Satisfactory Colposcopy Research Articles

Colposcopic findings in human immunodeficiency virus positive patients in Port Harcourt

Colposcopy is an outpatient procedure that involves visualization of the cervix, vagina and vulva using a magnifying optical instrument called the colposcope. Human Immunodeficiency Virus infection is associated with increased incidence of cervical malignancies which can be detected by colposcopy. To determine prevalence of premalignant and malignant lesions of the cervix using colposcopic assessment among HIV positive women at the University of Port Harcourt Teaching Hospital (UPTH), Alakahia between June 2015 and August 2015.One hundred HIV positive women were recruited by simple random sampling (by balloting) with an uptake rate of 97%. Informed consent was obtained from each individual and data was collected using a semi-structured interviewer administered questionnaire. They all had colposcopic examination. Data analysis was done using SPSS. Ethical approval was obtained from the hospital’s ethical committee before the research was commenced.Ninety seven out of one hundred subjects had satisfactory colposcopy. The prevalence of premalignant lesions from colposcopy was 53.6%. The mean age respondents; 37.44 ±7.20 years, mean age for premalignant lesions; 37.73 ±7.49 years.The age range was 21-56 years.Thirty-four (35.4%) had coitarche before eighteen years of age, fifty-five (57.3%) had it after the age of eighteen, seven (7.3%) had no idea. Majority (68.8%) have had two or more sexual partners in their lifetime. The mean CD count was 543.77cells/mm.There was high prevalence of premalignant lesions among the HIV positive women. This indicates that a routinely scheduled colposcopic examination of the cervix, together with directed may aid early detection and treatment of the lesions, which will further decrease the incidence of cervical cancer among this population.

Topical imiquimod compared with conization to treat cervical high-grade squamous intraepithelial lesions: Multicenter, randomized controlled trial

ObjectiveIn a previous phase II trial, we showed that topical imiquimod (IMQ) therapy is an efficacious treatment for high-grade squamous intraepithelial lesion (HSIL). Aim of the present study was to investigate the non-inferiority of a 16-week topical, self-applied IMQ therapy compared to large loop excision of the transformation zone (LLETZ) in patients diagnosed with HSIL. MethodsPhase III randomized, controlled, multicenter, open trial performed by Austrian Gynecologic Oncology group. Patients with histologically proven cervical intraepithelial neoplasia (CIN)2 (30 years and older) or CIN3 (18 years and older) and satisfactory colposcopy were randomized to topical IMQ treatment or LLETZ. Successful treatment was defined as negative HPV high-risk test result 6 months after start of the treatment. Secondary endpoints were histological outcome and HPV clearance rates. ResultsWithin 3 years 93 patients were randomized, received the allocated treatment and were available for ITT analysis. In the IMQ group negative HPV test at 6 months after treatment start was observed in 22/51 (43.1%) of patients compared to 27/42 (64.3%) in the LLETZ group on ITT analysis (rate difference 21.2%-points, 95% two-sided CI: 0.8 to 39.1). In the IMQ group histologic regression 6 months after treatment was observed in 32/51 (63%) of patients and complete histologic remission was observed in 19/51 (37%) of patients. Complete surgical resection was observed in 84% after LLETZ. ConclusionIn women with HSIL, IMQ treatment results in lower HPV clearance rates when compared to LLETZ. LLETZ remains the standard for women with HSIL when treatment is required.Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01283763, EudraCT number: 2012-004518-32.

Value of colposcopy screening independently for cervical lesions in basic hospitals

