may stop intensive follow-up and return to current cytological screening every 3 years.

Do fertile women have an inferior treatment for high-grade precancerous lesions?

AIM

To investigate whether a concern for future pregnancy is reflected in the extent of large loop excision of the transformation zone (LLETZ) and to assess the clinical outcome.

METHODS

We reviewed the medical records of 275 women who underwent LLETZ for precancerous lesions in cervix. We divided them into two groups according to pregnancy possibility in the future: nonpotential versus potential group. The potential group was arbitrarily defined as women who met one of the following: (i) regardless of marital status, younger than 41 years with less than two parities and (ii) regardless of parity, younger than 46 years and unmarried. After propensity score matching (1:1, 44 women in each group), we compared the extent of LLETZ with respect to short-term recurrence.

RESULTS

After LLETZ, similar percentages of patients were finally diagnosed with ≥CIN3 (cervical intraepithelial neoplasia 3) in the two groups (27 [61.4%] vs 32 [72.7%], P = 0.257). Notably, the largest transverse diameter of LLETZ specimen was significantly larger in the nonpotential group (2.74 ± 1.06 vs 2.37 ± 0.62 cm, P = 0.047). There were more women with exocervical resection margin involvement in the potential group than in the nonpotential group (14 [31.8%] vs 6 [13.6%], P = 0.042). However, there was no significant difference in the incidence of short-term recurrence ≥HSIL (high-grade squamous intraepithelial lesion) within 24 months after LLETZ between the two groups (1 [2.3%] vs 1 [2.3%], P > 0.999).

CONCLUSION

Pregnancy possibility in the future may affect the extent of LLETZ, as assessed by the largest transverse diameter obtained. This finding may be associated with increased resection margin involvement in women with future pregnancy possibility.

Human Papillomavirus in Kidney Transplant Recipients

Human papillomavirus (HPV) is a common infection in kidney transplant recipients. HPV causes cervical, anal, vulvar, vaginal, penile and head and neck cancers. Kidney transplant recipients have a disproportionate burden of disease given prolonged immunosuppression. Given the long pre-invasive state of precancer lesions such as cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN) most HPV-cancers are preventable with screening and targeted treatment of disease. Pre-transplant vaccination of age-eligible kidney transplant recipients is otherwise ideal.

See-and-Treat for High-Grade Cytology: Do Young Women Have Different Rates of High-Grade Histology?

OBJECTIVE

To compare rates of cervical intraepithelial neoplasia grade 3 or greater (CIN3+) between women aged 21 to 24 and women aged 25 or older undergoing a see-and-treat strategy for high-grade squamous intraepithelial lesion (HSIL) cytology.

METHODS

In this retrospective cohort study, women treated with a see-and-treat loop electrosurgical excisional procedure (LEEP) for HSIL cytology at our university-based colposcopy clinic between 2008 and 2013 were identified. Data collected included age, race, parity, smoking status, method of contraception, history of abnormal cytology, HIV status, and LEEP histology. Cohorts were compared using Pearson chi-squared test of association and Fisher exact test.

RESULTS

Three hundred sixty-nine women were included in this analysis. The mean age was 30 (SD, 7.2; range, 21-56). Ninety-seven women (26.3%) were 21 to 24 years old. The rate of CIN3 in all women undergoing a see-and-treat LEEP for HSIL cytology was 65.9% (95% CI, 60.8-70.5). The rate of CIN 2 was 15.2% (95% CI, 11.9-19.2). Three women (1.1%) had invasive carcinoma. There was no difference in risk of CIN3+ in the young women compared with women aged 25 years or older (RR, 1.37; 95% CI, 0.92-2.02). Within this see-and-treat population, there was no correlation between presence of CIN3+ and race, smoking, contraception, or HIV status.

