Inclusion of HPV testing in routine cervical cancer screening for women above 29 years in Germany: results for 8466 patients

In a prospective cohort study 8466 women attending routine cervical cancer screening were recruited. Colposcopy was performed on women with any degree of atypia on cytology and/or a positive high-risk human papillomavirus (HPV)-DNA test (HC2; Hybrid Capture 2((c))), and for a randomly selected sample of 3.4% women with negative findings on both. Quality control included reviews of cytology, histology, colposcopy images and retesting of samples with polymerase chain reaction. Test diagnostic performances were based on 7908 women who had complete baseline and follow-up results. Routine histology identified 86 women with high-grade cervical intraepithelial neoplasia (CIN2+), which was confirmed by review histology in only 46 cases. Sensitivity of routine cytology for the detection of CIN2+ was 43.5%, with a specificity, positive predictive value (PPV), negative predictive value (NPV) of 98.0, 11.4 and 99.7%, respectively. Sensitivity of the HC2 test for the detection of CIN2+ was 97.8%, with a specificity, PPV and NPV, of 95.3, 10.9 and 100%, respectively. No high-grade neoplasia was detected in the randomly selected control group. A negative HPV-test result, even in combination with a positive Papanicolaou (Pap) result, virtually excluded any risk of underlying high-grade disease, but this was not the case for a negative Pap result. These data show that HPV testing is of value for the detection or exclusion of prevalent CIN in a routine cervical cancer-screening setting and could be used for further risk classification of women for follow-up management.     

Experience of Combined Liquid Based Cervical Cytology and High-Risk HPV mRNA for Cervical Cancer Screening in Thammasat University Hospital

Background: Cervical cancer is the second most common of malignancy found in Thai women. Human papillomavirus (HPV) infection is a major cause. The objective of the present study was to evaluate the prevalence of HPV infection and association with abnormal cervical cytology in Thai women. Materials and Methods: This study was conducted at the Gynecologic Clinic, Thammasat University, Pathum Thani, Thailand. A total of 2,144 cases who underwent annual cervical cancer screening by co-testing (liquid based cytology and HPV testing, DNA versus mRNA) during the priod from July 2013 to June 2016 were recruited in this study. Results: Prevalence of positive high risk (HR) HPV DNA and mRNA test were 19.7 and 8.4%, respectively with a statistically significant difference. Majority of cases of abnormal cytology in this study were atypical squamous cells of undetermined significance (ASC-US). In patients with ASC-US, positive HR HPV DNA was greater than in the mRNA group (10.1 and 4.5%, p<0.001). Nonetheless, there was no significant difference in participants with cervical intraepithelial neoplasia (CIN). HPV mRNA test had slightly lower sensitivity but higher negative predictive value (NPV) than the DNA test to detect abnormal cytology during cervical cancer screening (p<0.001). Both HPV test (DNA and mRNA) had equally efficacy to detect high grade precancerous lesion or higher (CIN 2). Conclusions: Prevalence of HR HPV DNA and mRNA were 19.7 and 8.4 percent, respectively. NPV of HPV mRNA was higher than DNA test. Both tests had equal efficacy to detect CIN 2 with sensitivity and specificity of 63% vs 55.7% and 83% vs 92%, respectively.     

Comparison between Visual Inspection of Cervix and Cytology Based Screening Procedures in Bangladesh