Objective To evaluate the value of colposcopy screening independently for cervical lesions in basic hospitals. Methods A retrospective cohort study of 574 patients who both underwent colposcopy and had pathologic results in our department. The consistency, authenticity and predictability of colposcopy and pathological results, the relevant factors affecting the accuracy of colposcopy diagnosis, and the analysis of unsatisfactory colposcopy results were analyzed. Results Agreement between colposcopic diagnosis and cervical pathology was 50.57%, and Kappa value of consistency was 0.358 (P<0.01). Agreement within one grade was 91.38 % (Kappa value was 0.871, P<0.01). The sensitivity of colposcopy in diagnosing of low-grade squamous intraepithelial lesion (LSIL) and above was high (96.91%), while the specificity was 52.60% (81/154); False positive rate was 47.40%, and false negative rate was 3.09%. The sensitivity of colposcopy in diagnosing of high-grade squamous intraepithelial lesion (HSIL) and above was 81.82% (153/187), and the specificity in diagnosing of LSIL and below was 90.68% (146/161); False positive rate was 9.3%, and false negative rate was 18.2%. The stage of cervical cancer and skills of colposcopist would be factors that influence the accuracy of colposcopy screening in HSIL and above (P<0.01). Average age in unsatisfactory colposcopy was (52±9)y, which was significantly different from satisfactory colposcopy cases (P<0.01). The proportion of early cervical lesions in patients with unsatisfactory colposcopy HSIL or above was high. Conclusions The complete coincidence rate between colposcopy and pathological diagnosis is limited, but the consistency within one grade is good; the stage of cervical lesions and the experience of examiners are the factors related to the accuracy of colposcopy in diagnosing HSIL and above lesions; Unsatisfactory colposcopy cases can be further combined with cytology and HPV examination for shunt and treatment. Key words: Colposcopy; Uterine cervical diseases; Sensitivity and specificity

The Role of Endocervical Curettage in Satisfactory Colposcopy

Introduction: Colposcopy examination remains the gold standard in assessment of the patients with abnormal cervical cytology. There is a controversy in performing endocervical curettage (ECC) on satisfactory colposcopy. This study was performed with the aim to investigate the role of ECC as a complementary method, besides colposcopic examination in patients with satisfactory colposcopy. Keywords: Satisfactory colposcopy, unsatisfactory colposcopy, endocervical curettage, abnormal cervical cytology.

New Approach in Preventing Infection after Cervical High Grade Squamous Intraepithelial Lesions Treatment

Most of the cervical high grade lesions are now treated in the outpatient setting. Generally, the procedure is considered to have low surgical morbidity however, little is known about perioperative infection rates following this procedure. In order to reduce postsurgical risk of infection and patient discomfort, and to minimize the post infection complication or scarring of the cervix, application of chlorhexidine vaginal suppositories with hyaluronic acid after cervical surgical treatment has been evaluated. The low rate (1.4%) of post-surgical infection in this series is due to the application of chlorhexidine vaginal suppositories after cervical surgical treatment in an Ambulatory Surgery Center qualified infection-prevention procedures. Noteworthy, the satisfactory colposcopy with the definition of the entire squamo columnar junction at the first follow-up demonstrates that preventing infection may aid to achieve an optimal tissue repair with a consequent satisfactory postsurgical diagnostic procedure. In our experience, the chlorhexidine 0.2% vaginal suppositories regimen displays no reported harms, scarce bacterial resistance, and good patient compliance and permits to reduce the postsurgical infection minimizing the patient discomfort after preinvasive cervical cancer treatment.

Contribution of Exocervical Biopsy, Endocervical Curettage, and Colposcopic Grading in Diagnosing High-Grade Cervical Intraepithelial Neoplasia

To determine the utility of random biopsy and endocervical curettage (ECC) during colposcopy among women who ultimately underwent cervical excisional biopsy. In a retrospective observational study, the charts were reviewed of every patient who underwent cervical excisional procedure performed between June 2010 and August 2011, including the antecedent colposcopic examination and any pathological specimens. A random sample of 15% all pathologic specimens was reviewed. Practice of biopsy, use of ECC, demographic factors, referral cytology results, lesion distribution, and size were assessed for correlation with high-grade cervical intraepithelial neoplasia 2 or worse (CIN 2+). A total of 555 patients were included in our analysis. Of them, 333 (60%) had CIN 2+ on colposcopy or excision. CIN 2+ was most likely in younger women and those referred for high-grade cytology. Among 111 women with no visual lesion seen at colposcopy, 66 underwent ECC alone, 33 had ECC and random biopsy, 9 were referred straight to excision, and 3 underwent random biopsy alone. Of the 99 who underwent ECC, this was consistent with the highest-grade lesion in 68% of cases. Among the 36 with random biopsy, this was consistent with the highest-grade lesion in 72% of cases.At the time of colposcopy, there were 326 who had CIN 2+ diagnosed with satisfactory colposcopy. Biopsy and ECC were performed in 278 cases. In 235 cases, biopsy alone showed CIN 2+; in 43, the biopsy and ECC both showed CIN 2+. In the remaining 48 cases, CIN 2+ was diagnosed with ECC alone. In those ultimately treated with excision, younger women and those whose referral cytology was high-grade both were at higher risk of high-grade histology. Random biopsy and ECC (even among satisfactory colposcopy) were significantly associated with disclosure of high-grade pathology.

