Repeat Papanicolaou Smear Research Articles

Aspergillus in a cervico-vaginal smear of an adult postmenopausal female: An unusual case

There are several case reports documenting opportunistic fungal infection in the female genital tract, withr Aspergillus spp being a rarely reported causative organism. We hereby report a case of Aspergillus infection in a 48 year-old, postmenopausal female with carcinoma of the cervix. She presented with features of pelvic inflammatory disease, and an initial routine cervico-vaginal smear revealed severe inflammation along with fungal bodies. The features were consistent with the presence of Aspergillus spp, while the background epithelial cells were negative for intraepithelial malignancy. She was offered therapy for pelvic inflammatory disease. A repeat Papanicolaou smear after two weeks was negative for intraepithelial organisms, but showed the evidence of a high-grade squamous intraepithelial lesion, with biopsy confirming squamous cell carcinoma.

Evaluation of cytologic screening results of the cervix

The aim of this study was to evaluate retrospectively cytologic screening for cancers and precancerous lesions of the cervix and to research whether biopsy is overused among women with a cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS). We examined 28 469 smears obtained over 5 years. The patients were referred when the result of the smear was abnormal for a colposcopic biopsy, endocervical curettage, or a repeat Papanicolaou smear. The results of the screening of 28 469 smears are as follows: 699 (2.45%) ASCUS, 67 (0.23%) low-grade squamous intraepithelial lesions (LGSIL), 43 (0.15%) high-grade squamous intraepithelial lesions (HGSIL), 1 epidermoid carcinoma, 31 (0.10%) atypical glandular cells, and 1 adenocarcinoma. Histologic examination of the cervix was done in 119 patients (17.0%) of ASCUS, 13 patients (10.9%) of LGSIL, and 15 patients (12.6%) of HGSIL and cervical carcinoma. In the 119 women with histological examination, histologic examination was generally performed in patients with ASCUS neoplastic Papanicolaou smear, and histologic diagnosis of low-grade, high-grade, or invasive lesion of the cervix was made in 23.5% of women with ASCUS; in these patients, 46.4% were cytologic LGSIL and 53.5 % were cytologic HGSIL and cervical carcinoma. In the aspect of these findings, we concluded that for patients with a cytologic diagnosis of ASCUS, more aggressive interventions should be performed.

Evaluation of cytologic screening results of the cervix

The aim of this study was to evaluate retrospectively cytologic screening for cancers and precancerous lesions of the cervix and to research whether biopsy is overused among women with a cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS). We examined 28 469 smears obtained over 5 years. The patients were referred when the result of the smear was abnormal for a colposcopic biopsy, endocervical curettage, or a repeat Papanicolaou smear. The results of the screening of 28 469 smears are as follows: 699 (2.45%) ASCUS, 67 (0.23%) low-grade squamous intraepithelial lesions (LGSIL), 43 (0.15%) high-grade squamous intraepithelial lesions (HGSIL), 1 epidermoid carcinoma, 31 (0.10%) atypical glandular cells, and 1 adenocarcinoma. Histologic examination of the cervix was done in 119 patients (17.0%) of ASCUS, 13 patients (10.9%) of LGSIL, and 15 patients (12.6%) of HGSIL and cervical carcinoma. In the 119 women with histological examination, histologic examination was generally performed in patients with ASCUS neoplastic Papanicolaou smear, and histologic diagnosis of low-grade, high-grade, or invasive lesion of the cervix was made in 23.5% of women with ASCUS; in these patients, 46.4% were cytologic LGSIL and 53.5 % were cytologic HGSIL and cervical carcinoma. In the aspect of these findings, we concluded that for patients with a cytologic diagnosis of ASCUS, more aggressive interventions should be performed

Results of a Phase II Double-Blinded Randomized Clinical Trial of Difluoromethylornithine for Cervical Intraepithelial Neoplasia Grades 2 to 3