Background: Cervical cancer continues to be a major problem in Bangladesh with approximately 18,000 newcases annually of which over 10,000 women die from it. Visual inspection of the cervix after 3-5% acetic acid(VIA) application is a simple and easy to learn method for cervical cancer screening, although cytology-basedscreening is more often applied in developed countries where it has successfully reduced the prevalence of cervicalcancer. Objective: To compare the efficacy of VIA and cytology-based primary methods for cervical cancerscreening in Bangladesh. Materials and Methods: This hospital based comparative study was conducted at theVIA centre and Colposcopy Clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU) from October2008 to October 2010. Results: Among 650 women, 74 (11.4%) were VIA+ve and 8 (1.2%) had abnormalitiesin their Pap smear reports. During colposcopy, 38 (7.7%) women had different grades of CIN and 4 (0.6%)had cervical cancer. The gold standard histology findings proved 20 women had CIN I, 14 had CIN II/II and 4had cervical cancer. Among the 38 histology diagnosed abnormalities, VIA test could identify 30 abnormalitiesincluding two cervical cancers. However, Pap smear could detect only 8 cases of histological abnormalities (2low grade and 6 had high grade lesion) and it missed all the cervical cancer cases. The sensitivity and specificityof VIA were 88.9% and 52.1%. The positive predictive value (PPV) and negative predictive value (NPV) were41.0%, and 92.6% respectively. Moreover, the sensitivity, specificity, PPV and NPV of Pap smear were 33.3%,95.8%, 75.0% and 79.3%, respectively. Conclusions: VIA test should be used as the primary screening tool evenwith its low sensitivity and specificity in low resource countries like Bangladesh. False positive results may begreater, but overtreatment can be minimized by colposcopy evaluation of the VIA positive women.     

Evaluation of adjunctive tests for cervical cancer screening in low resource settings

BACKGROUND: Visual inspection of cervix after application of acetic acid (VIA) is an effective screening tool for cervical cancer in low resource settings, but its low specificity leads to high referral rates. Adjunctive testing may overcome this drawback. AIMS: This pilot study was aimed to assess test performances of VIA, human papillomavirus (HPV) testing and Pap smear, individually and in simulated combinations, to determine the probable best screening option. SETTING AND DESIGN: Gynecology outpatient department (OPD); cross-sectional study. MATERIALS AND METHODS: One hundred women with complaints of irregular vaginal bleeding or discharge, post coital bleeding or unhealthy cervix on examination underwent Pap smear, HPV testing, VIA, colposcopy and biopsy, if indicated, in this screening order. STATISTICAL ANALYSIS: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each of the tests with a biopsy result of > or =HSIL taken as the gold standard. Simulated parallel and sequential combinations for VIA/Pap, VIA/HPV and HPV/Pap were calculated and compared with individual test performance. RESULTS: Prevalence of abnormal Pap smears was 5%, VIA positive 51% and HPV positive 16%. Sensitivity and specificity of VIA were 100% and 53.3% respectively. For HPV and Pap tests corresponding figures were 85.7%, 89.7% and 50%, 98.9% respectively. The best simulated combination with a balance of sensitivity and specificity was of VIA followed by HPV testing (sensitivity 85.7%, specificity 95.4%). CONCLUSION: Addition of HPV testing to VIA can increase the specificity of VIA, thereby reducing the referral rates without compromising the sensitivity of the test.     

Efficacy of Pap test in combination with ThinPrep cytological test in screening for cervical cancer

Background: Our aim was to investigate the efficacy of the Pap test in combination with the ThinPrepcytological test (TCT) in screening for cervical cancer in China. Design: From March 2006 to October 2008,988 women with the mean age 46.4 ± 10.5 years (range, 23-80 years) were recruited to receive cervical cancerscreening. Pap test results ≥ grade III and TCT findings ≥ ASCUS/AGUS were considered abnormal. Subjectswith a Pap test result ≥ grade IIb received TCT. Colposcopy and biopsies were performed in all participants, andfinal diagnosis was based on pathological findings. The sensitivity, specificity, positive predictive value (PPV),negative predictive value (NPV) and Youden index for predicting CIN I or above were determined. Results:The sensitivity, specificity, PPV, NPV and Youden index of the Pap test were 43.1%, 97.2%, 70.0%, 91.9%, and40.3%, respectively. The same values for TCT in predicting CIN were 80.0%, 63.2%, 16.0%, 97.3%, and 43.2%,respectively. The two tests in combination gave values for predicting CIN of 64.8%, 87.6%, 43.6%, 94.4%, and53.5%, respectively. Combined testing exhibited the highest Youden index (53.4%). Conclusion: The Pap testwith a reduced threshold in combination with the TCT has high sensitivity and high specificity in screening forcervical cancer.     