Abnormal cervicovaginal cytology, unsatisfactory colposcopy and the use of vaginal estrogen cream: an observational study of clinical outcomes for women in low estrogen states.

To determine the effectiveness of vaginal estrogen cream to improve the rate of satisfactory colposcopy and subsequent smear result in patients in a hypoestrogenic state and an abnormal Papanicolaou smear. To delineate between abnormal smears secondary to atrophy and inflammation from preneoplastic change and suggest an effective treatment strategy to deal with this challenging situation. Patients with abnormal cervicovaginal smears who were in a low estrogen state (postmenopausal or amenorrheic postnatal) undergoing colposcopy were identified. All patients had an unsatisfactory colposcopy and were treated with vaginal estrogen cream twice per week for 6 weeks and underwent repeat colposcopy, smear and targeted biopsy where required. Fifty-four patients had an abnormal smear and were clinically in a low estrogen state, with four having previously had a hysterectomy. After 6 weeks of vaginal estrogen therapy, 32 out of 50 patients' colposcopic examinations were satisfactory. Also, 40 out of 54 patients' smears returned to normal after treatment. Of the 14 patients with persistent smear abnormalities, only three were diagnosed with true high-grade pre-invasive disease. The use of vaginal estrogen cream for patients with smear abnormalities and a low estrogen status improves the satisfactory colposcopy rate and improves the accuracy of the prediction of true high-grade pre-invasive disease. This treatment may then reduce the number of patients that require definitive treatment for their screen-detected abnormalities in this patient population.

A normal colposcopy examination fails to provide psychological reassurance for women who have had low-grade abnormal cervical cytology.

Worldwide, each year, large numbers of women are referred for colposcopy following low-grade abnormal cervical cytology. Many have no visible abnormality on examination. The risk of cervical intra-epithelial neoplasia grade 2/3 (CIN2/3) in these women is low. It is unknown whether, for women, a normal colposcopy resolves the anxiety which often follows the receipt of an abnormal cytology result. We investigated the prevalence of adverse psychological outcomes over 30months following a normal colposcopy. This cohort study was nested within the UK TOMBOLA randomized controlled trial. Women aged 20-59years, with recent low-grade cytology, who had a satisfactory colposcopy examination and normal transformation zone, completed the Hospital Anxiety and Depression Scale (HADS) and Process Outcome Specific Measure (POSM) at recruitment and during follow-up (12, 18, 24 and 30months post-recruitment). Outcomes included percentages reporting significant anxiety (HADS anxiety subscale score ≥11), significant depression (HADS depression subscale score ≥8) or worries about the result of the next cytology test, cervical cancer, having sex, future fertility and general health at each time point (point prevalence) and during follow-up (cumulative prevalence). The study included 727 women. All psychological measures (except depression) had high prevalence at recruitment, falling substantially by 12months. During follow-up, the cumulative prevalence of significant anxiety was 27% and significant depression was 21%. The most frequently reported worry was that the next cytology test would be abnormal (cumulative prevalence of 71%; point prevalence of ≥50% at 12 and 18months). The cumulative prevalence values of worries about cervical cancer, having sex and future fertility were 33%, 20% and 16%, respectively. For some women who have low-grade cytology, a normal colposcopy does not appear to provide psychological reassurance.