Our purpose was to conduct a double-blinded randomized trial of difluoromethylornithine (DFMO) at 0.125, 0.5 gm/m2, versus placebo in the treatment of cervical intraepithelial neoplasia (CIN) grades 2 to 3. A promising phase I study has shown histopathologic responses at these dose levels. Patients with histopathologically confirmed CIN 2-3 lesions were recruited from a colposcopy clinic and underwent Papanicolaou testing, human papillomavirus testing, and colpophotography. They took oral contraception and DFMO or placebo elixir for 28 days and filled out the National Cancer Institute common toxicity calendars. They returned for follow-up and a repeat Papanicolaou smear, colpophotograph, and loop excision of the cervix. There were no statistically significant differences among the arms in histopathologic response. This could no be explained by any biases in risk factors. The prominent toxicities were diarrhea, dizziness, nausea, and headaches. There were no differences in the toxicities among arms. The Papanicolaou smear was a poor biomarker of response and correlated poorly with the histopathology. DFMO is no active at 0.125 and 0.5 gm/m2 for 28 days when given orally in CIN 2-3. Higher oral doses or longer administration is necessary, supporting data from breast trials. Alternatively, a trial of topical DFMO might merit attention as activity has been noted in trials of actinic keratoses.

Utility of cervicography in HIV-infected and uninfected adolescents

Purpose To compare cytology with cervicography in HIV-infected and uninfected adolescent females Methods At the time of analysis, 334 girls aged 13–19 years from 13 U.S. cities were participating in a prospective study of HIV infection. All subjects had cytology and a Cervigram™ (cervicography) performed at two consecutive visits 6 months apart, referred to as visit (V) 1 and 2. Cervigrams™ were sent to the parent company for diagnosis and were categorized as: “negative” or “positive” (compatible with low-grade or high-grade squamous intraepithelial lesions [SIL]). Cytology was considered abnormal if the subject had SIL at either V1 or V2. Sensitivity, specificity, and positive predictive value (PPV) of the Cervigram™ were calculated compared with repeat Papanicolaou (Pap) smears. Results Two consecutive adequate Pap smears were available for analysis in 200 adolescents; 51% (95% CI, 43–59) of the 142 HIV-positive youth and 19% (95% CI, 9–29) of the 58 HIV-negative youth had SIL on at least one Pap smear ( p < .001). A positive Cervigram™ was observed in 44% (95% CI, 36–53) of the HIV-infected group and 29% (95% CI, 17–41) of the HIV-uninfected group ( p = .06). For the HIV-infected group, the sensitivity, specificity, and PPV of the Cervigram™ to detect SIL were 58% (95% CI, 45–71), 69% (95%CI, 57–80), and 64% (95%CI, 52–77), respectively. For the HIV-uninfected group, the sensitivity, specificity, and PPV were 64% (95% CI, 31–89), 80% (95% CI, 65–90), and 44% (95% CI, 19–68), respectively. The combined sensitivity, using both the Pap smear and Cervigram™ result from V1 to detect SIL, was 82% (95% CI, 71–91 for HIV+ and 48–98 for HIV−) in both groups. However, the PPV based the performance of the Cervigram™ in Pap smear-negative women as 33% (95% CI, 17–53) and 15% (95% CI, 2–45) for the HIV-infected and uninfected group, respectively ( p = not significant [ns]). Conclusion Although the sensitivity of a single Pap smear increased significantly when the Cervigram™ was used as an adjunct, the low PPV in both HIV-infected and uninfected groups, suggests that cervicography has a limited utility for precancer and cervical cancer screening in high-risk adolescent populations.

The significance of hyperkeratosis/parakeratosis on otherwise normal Papanicolaou smears

Objective: The purpose of this study was to determine whether hyperkeratosis/parakeratosis found on an otherwise normal Papanicolaou smear was associated with abnormalities after comprehensive evaluation. Study Design: We conducted a retrospective cohort study of 566 women identified with hyperkeratosis/parakeratosis on Papanicolaou smears from a 7-year period. All women underwent repeat Papanicolaou smear, colposcopy, and biopsy as indicated. Statistical analysis included χ2 and Fisher exact tests as appropriate. Results: Final abnormal diagnoses included human papillomavirus (HPV) changes (17%), mild dysplasia (5%), and moderate/severe dysplasia (0.4%). We found no carcinomas. Women younger than age 50 years were more likely to have an abnormality (34% vs 19%, relative risk 1.3, 95% CI 1.1-1.4, P <.001), primarily because of a higher prevalence of HPV changes on the biopsy specimen (21% vs 9%, relative risk 1.3, 95% CI 1.2-1.5, P <.001). Conclusion: Hyperkeratosis/parakeratosis on an otherwise normal Papanicolaou smear is associated with low-grade changes, particularly among reproductive-age women. (Am J Obstet Gynecol 2002;187:997-1001.)