Comparison of Efficacy in Abnormal Cervical Cell Detection between Liquid-based Cytology and Conventional Cytology

This study was conducted to 1206 women who had cervical cancer screening at Chonburi Cancer Hospital.The spilt-sample study aimed to compare the efficacy of abnormal cervical cells detection between liquid-basedcytology (LBC) and conventional cytology (CC). The collection of cervical cells was performed by broom anddirectly smeared on a glass slide for CC then the rest of specimen was prepared for LBC. All slides were evaluatedand classified by The Bethesda System. The results of the two cytological tests were compared to the gold standard.The LBC smear significantly decreased inflammatory cell and thick smear on slides. These two techniques werenot difference in detection rate of abnormal cytology and had high cytological diagnostic agreement of 95.7%. Thehistologic diagnosis of cervical tissue was used as the gold standard in 103 cases. Sensitivity, specificity, positivepredictive value, negative predictive value, false positive, false negative and accuracy of LBC at ASC-US cut offwere 81.4, 75.0, 70.0, 84.9, 25.0, 18.6 and 77.7%, respectively. CC had higher false positive and false negativethan LBC. LBC had shown higher sensitivity, specificity, PPV, NPV and accuracy than CC but no statisticalsignificance. In conclusion, LBC method can improve specimen quality, more sensitive, specific and accurate atASC-US cut off and as effective as CC in detecting cervical epithelial cell abnormalities.     

Prevalence and Risk Assessment of Cervical Cancer Screening by Papanicolaou Smear and Visual Inspection with Acetic acid of Pregnant Women at a Thai Provincial Hospital

Background Cervical cancer is the second most common in Thailand, but the mortality rate may be rising yearly. It is a cancer that can be prevented by early screening for precancerous lesions, several methods being available. Objective To identify the prevalence of abnormal Papanicolaou (Pap) smears and lesions with visual inspection with acetic acid (VIA) in pregnant women and assess risk factors for this group. Materials and Methods This prospective study was performed at Prapokklao Hospital, Thailand during April-July 2016. All pregnant women of gestational age between 12-36 weeks who attended antenatal clinic were recruited. All participants were screened for cervical cancer by Pap smear and VIA. If results of one or both were abnormal, colposcopic examination was evaluated by gynecologic oncologist. Results A total of 414 pregnant women were recruited. Prevalence of abnormal Pap smear and VIA were 6.0 and 6.7 percent, respectively. The most common abnormal Pap smear was low grade intraepithelial lesion (LSIL, 44%). Factor associated with abnormal Pap smear in pregnant women were low BMI, multiple partners and government officer. In pregnancy, Pap smear had higher sensitivity and specificity than VIA for detection of precancerous cervical lesion. Patients with young coitarche or more than 25 years of active sexual activity were high risk groups. Conclusions Prevalence of abnormal Pap smear and VIA in pregnant women was 6.0 and 6.7 percent, respectively. Factors associated with abnormal Pap smear were coitarche, years of sexual activity, low BMI, multiple partners and government officer.     

Influence of Demographic and Reproductive Factors on Cervical Pre-Cancer and Cancer in Bangladesh

Background: In Bangladesh, cervical cancer (CC) is the 2nd most common cancer with estimated 8068 new cases and 5,214 deaths every year. It is also revealed that different socio-demographic factors have association with CC. This study was performed to evaluate the colposcopy outcomes and the association of different demographic and reproductive risk factors with cervical pre-cancer and cancer. Methods: This retrospective cross-sectional study was carried out at the colposcopy clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU) between January 2010 and December 2016. Results: A total 16147 women attended the colposcopy clinic of BSMMU with VIA positive reports. Among them, 65.73% women were referred from different VIA centers of Dhaka district. Mean age of marriage of the subjects was 16. 93 (± 1) and mean age of 1st delivery was 18.45 years (± 4.10). Almost three-fourth of them were married before 18 years and had their 1st delivery by 20 years. Colposcopy examination of the VIA positive women revealed that 36.7% had CINI, 10.6% had CINII/ III and 7.1% had carcinoma of cervix. Considering CIN as disease the Sensitivity, Specificity, PPV and NPV of colposcopy were found 99.7%, 75.3%, 70.3% and 99.8% respectively. On other hand considering CIN2+ as disease the Sensitivity, Specificity, PPV and NPV of colposcopy were found 73.8%, 92.7%, 64.4% and 95.2% respectively. Statistical analysis revealed that higher age (p=0.000), lower level of education (p=0.007), lower socioeconomic status (p=0.014), higher parity (p=0.001) had individual influence on cervical pre-cancer and cancer. Conclusions: This study indicated higher age, low level of education, lower socio-economic condition and higher parity as most important socio-demographic factors for developing cervical pre-cancer and cancer in Bangladesh.     