CONCLUSIONS

Most women undergoing see-and-treat for HSIL cytology will have CIN3 on final histology. In this large cohort, women aged 21 to 24 did not have lower rates of CIN3 compared with women aged 25 and older, suggesting that see-and-treat is still a valid treatment option for the prevention of invasive disease in young women.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to November 2012). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

Prospective Comparison of Loop Excision under Colposcopic Guidance versus Vitom Guidance

Background: Aim of the study was to compare the quality of loop excision using a colposcope with results using the VITOM system. Results compared included cervical volume removed, intra- and postoperative complications, and positive resection margins. Methods: A total of 200 patients with histologically confirmed high-grade cervical premalignant lesions, persistent atypical cytological results and/or suspicious colposcopic findings, and cytological and histological discrepancies were included in the study. In transformation zone type 1 (T1) only a superficial cone biopsy was done, in zones type 2 and 3 (T2 and T3) a superficial outside cone biopsy or a deeper inside cone biopsy were done respectively, followed by endocervical curettage. Volume of removed tissue, complications, and positive resection margins were compared for the colposcopy and the VITOM groups. Findings: Demographic and reproductive features were similar between groups. In the VITOM group 49 % of patients had zone T1, 30 % had zone T2, and 21 % had zone T3. In the group of patients managed by colposcopy, 48, 45, and 7 % of patients had zone T1, T2 and T3 zone, respectively (p < 0.01). A "top hat" procedure was done in 65 % of patients in the VITOM group and in 38 % of patients in the colposcopy group (p < 0.05). Mean volume of removed cervical tissue measured was similar, with 1.2 cm³ measured in the VITOM group and 1.14 cm³ in the colposcopy group (p > 0.05). There were no significant differences in the type of procedure or the mean volume of removed tissue. Results were similar for both groups with respect to positive resection margins and complications. Conclusion: VITOM is a safe and reliable system. Results using the VITOM system are comparable to those obtained with conventional colposcopy. The potential advantage of VITOM is the broader availability of endoscopic systems in the operating theatre.

Surgery for cervical intraepithelial neoplasia

BACKGROUND

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Atypical squamous changes occur in the transformation zone of the cervix with mild, moderate or severe changes described by their depth (CIN 1, 2 or 3). Cervical intraepithelial neoplasia is treated by local ablation or lower morbidity excision techniques. Choice of treatment depends on the grade and extent of the disease.

OBJECTIVES

To assess the effectiveness and safety of alternative surgical treatments for CIN.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (up to April 2009). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of alternative surgical treatments in women with cervical intraepithelial neoplasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risks of bias. Risk ratios that compared residual disease after the follow-up examination and adverse events in women who received one of either laser ablation, laser conisation, large loop excision of the transformation zone (LLETZ), knife conisation or cryotherapy were pooled in random-effects model meta-analyses.

MAIN RESULTS

Twenty-nine trials were included. Seven surgical techniques were tested in various comparisons. No significant differences in treatment failures were demonstrated in terms of persistent disease after treatment. Large loop excision of the transformation zone appeared to provide the most reliable specimens for histology with the least morbidity. Morbidity was lower than with laser conisation, although the trials did not provide data for every outcome measure. There were not enough data to assess the effect on morbidity when compared with laser ablation.

AUTHORS' CONCLUSIONS

The evidence suggests that there is no obvious superior surgical technique for treating cervical intraepithelial neoplasia in terms of treatment failures or operative morbidity.

Histologic findings after a colposcopic biopsy showing CIN2

OBJECTIVE

To determine the risk of CIN3 and cancer in subsequent specimens among women with colposcopic biopsy showing CIN2.

METHODS

A retrospective review of demographic and medical information collected at colposcopy. Patient records were again reviewed 8 to 26 months later for information on procedures and histology results.

RESULTS

Histologic evaluation of specimens showed no lesions in 14, atypia or koilocytosis in 21, CIN1 in 25, CIN2 in 26, CIN 3 in 27, ungraded CIN in 3, and cancer in 3. No cancers were found in women at or below the median age of 33 years or those with satisfactory colposcopy. However, cancers were found in women with negative repeat cytology and negative colposcopic impression.

CONCLUSION

Observation may be an option for young women with CIN2 on colposcopic biopsy if they are reliable for follow up and the entire squamocolumnar junction is seen.

Risk of invasive cervical cancer in relation to management of abnormal Pap smear results

OBJECTIVE

We sought to evaluate the management of women with abnormal cytology in terms of subsequent risk of invasive cervical cancer.

STUDY DESIGN

The screening histories of all invasive cervical cancer cases diagnosed in Sweden 1999-2001 and of 5 population-based controls per case were reviewed. In all, 159 patients and 258 control subjects aged < 67 years had an abnormal smear result 0.5-6.5 years prior to cancer diagnosis. The cervical cancer risk was estimated in relation to management by calculating odds ratios.