Spotlight on gynecology

OBJECTIVE: Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration–approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up.STUDY DESIGN: Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration–approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparision of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared.RESULTS: As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus–negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy (p < 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these women grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was evident on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case).CONCLUSION: The Food and Drug Administration–approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions. (Am J Obstet Gynecol 1997;177:930-6.)

Usefulness of concurrent Papanicolaou smear at time of cervical biopsy.

The reliability and cost-effectiveness of a repeat Papanicolaou (Pap) smear performed at the time of colposcopic biopsy is uncertain. To evaluate the usefulness of this practice, Pap smear and biopsy results of 718 patients were reviewed and compared: 619 patients had Pap smears performed prior to colposcopy with a 1.1% false-negative rate, 97.5% sensitivity, and 83.6% positive predictive value. Ninety-nine patients had Pap smears performed at the time of colposcopy with a 19.1% false-negative rate, 56.8% sensitivity, and 92.6% positive predictive value. Repeat Pap smear at the time of colposcopy resulted in significant changes in the management of only 2 patients (2%) and more careful follow-up in one (1%). Pap smears performed at colposcopic biopsy are less sensitive than those done prior to biopsy (P < 0.001). The clinical benefit of this practice is marginal, considering the added costs and potential detrimental effects to the colposcopic examination, provided patients receive adequate follow-up.

Is colposcopy always necessary with atypical glandular cells of undetermined significance on Papanicolaou smears?

The objective of this study was to review a 5-year experience with atypical glandular cells of undetermined significance (AGUS) on Papanicolaou smear and to use the information to devise a triage method for patients presenting with this abnormality. Our Papanicolaou smear database was used to identify patients who were found to have AGUS results between January 1, 1994 and December 31, 1998. The medical records of these patients were reviewed for the results of follow-up studies, including repeat Papanicolaou smear, endocervical curettage, colposcopic directed biopsies, and endometrial biopsy. During the study period, 27,859 Papanicolaou smears were performed, with 306 (1.1%) being reported as AGUS; 18 patients had two AGUS smears. An additional 24 patients did not meet study criteria. The study group then consisted of 264 patients, of whom 244 (92.4%) reported for follow-up. There were 167 (63.3%) with atypical endocervical cells of undetermined significance (AECUS), 14 (5.3%) with atypical endometrial cells of undetermined significance, and 83 (31.4%) with AECUS plus a squamous cell abnormality. The overall prevalence of a high-grade squamous intraepithelial lesion (HSIL) was 11.8%. The prevalence of HSIL in the AECUS plus squamous cell abnormality group was 25.4%. None of the atypical endometrial cell group had HSIL. In the AECUS, favor dysplasia category, 29.4% had HSIL, whereas in the AECUS, favor reactive process or in unqualified, 2.3% had HSIL. Eighty-one patients underwent endometrial biopsy: three (3.7%) were found to have endometrial adenocarcinoma, and two (2.5%) had complex atypical endometrial hyperplasia. The prevalence of HSIL in patients with AECUS, favor reactive process or AECUS, unqualified Papanicolaou smears is low. Colposcopy is not necessary as an initial triage process for this category of patients. A significant percentage of patients with AECUS, favor dysplasia or AECUS with a squamous epithelial abnormality Papanicolaou smears have HSIL; this subset of patients should be investigated with colposcopy.

Significance of Atypical Squamous Cells of Undetermined Significance on ThinPrep Papanicolaou Smears