Comparative Study of Smart Scope® Visual Screening Test with Naked Eye Visual Screening and Pap Test

Background: Cervical cancer is a major contributor to mortality and morbidity in women. Naked eye visual screening (NE test) and Pap test are commonly used for cervical cancer screening.  Both tests have inherent limitations like low sensitivity (Pap test) and subjectivity in interpretation, lack of permanent record and overestimation (NE test). Here, Smart Scope® visual screening test (SS test) was compared with NE and Pap tests. Smart Scope® is a small, hand-held device that captures cervical images attached to a tablet to store data. Objective: To compare SS test with Pap and NE tests. Study Design: This prospective observational study was conducted at a tertiary care hospital in India, over 16 months. A total of 509 women in the age group of 25 to 65 years were included in the study as per the inclusion criteria. All the participants underwent Pap test, NE test and SS test. Screen positives on any one test were advised colposcopy and biopsy. Results: Out of 154 screen-positive women, 49 visited for follow-up colposcopy-guided biopsy. Nine incidental biopsies of screen-negative women were included in the data.  Thus, statistical analysis was carried out based on 58 available histopathology results. Out of 58 biopsies, 8 were normal, 30 were benign lesions, 18 were precancerous and 2 were cancerous lesions. SS test was found to have a sensitivity and NPV of 100% each, PPV of 45.4% and a specificity of 36.8%. Sensitivity and specificity of NE test was 90% and 39.5% respectively, PPV was 43.9% and NPV was 88.2%. Pap smear had a sensitivity of 25% and specificity of 84.2%, PPV of 45.5% and NPV of 68.08%. Conclusion: SS test has great potential to be a primary screening test in low-resource settings due to its better sensitivity and NPV as compared to NE and Pap tests.     

Accuracy of Visual Inspection with Acetic acid in Detecting High-Grade Cervical Intraepithelial Neoplasia in Pre- and Post-Menopausal Thai Women with Minor Cervical CytologicalAbnormalities

Purpose: To determine the accuracy of visual inspection with acetic acid (VIA) in detecting high-gradecervical intraepithelial neoplasia (CIN) in pre- and post-menopausal women with atypical squamous cells ofundetermined significance (ASC-US) and low grade squamous intraepithelial lesion (LSIL) Papanicolaou (Pap)smears. Materials and Methods: Two hundred women (150 pre-menopausal and 50 post-menopausal) with ASCUSand LSIL cytology who attended the colposcopy clinic, Thammasat University Hospital, between March 2013and August 2014 were included. All women underwent VIA testing and colposcopy by gynecologic oncologists.Diagnostic values of VIA testing including sensitivity, specificity, positive predictive value (PPV) and negativepredictive value (NPV) for detecting high-grade CIN were determined using the histopathology obtained fromcolposcopic-directed biopsy as a gold standard. Results: VIA testing was positive in 54/150 (36%) pre-menopausalwomen and 5/50 (10%) post-menopausal women. Out of 54 pre-menopausal women with positive VIA testing,15 (27.8%) had high-grade CIN and 39 (72.2%) had either CIN 1 or insignificant pathology. Ten (10.4%), 43(44.8%) and 43 (44.8%) out of the remaining 96 pre-menopausal women with negative VIA testing had highgradeCIN, CIN 1 and insignificant pathology, respectively. Out of 5 post-menopausal women with positive VIAtesting, there were 4 (80%) women with high-grade CIN, and 1 (20%) women with insignificant pathology. Outof 45 VIA-negative post-menopausal women, 42 (93.3%) women had CIN 1 and insignificant pathology, and 3(6.7%) had high-grade CIN. Sensitivity, specificity, PPV and NPV of the VIA testing were 59.4%, 76.2%, 32.2%and 90.8%, respectively (60%, 68.8%, 27.8% and 89.6% in pre-menopausal women and 57.1%, 97.7%, 80%and 93.3% in post-menopausal women). Conclusions: VIA testing may be used as a screening tool for detectinghigh-grade CIN in women with minor cervical cytological abnormalities in a low-resource setting in order tolower the rate of colposcopy referral.     