Accuracy of visual inspection with acetic acid to detect cervical cancer precursors among HIV-infected women in Kenya

Visual inspection with acetic acid (VIA) is becoming a more widely recommended and implemented screening tool for cervical cancer prevention programs in low-resource settings. Many of these settings have a high prevalence of HIV-infected women. We carried out a cross-sectional validation study to define the sensitivity, specificity and predictive values of VIA among HIV-infected women. Women enrolled in HIV care at the Family AIDS Care and Education Services clinic in Kisumu, Kenya, were recruited for participation. All participants underwent VIA followed by colposcopy performed by a second blinded clinician. At colposcopy, lesions suspicious for cervical intraepithelial neoplasia 2 or greater (CIN2+) were biopsied. Disease status was determined by final histopathologic diagnosis in women who underwent biopsies. A satisfactory colposcopy with no lesions was considered a negative result. From October 2010 to June 2012, 1,432 women underwent VIA and colposcopy. A total of 514 (35.7%) women had a positive VIA, and 179 (12.2%) had CIN2+ confirmed by colposcopically directed biopsy. Sensitivity, specificity, positive and negative predictive values of VIA for CIN2+ were 86.6, 71.6, 30.3 and 97.4%, respectively. Specificity, but not sensitivity, increased with older age. Among older women, sensitivity was affected by CD4+ count and use of antiretroviral therapy. Although they are impacted by age and immune status, test characteristics for VIA among HIV-infected women are similar to what has been reported for general populations. Recommendations to use VIA as a screening tool should not vary by HIV status.

Interventions for preventing blood loss during the treatment of cervical intraepithelial neoplasia.

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Surgical treatments for CIN are commonly associated with blood loss. To assess the effectiveness and safety of interventions for preventing blood loss during the treatment of CIN. We searched the Cochrane Gynaecological Cancer Group Trials Register, MEDLINE, EMBASE and CENTRAL up to November 2012. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. Randomised controlled trials (RCTs) of vasopressin, tranexamic acid, haemostatic sutures, Amino-Cerv or Monsel's solution in women undergoing surgery for CIN. Two reviewers independently abstracted data and assessed risk of bias. Risk ratios comparing adverse events in women who received one of the interventions were pooled in a random-effects meta-analyses or included in single trial analyses. Twelve RCTs (N = 1602, of whom 1512 were assessed) were included.Vasopressin significantly reduced perioperative bleeding (mean difference (MD) = -100.80, 95% confidence interval (CI) -129.48 to -72.12) and was associated with a decreased risk of bleeding that required haemostatic sutures or further vasopressin, compared to placebo (risk ratio (RR) = 0.39, 95% CI 0.27 to 0.56).Tranexamic acid significantly reduced risk of secondary haemorrhage (RR = 0.23, 95% CI 0.11 to 0.50), but not primary haemorrhage (RR = 1.24, 95% CI 0.04 to 38.23) after knife and laser cone biopsy, compared with placebo. There was also a statistically significant reduction in postoperative blood loss compared with placebo (MD = -55.60, 95% CI -94.91 to -16.29).Packing with Monsel's solution resulted in less perioperative blood loss (MD = -22.00, 95% CI -23.09 to -20.91) and decreased the risk of dysmenorrhoea (RR = 0.37, 95% CI 0.16 to 0.84), unsatisfactory colposcopy (RR = 0.43, 95% CI 0.30 to 0.63) and cervical stenosis (RR = 0.35, 95% CI 0.25 to 0.49) compared to routine suturing, but was not statistically different to sutures for risk of primary and secondary haemorrhages.Amino-Cerv antibiotic gel failed to make a difference on secondary haemorrhage but was associated with significantly less vaginal discharge at 2 weeks compared with routine care (RR = 0.27, 95% CI 0.09 to 0.86).There was no significant difference in blood loss between women who received ball electrode diathermy and those who received Monsel's paste (MD = 4.82, 95% CI -3.45 to 13.09). Bleeding associated with surgery of the cervix appears to be reduced by vasopressin, used in combination with local anaesthetic. Tranexamic acid appears to be beneficial after knife and laser cone biopsy. There are insufficient data to assess the effects on primary haemorrhage. There is some evidence that haemostatic suturing has an adverse effect on blood loss, cervical stenosis and satisfactory colposcopy.