Objective. The aim of this study was to assess the prevalence and risk factors predictive of dysplasia among women seen in a gynecologic oncology service with the cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS) on Papanicolaou smears obtained by the ThinPrep method.Methods. Patients with ASCUS ThinPrep Papanicolaou smears seen at the Division of Gynecologic Oncology, University of Vermont, between 1997 and 1999 were identified. The cytologic smears were reviewed and subtyped into reactive or suggestive of squamous intraepithelial lesion (SIL). The charts of these patients were reviewed and the following information was abstracted: age, gravidity, parity, menopausal status, use of hormonal replacement therapy, smoking, history of pelvic cancer, history of radiation therapy, history of abnormal Papanicolaou smear and its treatment, history of human papillomavirus (HPV) infection, and follow-up information including results of repeat Papanicolaou smears, colposcopy, and biopsies. The prevalence of dysplasia was calculated. The demographic features of women with ASCUS, reactive, were compared with those with ASCUS, SIL, using a two-sample t test, χ2, and Fisher's exact test. Risk factors predictive of dysplasia were calculated using the odds ratio and the 95% confidence interval. P < 0.05 was considered significant.Results. One hundred twenty-six patients with ASCUS on ThinPrep Papanicolaou smear were identified; 63 patients had ASCUS, reactive, and 63 patients had ASCUS, SIL. The demographic features of both groups were similar. The overall prevalence of dysplasia was 15.9% and was significantly higher among women with ASCUS, SIL, than among women with ASCUS, reactive (25.4% versus 6.4%, P = 0.003). The type of ASCUS cytology (reactive versus SIL), smoking, and history of HPV were significant risk factors for dysplasia (P = 0.003, 0.037, and 0.042, respectively).Conclusions. The prevalence of dysplasia among women seen in a gynecologic oncology service with ASCUS cytology on ThinPrep Papanicolaou smears is 15.9%. Women with ASCUS favor SIL, those who smoke, and those with a history of HPV are at higher risk for dysplasia and should be offered colposcopy.

Cervical screening behavior of women with atypical squamous cells of undetermined significance (ASCUS).

Expectant follow-up based on early repeat Papanicolaou (Pap) smear(s) is the most commonly recommended management of patients with atypical squamous cells of undetermined significance (ASCUS). In a cervical cytology laboratory in northern Italy, a retrospective study of 1,087 ASCUS patients aged 25-64 was conducted. The primary aim was to assess the actual probability of early repeat Pap smear and associated factors. Univariate comparisons were based on the actuarial method. Multivariate associations were evaluated by Cox regression analysis. The cumulative probability of early repeat Pap smear was 0.11 at 6 mo, 0.29 at 12 mo, and 0.41 at 24 mo, with a multivariate association with screening sector (relative hazard, 3.0 for public offices and 2.8 for private offices vs. organized screening) and previous Pap smear history. Laboratory recommendation, patient age, place of birth, place of residence, marital status, and occupation exerted no independent effect. In conclusion, the probability of early repeat Pap smear was poor and independent of demographic and social factors. The frequency of follow-up failures emerged as a major problem with ASCUS management.

Spontaneous resolution rate of grade 1 cervical intraepithelial neoplasia in a private practice population

Objective: The purpose of this study was to assess the rate of spontaneous resolution of grade 1 cervical intraepithelial neoplasia in a private practice patient population. Study Design: One hundred consecutive women with biopsy-proven grade 1 cervical intraepithelial neoplasia were offered expectant management in the form of repeat Papanicolaou smears every 3 months up to 1 year or treatment. Women with inadequate colposcopic examination, positive endocervical sampling, or discordant Papanicolaou smears were excluded. Results: Eighty-nine (89%) women agreed to undergo expectant management. Of these, 67 (75.3%) experienced spontaneous resolution of lesions on the basis of 2 subsequent and consecutive normal smears corroborated by colposcopy. The median time to resolution was 9 months (n = 38). Seventeen (19.9%) women were treated at 1 year for persistent atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions by loop electrosurgical conization. Of these, 1 (1.1%) had a more advanced lesion (grade 2 cervical intraepithelial neoplasia). Four (4.5%) had progression before 1 year and were treated. Only 1 (1.1%) patient was lost to follow-up. Conclusion: Expectant management of grade 1 cervical intraepithelial neoplasia is safe and cost-effective in a reliable patient population. (Am J Obstet Gynecol 1999;181:278-82.)

Is cervicography a useful diagnostic test? A systematic overview of the literature.

The appropriate approach to women with mild dyskaryotic changes on Papanicolaou smear is subject to controversy. Our aim was to assess the usefulness of cervicography as a diagnostic test in detecting cervical cancer or its precursors. We undertook an extensive literature search looking for pertinent studies of cervicography published between 1966 and 1996. Eligible studies included those in which the reference standard (colposcopy) was done on all patients. The following information was calculated: sensitivity, specificity, positive predictive value, negative predictive value, disease prevalence, and likelihood ratios. Cervicography has a high false-positive rate. This rate ranged from 8.2 to 61.0 percent (median 42.1 percent) for any dysplasia and 9.8 to 63.4 percent (median 50.6 percent) for high-grade cervical lesions. Likelihood ratios for a positive test result ranged from 1.0 to 10.6. Likelihood ratios for a negative result ranged from 0.02 to 1.0. The usefulness of cervicography is heavily dependent on the approach used to evaluate abnormal findings on a Papanicolaou smear. If a provider typically offers colposcopy to all patients with low-grade cytologic findings on a Papanicolaou smear, cervicography will decrease colposcopy use and allow for detection of cases of high-grade dysplasia missed by the index Papanicolaou smear. If a provider typically uses watchful waiting with repeat Papanicolaou smears for all patients who have low-grade cytologic findings, cervicography will substantially increase the use of colposcopy. Many of these colposcopies will be done as a result of false-positive cervigrams.