RESULTS

Histologic assessment of low-grade squamous abnormalities strongly reduced the risk compared to repeated cytology (odds ratio, 0.46; 95% confidence interval, 0.24-0.89). Delaying histologic assessment was also associated with a higher risk (odds ratio, 5.65; 95% confidence interval, 1.39-23.05). After high-grade squamous atypia, absence of any cytologic or histologic specimen was a major determinant of cancer risk (odds ratio, 12.52; 95% confidence interval, 1.42-infinitive).

CONCLUSION

For adequate protection against invasive cervical cancer, further assessment with histology must be recommended also for women with low-grade squamous abnormalities.

Biomarkers in cervical precancer management: the new frontiers

The major cause of cervical cancer and its pre-invasive lesions is persistent infections with oncogenic human papillomavirus (HPV). Viral replication and integration in the cervix depends on the ordered expression of viral gene products, which can lead to overexpression of multiple molecular proteins or biomarkers. These novel biomarkers allow the monitoring of essential molecular events in histological or cytological specimens and are likely to improve the detection of lesions that have a high risk of progression in both primary screening and triage settings. This review focuses on these molecular markers and their role in the diagnosis and management of cervical dysplasia and cancer.

Is this the end of the line for the moderate dyskaryotic smear?

OBJECTIVE

The British Society for Clinical Cytology has recently proposed that the terminology for cervical smear reporting is to be changed from a 3-tier system (mild, moderate, severe dyskaryosis) to a 2-tier system of low-grade and high-grade dyskaryosis. This modification eliminates the central category of moderate dyskaryosis which would be incorporated into the high-grade group. The aim of this study was to investigate the role of the moderate dyskaryotic smear in clinical practice.

MATERIALS AND METHODS

A retrospective review of all women who were referred for colposcopy because of a moderate dyskaryotic smear was carried out for a 6-month period. Data collected included colposcopic impression, procedure performed and final histopathology. Two cytologists who were unaware of the original smear report were asked to reclassify these smears using the new 2-tier system. Their findings were compared with the documented colposcopic and histopathology results.

RESULTS

One hundred women with moderate dyskaryotic smears were referred for colposcopy during the study period. Most of these were reclassified as high-grade dyskaryosis using the new system. Fifty-six (72%) of the moderate dyskaryotic smears which were correctly regraded as high grade by cytologist 1 were found to have cervical intraepithelial neoplasia 2/3 on final histopathology, whereas for cytologist 2, 66 (68%) were found to have high-grade cervical intraepithelial neoplasia.

CONCLUSION

There is no clinical benefit in retaining the term moderate dyskaryosis. This study emphasizes the need for a uniform 2-tier system.

Treatment of high-grade squamous intraepithelial lesions: A “see and treat” versus a three-step approach

OBJECTIVE

The study's subject was to examine the correlation between histologic findings in patients with high-grade squamous intraepithelial lesion (HGSIL) who have undergone loop electrosurgical excisional procedure (LEEP) with and without prior colposcopically directed biopsy.

STUDY DESIGN

This retrospective study included 144 patients with cytologic HGSIL, of which 62 were treated by a three-step protocol, in which LEEP was performed only if the colposcopically directed cervical biopsies were positive (CIN II-III), and 82 women who were treated by "see and treat" protocol, in which LEEP was immediately performed if colposcopy was suggestive of CIN II or III lesions.

RESULTS

There were no differences in the final histological findings between the groups.

CONCLUSIONS

The colposcopically directed LEEP after a HGSIL on PAP-smear may reduce the time interval between diagnosis and treatment with a similar accuracy of diagnosis compared to the standard three-step protocol.

Cervical Cancer: The Indian Perspective

Cancer of the uterine cervix is the commonest gynaecologic cancer in India, with most women presenting with disease extending beyond the cervix. The majority of women belong to the lower socioeconomic status, are rural, aged between 35 and 64 years and highly noncompliant for complete treatment and follow-up. Opportunistic screening with cytology, colposcopy and test for Human Papilloma Virus and appropriate treatment are available on payment at urban private medical centres but are not available at urban and rural government health centres that are accessed by women of the lower socioeconomic status. The Government's investment in health is 0.9% of the GDP. Thus cytology screening as a government health measure is not feasible. The 'social vaccine' of health empowerment along with visual inspection and appropriate referral by the rural and urban health personnel (Department of Health and Family Welfare); with an additional input of health awareness and motivation by Anganwadi Workers (Department of Women and Child Development), elected women representatives in the Panchayats (Department of Rural Development and Panchayati Raj) and non-governmental development agencies could be a collaborative effort towards "downstaging" cervical cancer. This could lay the foundation for the introduction of cytology screening when resources are available.