Evaluation of Endocervical Canal in Women With Minimal Cervical Cytological Abnormalities

This study aimed to examine the endocervical canal curettage (ECC) results of patients with atypical squamous cells of undetermined significance (ASC-US) or low-grade intraepithelial lesion (LSIL) and secondarily to explore the features of patients who are at greatest risk for endocervical involvement. This is a retrospective analysis of 846 women who underwent ECC with ASC-US or LSIL on cervical cytology between January 2003 and April 2011. Records of demographic data and colposcopic impression were evaluated. Histopathological results of biopsies and ECC were classified into 2 categories as less than cervical intraepithelial lesion 2 (CIN 2) and CIN 2+ lesions for comparison. Multivariate analysis was performed using binary logistic regression analysis to identify predictors of ECC results. CIN 1 lesions were detected in 8.9% of patients, and the rates of CIN 2 or 3 and invasive/microinvasive cancers in ECC were 3.8% and 0.7%, respectively. Cervical intraepithelial lesion 2 or worse lesions were detected in 1.6% (7/419) of the patients with normal colposcopic findings. There was no statistically significant difference in the rate of CIN 2+ lesion in endocervical canal between the patients with or without satisfactory colposcopic examination (4.4% vs 4.1% p = .69). A total of 1.7% of the patients who did not have cervical biopsy and also 1.1% of the patients who had less than CIN 2 biopsy results were diagnosed with CIN 2+ lesion by ECC despite the satisfactory colposcopy. Only a positive biopsy result for dysplasia was found to be an independent factor for the detection of a dysplastic lesion in endocervical canal (odds ratio = 0.06; 95% CI = 0.01-0.35; p = .02). Endocervical canal curettage had minimal diagnostic utility for the detection of CIN 2 or worse lesions in women with ASC-US or LSIL smear result and normal colposcopic findings. In addition to this, the presence or absence of CIN 2+ lesions diagnosed by means of endocervical curettage was independent of a satisfactory or unsatisfactory colposcopic examination.

MANAGEMENT OF HSIL (CIN II) IN NULLIPAROUS PATIENTS

MANAGEMENT OF HSIL (CIN II) IN NULLIPAROUS PATIENTS (Abstract): Cervical carcinogenesis evolves in several stages over a relatively long period of time (7-20 years) and it can be diagnosed by multiple non-invasive screening methods (PAP smear, HPV genotyping, colposcopy) and consecutively treated. It is known that 50% of CIN II cases regress spontaneous and 30% progress to CIN III or cervical cancer. Management of HSIL (CIN II) has a major importance for clinicians because many patients are young and it is important to preserve the obstetrical outcome. Therefore, in this study, 3 types of management for CIN II were proposed in nulliparous patients: 1. conservative management; 2. LOOP / LLETZ; 3. conization. The main goal of the study was to evaluate if, in very carefully selected cases, conservative and minimally invasive management may be a viable therapeutical option, in order to preserve obstetrical outcome of the patients, knowing that conization determine a moderate to severe shortening of the cervix and increases the risk of second trimester abortion or preterm delivery, especially by premature rupture of membranes; conization can determine infertility by cervical stenosis. In our limited study a less aggressive management of cervical lesions provided better obstetrical outcomes both in terms of getting pregnant and in duration of pregnancy. Although current management of CIN II is considered to be similar to CIN III, in carefully selected nulliparous patients (high social status, high education, compliant patients), with satisfactory colposcopy (squamous-cylinder junction visible in colposcopy, lesions at a distance from the cervical os and endocervical cytology without pathological changes) and the CL less than 30-32 mm, we can opt for conservative management (by follow-up) or loop diathermy (single or multiple) or LLETZ, with a rigorous follow-up, thus preserving the obstetrical outcome.