Evaluation of Several Screening Approaches for Detection of Cervical Lesions in Rural Shandong,China

Purpose: The study was designed to: (1) investigate the prevalence of high-risk human papillomavirus (HRHPV)infection and cervical neoplasia; and (2) evaluate clinical performance of visual inspection with aceticacid/ Lugol’s iodine (VIA /VILI), Pap smear, high-risk human papillomavirus (HR-HPV) DNA test for detectingcervical intraepithelial neoplasia grade 2 or worse (CIN2+) and (3) explore appropriate screening approach inrural areas of Shandong Province. Materials and Methods: A total of 3,763 eligible women from Yiyuan Countyin Yimeng mountainous areas of rural Shandong, China, were enrolled and underwent Pap smear, HR-HPVDNA testing by Hybrid Capture 2 (HC2), and VIA /VILI tests. Women positive in any test were referred tocolposcopy and biopsy as indicated. Results: The prevalence of HR-HPV infection among all enrolled womenwas 11.1% and that in healthy women was 9.9%. In total 33 cases of CIN1, 16 cases of CIN2, 6 cases of CIN3 butnone of cervical cancer were detected and the crude prevalence of CIN2+ was 0.58%. For detecting CIN2+, thesensitivity of HR-HPV DNA testing, VIA/VILI, Pap smear was 90.9%, 77.3%, 81.8%, respectively. Pap smearhad the best specificity of 98.2%, followed by HR-HPV DNA testing with specificity of 89.4%, VIA/VILI hadthe lowest specificity of 81.2%. Colposcopy referral rate of HR-HPV DNA testing, VIA/VILI, Pap smear was11.1%, 18.5%, 2.3%, respectively. Conclusions: Our results suggest that HR-HPV DNA testing alone might beappropriate for primary cervical cancer screening in rural low-resource areas of Shandong Province, China.     

Can Self Vaginal Douching for High Risk HPV Screening Replace or Assist Efficacy of Cervical Cancer Screening?

Objective: To study the accuracy of self vaginal douching and collection for HPV types 16, 18, 31 and 33 inwomen visiting Thammasat Hospital for the explicit purpose of cervical screening. Methods: A pelvic examinationand Pap smear were performed for all women who came for cervical screening. Specimens were also collected byself vaginal douching before cervical screening and sent to the cell and molecular biology laboratory for analysisof human papillomavirus (HPV) types 16, 18, 31 and 33 using the polymerase chain reaction (PCR). Results:HPV prevalence was 3.6% overall from 250 women in this study. Twenty-four (9.6%) women had an abnormalcytology screening result. No cancer was found. Four women had a high grade squamous intraepithelial lesion(HSIL) and 14 had a low grade squamous intraepithelial lesion (LSIL) from colposcopic biopsy. Self vaginaldouching for HPV 16, 18, 31 and 33 was used to predict abnormal Pap smear. Sensitivity, specificity, positivepredictive value (PPV) and negative predictive value (NPV) were 12.5%, 97.5%, 33.3% and 91.3%, respectively.Conclusion: From our analysis of self vaginal douching for HPV detection using cases from Thammasat universityhospital, it cannot replace the Pap smear.     