Human papillomavirus testing as triage for atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions: Sensitivity, specificity, and cost-effectiveness

OBJECTIVE: Our purpose was to evaluate the cost-effectiveness of the use of a Food and Drug Administration–approved human papillomavirus test in triaging patients with Papanicolaou smears showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion for colposcopy compared with an algorithm that used cytologic follow-up. STUDY DESIGN: Four hundred sixty-two women referred to our Colposcopy Clinic with a Papanicolaou smear report of atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion underwent repeat Papanicolaou smear, cervical colposcopy, directed cervical biopsy, and endocervical curettage. In addition, human papillomavirus testing by the Food and Drug Administration–approved HPV Profile (Digene Diagnostics, Silver Spring, Md.) test was done. A comparision of sensitivity, specificity, and cost-effectiveness of an algorithm determining the need for colposcopy on the basis of repeat cytologic testing versus an algorithm that incorporated repeat cytologic testing and human papillomavirus screening was done. The cost-effectiveness of both of these triage algorithms was also compared. RESULTS: As expected, high-risk human papillomavirus deoxyribonucleic acid was detected with greater frequency in relation to increasing severity of cervical intraepithelial neoplasia. In 268 women, the follow-up smear obtained in our clinic was reported as negative. High-risk human papillomavirus types were found in 23.5% of these women. In the human papillomavirus–negative women, 5.9% had grade 2 or 3 cervical intraepithelial neoplasia confirmed on cervical biopsy. In comparison, 20.6% of those with a positive result of the human papillomavirus test had grade 2 or 3 cervical intraepithelial neoplasia on biopsy ( p < 0.001). Despite this difference, the sensitivity of a positive result of a high-risk human papillomavirus test in predicting the presence of grade 2 or 3 cervical intraepithelial neoplasia was only 52%. Among the women for whom a follow-up clinic Papanicolaou smear was reported as showing atypical squamous cells of undetermined significance or a low-grade squamous intraepithelial lesion, there was no difference in the frequency of biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia between those women with a positive human papillomavirus test result and those with a negative test result. Colposcopy would have been recommended for 194 women because of a repeat clinic smear revealing atypical squamous cells of undetermined significance, a low-grade squamous intraepithelial lesion, or a high-grade squamous intraepithelial lesion, and in 21.6% of these women grade 2 or 3 cervical intraepithelial neoplasia was shown on biopsy (sensitivity 63%, specificity 62%). Colposcopy would have been recommended for 180 women because high-risk human papillomavirus or a high-grade squamous intraepithelial lesion was detected at the clinic visit, and in 25% of this group grade 2 or 3 cervical intraepithelial neoplasia was evident on biopsy (sensitivity 67%, specificity 66%). Sensitivity and specificity were virtually identical for the two algorithms, but the cost of human papillomavirus testing was nearly double that of triage based on repeat cytologic testing alone ($692 vs $1246 per case). CONCLUSION: The Food and Drug Administration–approved HPV Profile test is not a cost-effective triage for patients referred with Papanicolaou smears reported as showing atypical squamous cells of undetermined significance or low-grade squamous lesions. (Am J Obstet Gynecol 1997;177:930-6.)