Predicting absolute risk of CIN3 during post-colposcopic follow-up: results from the ASCUS-LSIL Triage Study (ALTS)

OBJECTIVE

At present, clinical management of women referred to colposcopy but found to have <CIN2 remains unclear. Using data from the ASCUS-LSIL Triage Study (ALTS) to inform clinical management, we calculated the absolute risk for developing CIN3 within 2 years of referral to an enrollment colposcopy.

STUDY DESIGN

Women included in the analyses: (1) were initially referred to ALTS with a community cytologic interpretation of atypical squamous cell of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesions (LSIL); (2) had a colposcopic evaluation and biopsy, if indicated, resulting in a diagnosis <CIN2; and, therefore (3) were followed without treatment. Results from subsequent human papillomavirus (HPV) testing, liquid-based cytology interpretations, and a second colposcopic evaluation at least 6 months after and within 2 years of the first colposcopic evaluation were used to calculate absolute risks for CIN3.

RESULTS

Women with HPV-negative test results were at low risk for CIN3 regardless of other test results. Among HPV-positive women, increasing absolute risks of CIN3 were observed with increasing cytology severity: 7% (normal), 11% (ASCUS and LSIL), and 45% (HSIL). The highest absolute risk for CIN3 (67%) was observed for HPV-positive women with HSIL and a colposcopic impression of high-grade/cancer on the second colposcopy.

CONCLUSION

In the ALTS population, after the first colposcopic diagnosis of <CIN2, clear risk stratification for CIN3 outcomes was obtained among women with a subsequent HPV-positive test. Because absolute risk for histologic CIN3 outcomes was high for women with HPV positive tests, HSIL cytology, and a high-grade impression at second colposcopy, it is worth considering whether this combination of findings might warrant immediate excisional therapy in some circumstances.

Women in a region with high incidence of cervical cancer warrant immediate colposcopy for low-grade squamous intraepithelial lesion on cervical cytology

The objective of this study was to determine the prevalence of high-grade histologic diagnoses in women who had low-grade squamous intraepithelial lesion (LSIL) on Pap smear in an area with high incidence of cervical cancer. We conducted a retrospective study of 220 women with LSIL cytology undergoing colposcopic examination in Chiang Mai University Hospital between January 1999 and July 2004. The histologic diagnoses, obtained from colposcopically directed biopsy or electrical loop excision after initial colposcopy, showed that 80 (36.4%) women had histologically confirmed high-grade lesions and 11 (5%) women had microinvasive (9) and frankly invasive (2) carcinomas. Overall, 41.5% of women with LSIL on Pap smear had significant underlying lesions, requiring appropriate treatment. In conclusion, in the region with high incidence of cervical cancer, women with LSIL cytology are at increased risk of having underlying high-grade lesions and invasive cancer. Immediate referral for colposcopy is warranted.

Long-term follow-up after large-loop excision of the transformation zone: evaluation of 22 years treatment of high-grade cervical intraepithelial neoplasia

Early treatment of cervical intraepithelial neoplasia (CIN) significantly reduces the risk of invasive cancerous progression. Residual and recurrent high-grade CIN should be detected and retreated in an early phase. Therefore, a postsurgery cytologic follow-up protocol was introduced at 3, 6, 9, and 12 months and yearly thereafter for 5 years. The aim of this study is to evaluate the long-term experience in treating high-grade CIN using large-loop excision of the transformation zone (LLETZ). Additionally, the long-term follow-up in this study gains the opportunity to document the pattern of disease recurrence beyond 5 years. The average follow-up of the 1696 women included in this study was 6.5 years. Overall, 8.5% of the patients who underwent LLETZ showed a high-grade repetitive CIN and three patients had invasive carcinoma. Eighty percent of those lesions were probably residual, whereas 20% of all high-grade repetitive lesions appeared more than 2 years after initial surgery and were considered recurrent lesions. Half of the recurrent lesions occurred more than 5 years after LLETZ.