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

Objective: Various screening methods for cervical cancer are proved to be effective in reducing such type of cancer.We aims to introduce a new portable device as an alternative method for cervical cancer screening. The performanceof device was tested on the assessment of cervical lesions using cervicograph score with the cervical cytology.Methods: 325 non-pregnant women were tested from March 2013 to August 2015. The cervical and vaginal cellsfrom the sample were collected for cytology, then all of them received the digital cervicography conducted with ournew device and scored using cervicograph score. Small pieces of cervical tissues were also collected for histologicexamination. SPSS software version 18.0 was used for the statistical analysis. Results: We grouped cytology resultsand cervicograph scores to 2 subgroups, ≤ ASC-US and ≥ LSIL, and 0-3 points and 4-6 points, respectively. The datathen correlated with histology results which sub-grouped to ≤ CIN 1 and ≥ CIN 2. The accuracy, sensitivity, specificity,and positive predictive value (PPV) of cervicograph scores 4-6 points to detect CIN 2+ were 92%, 72.41%, 97%, and84%, respectively which were not inferior to Pap smear did. Conclusion: The digital cervicography device providessimilar accuracy to Pap cytology screening and is suitable to use in the area that lacks cytoscreeners. Large scale useand generalization are required for this new device.     

巴氏涂片联合液基细胞学筛查宫颈癌癌前病变的价值

目的:探讨巴氏涂片法联合液基细胞学（liquid-based cytology test,LCT）筛查宫颈癌癌前病变的应用价值。方法:选取1 000例2014年3月至2017年4月进入我院进行宫颈癌癌前病变筛查的患者作为研究对象,对其进行巴氏涂片法、液基细胞学及两者联合检测,比较三种方式的灵敏度、特异度、准确度、约登指数。结果:单用巴氏涂片法检测的灵敏度、特异度、准确度、约登指数分别为45.90%、96.06%、93.00%、0.42,单用LCT检测分别为77.05%、90.31%、89.50%、0.67,LCT联合巴氏涂片法检测分别为78.69%、97.87%、96.70%、0.76。单独使用LCT检测的灵敏度较单独使用巴氏涂片高（P＜0.05）,而两种方法的特异度、准确度比较无显著差异（P＞0.05）。LCT联合巴氏涂片法检测的灵敏度较单独使用巴氏涂片法有明显提高（P＜0.05）,准确度较单独使用LCT检测法有显著提高,特异度无显著差异（P＞0.05）。单用LCT检测判断正确的比例比单用巴氏涂片法判断正确的比例高（NRI值=0.24）;LCT联合巴氏涂片法检测判断正确的比例比单用巴氏涂片法和单用LCT法判断正确的比例均高,其中NRI值分别为0.34和0.32。结论:巴氏涂片法联合液基细胞学能准确地检测出宫颈癌病变,数据较准确可靠,有较高的临床应用价值。     

Health Literacy,Knowledge on Cervical Cancer and Pap Smear and Its Influence on Pre-Marital Malay Muslim Women Attitude towards Pap Smear

Background: Cervical cancer is preventable. In Malaysia, women are found to have good awareness of the disease and yet, the Pap smear uptake is still poor. Measuring health literacy level could explain this discrepancy. This study aims to determine the relationship between health literacy, level of knowledge of cervical cancer and Pap smear with attitude towards Pap smear among women attending pre-marital course. Methods: A cross sectional study was performed in three randomly selected centres that organised pre-marital courses. All Malay Muslim women participants aged 18 to 40 years old were recruited while non-Malaysian, illiterate, and had hysterectomy were excluded. Validated self-administered questionnaires used were European Health Literacy Questionnaire (HLS-EU-Q16 Malay) and Knowledge and attitude towards Cervical Cancer and Pap Smear Questionnaire. The mean percentage score (mean± SD) was calculated, with higher scores showed better outcomes. Multiple linear regression was used to measure the relationship of independent variables with attitude towards Pap smear. Results: A total of 417 participants were recruited with a mean age of 24.9 ± 3.56 years old. Prevalence of awareness of cervical cancer was 91.6% (n=382, 95% CI: 89.0%, 94.2%) and mean percentage score was 74.7%±7.6. Prevalence of awareness of Pap smear was 59.0% (n=246, 95% CI: 54.2%, 63.8%) and mean percentage score was 80.2% ± 6.5. The health literacy mean score was 13.3±3.6, with minimum score 0 and maximum score 16. The mean percentage score of attitudes towards Pap smear was 64.8%±9.3. Multiple linear regression analysis demonstrated significant relationship between health literacy (p=0.047) and knowledge of Pap smear (p<0.001) with attitude towards Pap smear. Conclusion: A higher health literacy with high knowledge of Pap smear improves the attitude towards Pap smear. Pre-marital course is an opportunistic platform to disseminate information to improve health literacy and knowledge of cervical cancer and Pap smear screening.     