Follow-up of Abnormal Papanicolaou Smears in a Hospital-Based Adolescent Clinic

Study ObjectiveTo present data on the spectrum of abnormal Papanicolaou (PAP) smears in adolescents and to determine factors that influence compliance with recommendations to return for repeat PAP smears or for colposcopic exanmination. DesignRetrospective chart review with follow-up telephone calls to patients who did not follow recommendations for colposcopy. SettingAdolescents receiving health care in a hospital-based adolescent clinic. ParticipantsPatients with abnormal PAP smears between July 1, 1994 and June 30, 1995. Main Outcome MeasuresCompliance with follow-up for abnormal PAP smears including referral to the colposcopy clinic, and the results of repeat PAP smears and colposcopy. ResultsOf 888 adolescents undergoing PAP smear evaluation 119 (13.4%) had an abnormal PAP smear during the study year (index PAP). The results of the index PAP were 97 (81.5%) atypia and 22 (18.5%) squamous intraepitheliallesion low grade (SIL LG). The index PAP was the first abnormal PAP smear for 92 of the patients (77%); 27 had one or more previous abnormal PAP smears (18 atypia, 7 SIL LG, 2 SIL high grade [HG]), and 13 had been referred for colposcopy in the past. For 76 of 92 patients with atypia on index PAP (84%), the index PAP was the first abnormal PAP smear. Of these 76 patients, 51 had a second PAP smear: 27 (53%) were normal, 13 (25%) atypia, and 11 (22%) SIL LG.Sixty patients were referred to the colposcopy clinic, but only 37 actually kept the colposcopy appointment despite outreach. The only significant factor for obtaining colposcopy was a visit to the Adolescent Clinic after notification of the abnormal PAP smear result and before the colposcopy appointment; 79% of those who had a visit obtained colposcopy compared with 45% of those who did not have such a visit (p = 0.007). There were no significant differences by race, insurance status, age, PAP smear result, previous referral for colposcopy, or number of reminders with compliance with recommendations for repeat PAP smears or colposcopy. ConclusionsAlthough a sizable propol1ion of adolescents with abnormal PAP smears have significant pathology on repeat PAP smears, adolescents with abnormal PAP smears have a high failure rate in keeping appointments for follow-up PAP smears and colposcopy. Interventions that target all adolescents with abnormal PAP smears need to be designed and tested to aid follow-up.

Women's triage and management preferences for cervical cytologic reports demonstrating atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesions.

To determine women's triage test preferences for the evaluation and management of atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) Papanicolaou smear reports. A 35-item questionnaire. Primary care clinic waiting rooms. A convenience sample of 968 women. Women received standardized descriptions of the meaning of ASCUS and LSIL Papanicolaou smear classifications and uniform descriptions of the 4 triage tests: Papanicolaou smear, human papillomavirus DNA test, cervicography, and colposcopy. Subjects' responses to questionnaire. More women (58.4%) preferred a repeat Papanicolaou smear for an ASCUS report than would choose human papillomavirus DNA testing (7.3%), cervicography (20.6%), or colposcopy (13.8%) (P < .001, chi 2). Alternatively, 51% of women wanted colposcopy to evaluate an LSIL report compared with the other 3 options (P < .001, chi 2). Test accuracy was the most important factor that influenced women's decisions for each test, compared with cost, discomfort, and other reasons (P < .001, chi 2). Positive predictors for women's selection of colposcopy to evaluate a Papanicolaou smear showing LSIL included older age (P < .01, logistic regression analysis), higher level of income (P < .001, chi 2), greater level of education (P < .001, logistic regression analysis), greater level of knowledge of colposcopy and Papanicolaou smears (P < .001, logistic regression analysis), family history of cervical cancer (P < .01, chi 2), and history of cervical dysplasia (P = .02, chi 2). Most women preferred a repeat Papanicolaou smear to further evaluate an initial Papanicolaou smear demonstrating ASCUS and colposcopy to evaluate a report of LSIL. Women identified test accuracy as the most important reason for triage test selection. Multiple factors, primarily involving patient and family history of cervical neoplasia, level of education, income, age, and knowledge of tests, influence women's desire for specific triage tests. Because no optimal management of women with ASCUS and LSIL Papanicolaou smear reports has been determined, consideration of women's triage test preferences should complement overall patient care.