Recent innovations in colposcopy practice

Colposcopic practice continues to evolve. As its need has expanded, so has the role of training, audit and continuing medical education. The recently published National Health Service Cervical Screening Programme clinical guidelines document covers almost every aspect of clinical practice in an evidence-based directory. Excision of the transformation zone (TZ) may be a very minor or major entity. The recent TZ classification system of the International Federation of Cervical Pathology and Colposcopy attempts to clarify and standardize nomenclature so that therapy can be realistically compared. The role of human papillomavirus (HPV) in clinical practice continues to be controversial and has not yet found a place in the UK. For the evaluation of borderline nuclear abnormal smear and for post-treatment surveillance, HPV is clinically useful and efficient. Other biological tumour markers are likely to become clinically useful as their predictive profiles emerge.

Ambulatory gynaecology: What can we do?

The aim of ambulatory gynaecology is to admit, treat and discharge the patient on the same day in an outpatient setting. Traditional inpatient operations are being rapidly replaced by office, outpatient or day surgery procedures. In this review, a brief assessment of current ambulatory gynaecological practice is attempted, followed by a discussion of audit and quality assessment methods. Epidemiological studies, clinical trials, socio-economic studies and meta-analyses offer research opportunities in the ambulatory setting. There is a need to review the training of junior gynaecologists and nurses in this field. At present, only a few gynaecology residency programmes offer experience in outpatient procedures and ambulatory care. Specific issues that need to be addressed include training, patient selection, consenting issues, decisions to cancel/transfer as inpatients, and the management of common gynaecological problems.

Contribution of combined colposcopy and cytology in cervical pathology

AIM

The regular Papanicolaou (Pap) smear is the cornerstone of women's preventive healthcare. The introduction of the regular Pap smear as a screening tool for cervical cancer has markedly decreased the number of deaths from cervical cancer. During the past decade, however, the rate of death from cervical cancer has remained relatively static. This screening method is known to have a high percentage of false negative results. To improve the detection of cervical lesions using the Pap smear in screening, a number of adjunct procedures have been developed. The purpose of this study is to evaluate the utility of a magnified chemoluminescent screening examination (Colposcopy) combined with the Pap smear in detecting cervical abnormalities.

METHODS

We investigated a cohort of 58 subjects who have been forwarded for colposcopic evaluation due to referral cytology suggestive of persistent inflammatory process not otherwise specified, and cervical intraepithelial or invasive neoplasia, in Chania Colposcopic clinic.

RESULTS

The higher the lesion detected by cytology, the more severe the corresponding colposcopic impression viewed.

CONCLUSION

The data presented here are in harmony with previous reports and share our experience in a Regional Community Hospital Colposcopy Clinic. An integrated cytology-colposcopy program facilitates the assessment and identification of women harboring cervical pathological conditions.

Costs of Colposcopy Services and Their Impact on the Incidence and Mortality Rate of Cervical Cancer in Canada

OBJECTIVE

Organized cervical cancer screening services consisting of conventional Papanicolaou cervical smears, colposcopy, and related treatment modalities are readily available in all provinces. The purpose of this report was to study the impact of colposcopy usage and costs on cervical cancer incidence and mortality rates in several Canadian provinces. Knowledge of such information is essential before newer technology such as liquid-based cytology and human papillomavirus testing is introduced or replaces the traditional systems used.

MATERIALS AND METHODS

The Ministries of Health of five provinces were contacted and asked to furnish information on the number of colposcopic services and fee-for-service costs for these and for cryosurgery, carbon dioxide laser vaporization, loop electrosurgical excisions, and cold-knife conizations for the year 2000. Canadian Cancer Society estimates of incidence and mortality rates for cervical cancer were also obtained.

RESULTS

All provinces had similar incidence and mortality rates for cervical cancer; however, the number of colposcopic services on a per-capita basis varied substantially, with Manitoba and Ontario having rates that were approximately two or three times higher. Fee-for-service payments for colposcopy were similar in the Provinces studied but unit costs for surgical treatment services were highest in Ontario and British Columbia.

CONCLUSIONS

Although both the incidence and mortality rates for cervical cancer in Canada fell dramatically after the Walton Report in 1976, these rates have plateaued over the past decade despite widespread availability of colposcopy and related ambulatory treatment services. Higher rates of colposcopy usage do not seem to result in lower incidence rates for this disease. Unit costs for colposcopy are similar among the provinces reviewed, but substantial difference exists for certain treatment services. Additional studies are recommended before the widespread introduction or replacement of existing methods with newer, more costly techniques.