The effectiveness of conization treatment for post-menopausal women with high-grade cervical intraepithelial neoplasia

The aim of this study was to evaluate the effectiveness of conization in the diagnosis and treatment of high-grade cervical intraepithelial neoplasia (CIN) in post-menopausal women. A total of 101 post-menopausal patients who were diagnosed with high-grade lesion CIN by biopsy and in whom conization was used as the primary treatment were examined and 202 pre-menopausal patients were studied as the controls. Clinical and pathological data including symptoms, cytological examination and HPV DNA test results before and after conization treatment were analyzed. Both the cytological abnormalities (57.9 vs. 58.5%, P=0.260) and the positive rate of the HPV DNA test (89.5 vs. 86.4%, P=0.812) did not show a significant difference between the post- and pre-menopausal group. The rate of satisfactory colposcopy was significantly lower in post-menopausal patients compared with pre-menosausal patients (23.2 vs. 68.9%, P<0.001). Post-menopausal patients presented a significantly lower diagnostic consistency between colpscopy-directed biopsy and conization (46.4 vs. 68.9%, P=0.004), and a significantly higher positive margin rate of conization (20.8 vs. 10.9%, P=0.020). A total of 10 of the 101 post-menopausal and 2 of the 202 pre-menopausal women were diagnosed with invasive cancer by conization and underwent further treatment. In conclusion, these data suggest that conization, as a conservative primary treatment, is not suitable for post-menopausal women with high-grade lesion CIN due to the lower rate of satisfactory colposcopy, lower consistency of diagnosis between colposcopy-directed biopsy and conization, and a higher positive margin of conization.

2011 Colposcopic Terminology of the International Federation for Cervical Pathology and Colposcopy

New colposcopy terminology was prepared by the Nomenclature Committee of the International Federation of Cervical Pathology and Colposcopy after a critical review of previous terminologies, online discussions, and discussion with national colposcopy societies and individual colposcopists. This document has been expanded to include terminology of both the cervix and vagina. The popular terms "satisfactory colposcopy" and "unsatisfactory colposcopy" have been replaced. The colposcopic examination should be assessed for three variables: 1) adequate or inadequate, with the reason given; 2) squamocolumnar junction visibility; and 3) transformation zone type. Other additions were the localization of the lesion to either inside or outside the transformation zone and determinants of size as well as location of cervical lesions. Two new signs were included in the terminology-the "inner border sign" and "ridge sign." The following definitions have been added: congenital transformation zone, polyp (ectocervical or endocervical), stenosis, congenital anomaly, and posttreatment consequence. In addition, the terminology includes standardization of cervical excision treatment types and cervical excision specimen dimensions. The International Federation of Cervical Pathology and Colposcopy recommends that the 2011 terminology replace all others and be implemented for diagnosis, treatment, and research.

The utility of endocervical curettage: does routine ECC at the time of colposcopy for low-grade cytologic abnormalities improve diagnosis of high-grade disease?

To determine the use of endocervical curettage at the time of colposcopy for low-grade cytologic abnormalities. We conducted a retrospective chart review of women with low-grade Papanicolaou smears who had undergone satisfactory colposcopic examinations with identifiable lesions. We evaluated results during a 2-year period thereafter to determine whether endocervical curettage increased the diagnosis of high-grade dysplasia. The study group consisted of 374 patients. Of these patients, 16 had endocervical curettages suggestive of high-grade dysplasia. Of these 16 patients, 4 did not have concomitant high-grade dysplasia identified on ectocervical biopsy. Therefore, 93 to 94 endocervical curettages needed to be performed to detect 1 case of high-grade dysplasia that would not have been identified otherwise. Routine endocervical curettage at the time of satisfactory colposcopy for low-grade cytologic abnormalities with a visible lesion does not significantly improve the diagnosis of high-grade dysplasia.

Clinical, colposcopic and pathological characteristics of cervical and vaginal high-grade lesions negative for HPV by Hybrid Capture 2