The Cost Effectiveness of Repeat Papanicolaou Smear at the Time of Initial Colposcopy

The Cost Effectiveness of Repeat Papanicolaou Smear at the Time of Initial Colposcopy

Conservative management of options for patients with dysplasia involving endocervical margins of cervical cone biopsy specimens

OBJECTIVE: Our purpose was to study the feasibility of conservatively managing selected cases of dysplasia involving endocervical cone margins. STUDY DESIGN: A retrospective review of patients conservatively managed after being found to have squamous cell dysplasia involving the endocervical margins of their cervical cone biopsy specimens. In phase I patients who had cold-knife conization with positive endocervical margins underwent repeat Papanicolaou smears and colposcopy, with biopsies and endocervical curettage as indicated. Those found free of disease were followed up with frequent Papanicolaou smears. In phase II patients with dysplasia to the endocervical resection edges on loop electrical excision procedure biopsy specimens were followed up with frequent cytologic studies. RESULTS: In phase I, 31 patients with positive endocervical margins on cold-knife conization and no evidence of dysplasia on reevaluation were followed up for 1 to 18 years. Dysplasia was detected in one patient during cytologic surveillance. In phase II, 11 patients were followed up for 12 to 31 months; only one patient has dysplasia. CONCLUSION: Selected patients with squamous cell dysplasia at endocervical cone biopsy margins may avoid additional surgery. (Am J Obstet Gynecol 1996;174:1695-700.)

Human papillomavirus testing by hybrid capture appears to be useful in triaging women with a cytologic diagnosis of atypical squamous cells of undetermined significance

OBJECTIVE: Our purpose was to determine the clinical value of human papillomavirus deoxyribonucleic acid testing with the hybrid capture test, specifically to examine whether human papillomavirus testing could identify which women with Papanicolaou smears read as atypical squamous cells of undetermined significance were most likely to have histologically confirmed cervical intraepithelial neoplasia. STUDY DESIGN: Hybrid capture testing for 14 human papillomavirus types, repeat Papanicolaou smears, and colposcopically directed biopsies were performed concurrently on 217 women referred to a student health colposcopy clinic with a previous Papanicolaou smear read as atypical squamous cells of undetermined significance. RESULTS: Human papillomavirus deoxyribonucleic acid positivity was associated with an eightfold increased likelihood of histologic confirmation of cervical intraepithelial neoplasia. The sensitivity of hybrid capture for any cervical intraepithelial neoplasia was 86% ( 43 50 ) and for grade 2 or 3 was 93% ( 14 15 ), whereas the corresponding values for the repeat Papanicolaou smear were 60% ( 30 50 ) and 73% ( 11 15 ), respectively. Moreover, high viral levels of human papillomavirus types known to be associated with cervical cancer were strongly predictive of high-grade cervical intraepithelial neoplasia. CONCLUSIONS: Testing for human papillomavirus deoxyribonucleic acid with hybrid capture appears to offer an effective means by which patients whose cervical Papanicolaou smears have been read as atypical squamous cells of undetermined significance could be triaged for colposcopy. In particular, sensitivity for high-grade cervical intraopithelial neoplasia could be maintained and specificity markedly improved by referring only those patients who had elevated levels of human papillomavirus deoxyribonucleic acid of cancer-associated viral types.

A polymerase chain reaction-enzyme-linked immunosorbent assay method for detecting human papillomavirus in cervical carcinomas and high-grade cervical cancer precursors

To develop and evaluate a novel polymerase chain reaction (PCR)-enzyme-linked immunosorbent assay (ELISA)-based method for detecting high-oncogenic-risk human papillomaviruses (HPV). An HPV assay based on PCR amplification of a region of the E6 open reading frame and ELISA detection of PCR products that specifically identify high-oncogenic-risk HPV types (eg, types 16, 18, 31, 33, 35, 39, 45, 56, 58, and 65) was developed. Dacron swabs were used to obtain samples from the cervices of 371 women referred for colposcopy. The swabs were analyzed using the PCR-ELISA method. The results of HPV DNA testing were then compared with the results of a repeat Papanicolaou smear and cervical biopsy obtained at the same visit. The sensitivity of the PCR-ELISA HPV test for detecting invasive cervical cancer or high-grade squamous intraepithelial lesions (SIL) was 90%. High-oncogenic-risk HPVs were detected in six of seven women with biopsy-confirmed invasive cervical cancer, 74 of 81 women with biopsy-confirmed high-grade SIL, 58 of 128 women with biopsy-confirmed low-grade SIL, and 46 of 155 women with no evidence of cervical disease by colposcopy and cervical biopsy. When used in conjunction with a repeat Papanicolaou test, 97% of the women with invasive cervical carcinoma and high-grade SIL lesions were identified. The PCR-ELISA-based HPV detection provides the potential for an automated, rapid, and sensitive test for cervical cancer and high-grade cervical lesions.