A comparative study of two methods of large loop excision of the transformation zone

OBJECTIVE

To determine whether the conventional large loop excision of the transformation zone (CLLETZ) and the "top-hat" technique (THLLETZ) differ in (a) completeness of excision of the cervical lesion, (b) depth of cervical tissue excised and (c) adequacy of follow up by cytology and colposcopy.

DESIGN

Retrospective case review.

SETTING

University Teaching Hospital, London.

SAMPLE

Five hundred and thirteen consecutive patients matched for age, parity, smoking history and referral cytology who had either CLLETZ (286-5%) or THLLETZ (227-44%) for cervical intraepithelial neoplasia (CIN).

METHODS

All procedures were performed or supervised by BSCCP-accredited colposcopists. All cytology and histology were reviewed by two specialist cytohistopathologists. Cervical stenosis was defined as difficulty in or inability in obtaining an endocervical brush smear.

MAIN OUTCOME MEASURES

Depth of cervical tissue excised, histology of endocervical margins, post-LLETZ cytologic and colposcopic findings.

RESULTS

The mean depth of excision in the CLLETZ group was 12.1 mm (SD = 4.4 mm) and 20.8 mm (SD = 6.4 mm) in the THLLETZ group. The incidence of involved endocervical margins was 2.8% in the CLLETZ group and 5.2% in the THLLETZ group (P= 0.1). There was CIN in the "top-hat specimen" of 10 THLLETZ cases (4.4%, CI = 95%). The first post-treatment cervical smear was inadequate in 5 (4.1%) cases in the CLLETZ group and 20 (11.7%) in the THLLETZ group (P= 0.022). Cervical stenosis was found in 21 (7.7%) cases in the CLLETZ group and in 64 (30.9%) cases in the THLLETZ group (P < 0.0001). Eleven (4%) patients in the CLLETZ group had cytological and/or colposcopic evidence of residual CIN compared with 12(5.8%) patients in THLLETZ group (P= 0.4). In the first follow-up assessment, 21.7% of the CLLETZ group had incomplete colposcopy compared with 48.7% in the THLLETZ group (P < 0.0001).

CONCLUSIONS

Compared with the CLLETZ, the THLLETZ (1) removed more cervical tissue but did not have a lower incidence of involved endocervical margins, and (2) resulted in significantly higher incidence of inadequate post-treatment colposcopic and cytological follow up. These data indicate that there is no justification to performing a "top-hat" LLETZ routinely.

Management of cervical premalignant lesions

Management of cervical preneoplasia starts with an abnormal smear result. The use of the Bethesda system is recommended. The management of patients with low-grade abnormal smear results varies around the world. Patients with atypical squamous cells on cytology are recommended to be subclassified into atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells where high-grade squamous intra-epithelial lesions (HSIL) cannot be excluded (ASCH) groups. While patients with ASCUS can be followed with cytology or colposcopy, the risk of having cervical intra-epithelial neoplasia (CIN) is higher in patients with ASCH. Such patients, as well as those with low-grade squamous intra-epithelial lesions on cytology, should be referred for colposcopy to ensure that diagnosis and treatment in CIN is detected. Patients with HSIL should be referred promptly for colposcopic assessment. This should, usually at the same clinic visit, be followed by large loop excision of the transformation zone (LLETZ). Although this is effective treatment, around 15% of patients will have persistent/recurrent disease on cytological follow-up. Patients with positive human papillomavirus DNA tests at follow-up seem to have a considerably higher risk of recurrent preneoplasia than those who have negative tests. Patients over 50 years of age have much higher recurrence risks than younger patients. These factors impact on second-line treatment and follow-up schedules. An important benefit of conservative treatment for CIN with LLETZ is retention of fertility. LLETZ is associated with an increased risk of preterm prelabour rupture of membranes and preterm birth, but not with other adverse pregnancy outcome measures. Conservative excisional management of adenocarcinoma in situ by LLETZ or cold knife cone biopsy is not reported to be as effective as that of CIN, with high risk of residual and recurrent disease at follow-up. Conversely, LLETZ may be acceptable treatment for micro-invasive squamous carcinoma if the excision margins are free of disease and there is no evidence of lymphovascular involvement. The ability to detect and treat premalignant lesions on the cervix reversed the natural history of cervical cancer. Methods of conservative treatment that evolved over decades have been proven safe and effective, allowing retention of fertility. Good clinical guidelines have been developed for most clinical scenarios while some uncertainties persist for other scenarios.