Objective Less than 5% of women with cervical or vaginal biopsy proven high-grade squamous intraepithelial lesions (HG-SIL) show a negative Hybrid Capture 2 (HC2) result. We analyzed 1) human papillomavirus (HPV) genotypes by PCR in order to determine whether these cases represent infections by common or unusual types, and 2) the clinical, colposcopic and pathological differential characteristics of these patients. Methods 646 women with a histological diagnosis of HG-SIL and a HC2 test collected within 6 months prior to the diagnosis were identified. Patients with a negative HC2 result were selected. HPV was typed in the biopsy specimen in all by PCR using SPF10 and GP5+/6+ primers, and p16 INK4a immunostaining was performed. The clinical and colposcopy findings of these women were compared with a control group of HG-SIL with positive HC2 result. Results 20 women (3.1%) with HG-SIL had a negative HC2. All biopsies were positive for p16 INK4. PCR analysis detected HPV types included in HC2 test in 55% of the cases, with an identical percentage of common viruses between women with relative light unit values above or below 0.40 (p = .361). False negative HC2 tests increased with age (p = .002) and were more frequent in patients with non satisfactory colposcopy or small sized lesions (p < .001). Conclusion A negative HC2 test is an infrequent event in women with HG-SIL. Common HPV types are identified in over half of the cases. Older women and patients with small lesions or non satisfactory colposcopy have a higher rate of HC2 negative results.

Random Biopsy After Colposcopy-Directed Biopsy Improves the Diagnosis of Cervical Intraepithelial Neoplasia Grade 2 or Worse

To evaluate the usefulness of additional random biopsies in the diagnosis of cervical intraepithelial neoplasia grade 2 (CIN 2) or worse (CIN 2+) after colposcopy-directed biopsy. A retrospective chart review was performed in 107 women with satisfactory colposcopy results after colposcopy-directed biopsy with random biopsy for abnormal cervical cytological evaluation at Soonchunhyang University Hospital between April 2008 and November 2009. Random biopsies were performed at the cervical squamocolumnar junction in lesion-free quadrants of the cervix. Loop electrosurgical excision procedure conizations were performed in 59 women. Age, referral cytology, lesion size, human papilloma virus (HPV) viral load, and HPV type were analyzed as possible indicators of lesion severity detected using random biopsy. The mean age was 39.3 years (range = 21-72 y), and 96 (89.7%) women were premenopausal. Sixty-three women had CIN 2+; of those, 8 (12.7%) were diagnosed using random biopsies: 6 had high-grade squamous intraepithelial lesions; 1 had low-grade squamous intraepithelial lesions; and 1 had atypical squamous cells of undetermined significance. Lesions diagnosed as CIN 2+ using random biopsies were significantly correlated with high-grade cytology (p <.001) and lesion size (p <.001) but not age (cutoff = 40 years), HPV viral load (cutoff = 300 relative light units; Hybrid Capture 2), or HPV genotype. Of 59 patients who underwent loop electrosurgical excision procedure conization, the disease severity of 9 (15.3%) cases was upgraded 1 or more grades, compared with the punch biopsy results. The detection of CIN 2+, particularly high-grade cytological abnormalities and large lesion size, can be increased by additional random biopsies after satisfactory colposcopy. Loop electrosurgical excision procedure conization can detect lesions not detected by punch biopsy.

Interventions for preventing blood loss during the treatment of cervical intraepithelial neoplasia.