See-and-treat strategy for diagnosis and management of cervical squamous intraepithelial lesions

In a see-and-treat protocol, patients referred for colposcopy because of an abnormal Pap smear in cervical-cancer screening can be treated by loop excision, without biopsy, during one visit to the clinic. However, overtreatment in the see-and-treat strategy has been reported to be 1.2-83.3% for low-grade squamous intraepithelial lesions (SIL) and to be 13.3-83.3% for high-grade SIL. Range of overtreatment narrowed to 4.0-23.5% for those with normal pathology and to 18.0-29.4% for those with normal or low-grade pathology when calculation of overtreatment was restricted to patients diagnosed with high-grade SIL on colposcopy and referral Pap smear. Most common treatment complications are bleeding and infection. Nonetheless, the strategy has become accepted internationally: low costs, decreased patient anxiety, and increased compliance make it appealing, especially in settings with limited health resources, and for patients at risk of not being treated in a timely manner or of not returning for a second appointment. Mathematical modelling may give information about the appropriateness and usefulness of this treatment while the results of long-term clinical trials are awaited.

Large loop excision and cold coagulation for management of cervical intraepithelial neoplasia

OBJECTIVES

To evaluate the efficacy of large loop excision of the transformation zone (LLETZ) combined with a single application of the cone probe of a Semm Cold Coagulator as a new treatment for women with cervical intraepithelial neoplasia (CIN).

METHODS

Retrospective case-record review of 666 women treated with large loop excision and cold coagulation (LLECC) from 1992 to 2000.

RESULTS

Of the women who had high-grade CIN at their initial consultation, 4.2% had abnormal cytologic results 6 months after treatment and 0.6% had abnormal cytologic results at 12 months. Of the women who had low-grade CIN at initial presentation, 3.8% had abnormal cytologic results 6 months after treatment and none (0%) at 12 months. Furthermore, there were no reported cases of cervical cancer in this cohort of women during the follow-up period. Short-term bleeding complications (within 24 h of the procedure) occurred in 1% of the women assessed.

CONCLUSIONS

Large loop excision combined with cold coagulation is a new and effective treatment for CIN. Randomized controlled trials are required to confirm these findings and determine the long-term safety of the technique.

Evidence Supporting the Current Management Guidelines for High-Grade Squamous Intraepithelial Lesion Cytology

OBJECTIVE

The study was undertaken to provide consensus guidelines for the management of women with a cytologic interpretation of high-grade squamous intraepithelial lesion (HSIL) on cytologic examination. This review article presents relevant literature supporting the proposed guidelines.

PARTICIPANTS

An independent panel of 121 experts in various aspects of the diagnosis and management of cervical cancer precursors, including representatives from 29 participating professional organizations, federal agencies, national and international health organizations, and others were invited by the American Society for Colposcopy and Cervical Pathology.

CONSENSUS PROCESS

Guidelines for the management of women with HSIL cytologic results were developed through a multistep process. Draft management guidelines were developed by the HSIL working group after formal literature reviews and obtained input from the professional community at large by way of an interactive internet-based bulletin board. At the American Society for Colposcopy and Cervical Pathology Consensus Conference, September 6 through 8, 2001, in Bethesda, Maryland, the guidelines were discussed, revised, and adopted by formal vote.

CONCLUSIONS

Evidence-based guidelines have been developed for the management of women with HSIL cytologic results.

The Quality of Community Colposcopic Practice

OBJECTIVE

To estimate the quality of community colposcopic practice in British Columbia through an assessment of the degree of correlation between colposcopy, cytology, and histology.

METHOD

We reviewed all new-patient colposcopies in British Columbia during 2001 by 37 gynecologists in 24 hospital-based clinics.

RESULTS

Colposcopic impression closely mirrored the referral cytology diagnosis in 89.8% of cases. As with cytology-biopsy comparisons, discordant cases were more likely to be overestimates of disease rather than underestimates, 18.8% versus 1.8%. Overestimates were usually biopsy sampling errors rather than false positive cytology. The overall correlation between cytology and biopsy was considered satisfactory in 79.4% of cases. Satisfactory agreement between the colposcopic diagnosis and accompanying biopsies occurred in 86.8% of patients. Five colposcopists had performance scores below this standard. Colposcopy with a sensitivity of 90.3% and a specificity of 57.3% as practiced in this provincial program would appear to be of a satisfactory level. The rate of intraepithelial or invasive disease increased from 40.6% in patients with low-grade squamous intraepithelial changes to 91.9% in patients with suspicious or malignant cytology. The value of the colposcopic impression to identify disease correlated best with the higher the grade of disease predicted (64.6% to 92.6%).

CONCLUSION

A measure of the colposcopic proficiency in the community can be estimated by comparing the level of agreement between the presenting cytology, colposcopic impression, and corresponding directed biopsies. The results of this study would indicate that 5 individuals had practice standards that were below average. An integrated cytology-colposcopy program facilitates the assessment and identification of below-average practice standards in a community.

Loop excision for high-grade squamous intraepithelial lesion on cytology: correlation with colposcopic and histologic findings

OBJECTIVE

Our purpose was to examine the correlation between colposcopic and histologic findings in patients who have undergone loop electrosurgical excision of the cervix (LEEP) for high-grade dysplasia on cytology without prior colposcopically directed biopsy.

STUDY DESIGN

A retrospective review was performed of all patients who underwent LEEP for high-grade squamous intraepithelial lesion (HGSIL) on Papanicolaou (Pap) smear without a prior cervical biopsy over a 17-month period. We correlated the histologic result with colposcopic findings at the time of LEEP.

RESULTS

Of 104 patients undergoing LEEP, 63 patients (61%) had cervical intraepithelial neoplasia (CIN) grade 2 or greater. Thirty-four (54%) of these 63 patients with histologically proved high-grade dysplasia had a normal or low-grade colposcopic examination. There were 10 patients with CIN 1 to CIN 1-2 and 1 patient with microinvasive squamous cell carcinoma.

CONCLUSION

Despite lack of correlation between colposcopic and histologic results, HGSIL on Pap smear is an appropriate indication for LEEP.

A “See and Treat” Management for High-Grade Squamous Intraepithelial Lesion Pap Smears

OBJECTIVE.: This study evaluates a "see and treat" intervention for high-grade squamous intraepithelial lesions (HSIL) on Pap smears. This is a case control study comparing cost-effectiveness, patient compliance, and pathology obtained from immediate colposcopy and large loop excision of the transformation zone of the uterine cervix. (LLETZ) MATERIALS AND METHODS.: At our institution before the onset of the study, a chart review of 100 patients with HSIL Pap smears was performed. This was the control group. Ninety percent of the patients' in the control group who had HSIL on Pap eventually had LLETZ. The next consecutive 100 women presenting to the clinic who met the same inclusion criteria underwent colposcopy and LLETZ at the same visit and were compared with the control group. Demographics, pathology, compliance, and cost were analyzed. RESULTS.: One hundred patients were treated with one visit colposcopy/LLETZ intervention. Histologic diagnosis of cervical intraepithelial neoplasia (CIN) 2,3 was confirmed in 94% of patients. Two percent of the patients had CIN 1, 1% had no histologic evidence of CIN, and 3% had microinvasive cancer to a depth of 0.5-1.5mm. Cost analysis revealed savings of $35,000 for the institution. Patient compliance was improved with a kept appointment rate of 82%. CONCLUSIONS.: "See and treat" intervention for HSIL Paps was an effective tool. Treating HSIL Paps without a separate visit for colposcopy is a cost-effective management. This method was more convenient for patients with only one disruption of daily schedules.

Management of precursor lesions of cervical carcinoma: history, host defense, and a survey of modalities

Before the initiation of screening and treatment for cervical cancer precursors, approximately 3% to 4% of women were destined to eventually develop cervical cancer. During the last 50 years the rate of cervical cancer incidence and mortality has decreased by more than 75% primarily because of the widespread availability of cervical cytologic screening and of treatment for documented cervical precancer. Successful screening of the entire population and appropriate treatment of lesions could theoretically reduce this risk to one tenth of the risk of an unscreened population [7,28]. The relatively recent understanding of the etiology of cervical cancer precursor lesions and of the immune response to them has given new direction to management options that incorporate healthy habits and dietary measures as part of traditional ablative or excisional treatment options. As we look to the future we can expect that new markers that more specifically identify individuals at-risk for cervical precancer and cancer will be developed and take precedence in cervical screening. At the same time, treating the cause of these lesions, rather than the result, should provide less traumatic and more successful therapies. To this end, harnessing the immune system through immune response modifiers and HPV vaccines seems to be on the horizon, as do new chemopreventative approaches. Of all human cancers, only cervical cancer, once the second most common cancer among women, stands on the threshold of being virtually eliminated.