Cervical intraepithelial neoplasia (CIN) is the most common pre-malignant lesion. Surgical treatments for CIN are commonly associated with blood loss. To assess the effectiveness and safety of interventions for preventing blood loss during the treatment of CIN. We searched the Cochrane Gynaecological Cancer Group Trials Register, MEDLINE, EMBASE and CENTRAL up to April 2009. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. Randomised controlled trials (RCTs) of vasopressin, tranexamic acid, haemostatic sutures, Amino-Cerv or Monsel's solution in women undergoing surgery for CIN. Two reviewers independently abstracted data and assessed risk of bias. Risk ratios comparing adverse events in women who received one of the interventions were pooled in a random-effects meta-analyses or included in single trial analyses. Twelve RCTs (N = 1602, of whom 1512 were assessed) were included.Vasopressin significantly reduced perioperative bleeding (mean difference (MD) = -100.80, 95% confidence interval (CI) -129.48 to -72.12) and was associated with a decreased risk of bleeding that required haemostatic sutures or further vasopressin, compared to placebo (risk ratio (RR) = 0.39, 95% CI 0.27 to 0.56).Tranexamic acid significantly reduced risk of secondary haemorrhage (RR = 0.23, 95% CI 0.11 to 0.50), but not primary haemorrhage (RR = 1.24, 95% CI 0.04 to 38.23) after knife and laser cone biopsy, compared with placebo. There was also a statistically significant reduction in postoperative blood loss compared with placebo (MD = -55.60, 95% CI -94.91 to -16.29).Packing with Monsel's solution resulted in less perioperative blood loss (MD = -22.00, 95% CI -23.09 to -20.91) and decreased the risk of dysmenorrhoea (RR = 0.37, 95% CI 0.16 to 0.84), unsatisfactory colposcopy (RR = 0.43, 95% CI 0.30 to 0.63) and cervical stenosis (RR = 0.35, 95% CI 0.25 to 0.49) compared to routine suturing, but was not statistically different to sutures for risk of primary and secondary haemorrhages.Amino-Cerv antibiotic gel failed to make a difference on secondary haemorrhage but was associated with significantly less vaginal discharge at 2 weeks compared with routine care (RR = 0.27, 95% CI 0.09 to 0.86).There was no significant difference in blood loss between women who received ball electrode diathermy and those who received Monsel's paste (MD = 4.82, 95% CI -3.45 to 13.09). Bleeding associated with surgery of the cervix appears to be reduced by vasopressin, used in combination with local anaesthetic. Tranexamic acid appears to be beneficial after knife and laser cone biopsy. There are insufficient data to assess the effects on primary haemorrhage. There is some evidence that haemostatic suturing has an adverse effect on blood loss, cervical stenosis and satisfactory colposcopy.

A clinical review of borderline glandular cells reported on liquid-based cervical cytology

To review the clinical outcome of women presenting with borderline glandular cells on liquid-based cervical cytology (LBC). Design Retrospective review. Women seen at a colposcopy clinic over a 26-month period referred with borderline glandular cells on LBC. Review of the case notes and cytology, pathology and colposcopy databases of all women referred with borderline glandular cells on LBC between June 2006 and August 2008. Final histological diagnosis. Sixty-nine women were identified (0.19% of all smears). Twenty-seven women (39.1%) had premalignant or malignant lesions, five (7.2%) had cancers and 22 (31.9%) had intraepithelial neoplasia, 19 (27.5%) of which were cervical squamous intraepithelial neoplasia (CIN) and three (4.3%) of which were cervical glandular intraepithelial neoplasia (CGIN). No women under 35 years of age with normal and satisfactory colposcopy had premalignant or malignant lesions. Despite normal and satisfactory colposcopy, three women over 35 years had significant lesions: one high-grade CIN, one CGIN and one squamous cell carcinoma. On the basis of our results, it would be considered acceptable to manage women under 35 years of age with normal and satisfactory colposcopy conservatively. In women above 35 years of age, we would recommend a diagnostic 'large loop excision of the transformation zone' procedure, irrespective of the colposcopic findings.

Can Vaginal Misoprostol Effectively Increase Rate of a Satisfactory Colposcopy? A Randomized Double-blind Placebo-controlled Trial

To evaluate the effectiveness of vaginal misoprostol in overcoming an unsatisfactory colposcopy in the patients who had abnormal cervical cytology and to evaluate side effects of vaginal misoprostol. Sixty patients with an unsatisfactory colposcopy during the period of September 2007-November 2008 were recruited and randomly allocated to receive either two tablets of 200 microg misoprostol (400 microg) or two tablets of similar-looking placebo vaginally. Colposcopic re-examination was performed approximately 6 h later. The results and side effects before and 2 weeks after the colposcopic re-examination were recorded. Six out of 30 patients in the misoprostol group (20.0%) had a satisfactory colposcopic re-examination compared with 2 out of 27 patients (7.4%) in the placebo group without statistically significant difference (P = 0.172). Three patients in the placebo group dropped out due to not present at the appointment time. Six out of 30 patients (20.0%) and 1 out of 30 patients (3.3%) in the misoprostol group had side effects before and 2 weeks after the colposcopic re-examination orderly. Twenty-seven patients in the placebo group did not have any side effects before and 2 weeks after the colposcopic re-examination. All side effects occurred were minimal and well tolerated. Four hundred micrograms of vaginal misoprostol were not proved to be effective in converting an unsatisfactory to a satisfactory colposcopy.