Accuracy of Cervical Visual Inspection with Acetic Acid Guide for 4-Quadrant Random Cervical Biopsies by General Practitioners in Women with Abnormal Pap Smears

Objective: To study the performance of visual inspection with acetic acid plus 4-quadrant cervical biopsy (V4B) by general practitioners in detecting high grade cervical lesion, compared to highest histopathologic grade from the American Society for Colposcopy and Cervical Pathology American Society for Colposcopy and Cervical Pathology (ASCCP) 2013 work up guidelines. Materials and methods: Patients with abnormal cervical cytologic screening results suggesting low grade lesions underwent V4B by general practitioners followed by colposcopy on the same day bases on ASCCP 2013 guidelines. Those with Pap smears indicative of high grade lesions or cervical cancer were sent to V4B before confirmed diagnosis and and therapeutic excisional procedures.Predictive performance of V4B was evaluated against the reference diagnosis. Results: Compared with the reference diagnosis in 100 of patients, V4B by general practitioners had sensitivity, specificity, PPV, and NPV of 67.9%, 100%, 100%, and 88.9%, respectively. There were 11.1% false negatives with no false positives. No complications were observed following this technique. Conclusion: Overall, V4B by general practitioners demonstrates moderate accuracy when compared with definite diagnosis by colposcopy and/or LEEP. This novel strategy performed better in those with low grade lesions on cervical cytological screening.     

Colposcopy Requirement of Papanicolaou Smear after Atypical Squamous Cells of Undetermined Significance (ASC-US) by Follow-up Protocol in an Urban Gynaecology Clinic,a Retrospective Study in Thailand

Background: ASC-US cases are managed according to the current American Society for Colposcopy andCervical Pathology (ASCCP) guideline in which a human papillomavirus (HPV) test and repeat Pap smear areperformed in the next 1 year. Colposcopy in cases of positive high risk HPV and persistent ASC-US or morein subsequent Pap smear is recommended. The HPV test is more expensive and still not currently a routinepractice in Thailand. Objective: To identify the risk factors of persisted abnormal Pap smear and the colposcopicrequirement rate in women with ASC-US. Materials and Methods: During 2008-2013, this study was conductedin Prapokklao Hospital, Chanthaburi, Thailand. Participants were women who attended gynaecology clinicfor cervical cancer screening. Women who had cytological reports with ASC-US were recruited. During thestudy period, 503 cases were enrolled. Colposcopic requirement was defined as those who were detected with anASC-US or more in subsequent Pap smears up to 1 year follow-up. Results: The colposcopic referral rate was23.2 (85/365) percent at 12 months. Prevalence of cervical intraepithelial neoplasia (CIN) 2/3 was 3.3 (12/365)percent. Loss follow-up rate of subsequent Pap smear and colposcopic appointment were 27.4 (138/503) and48.2 (41/85) percent, respectively. There was no invasive cancer. High risk factors for persisted abnormal Papsmears in subsequent test were premenopausal status, HIV infected patients and non-oral contraceptive pills(COC) users. Conclusions: Referral rate for colposcopy in women with ASC-US reports was rather high. Lossto follow-up rate was the major limitation. Immediate colposcopy should be offered for women who had highrisk for silent CIN.     

子宫颈癌癌前病变筛查中巴氏涂片法及L CT联合检测的应用

目的：探讨巴氏涂片法及液基细胞学（liquid-based cytology test,LCT）联合检测在子宫颈癌癌前病变筛查中应用的价值。方法选取行子宫颈癌癌前病变筛查的患者作为研究对象,对其进行巴氏涂片法、LCT及两者联合检测,以阴道镜病理活检标准为金标准,对检测结果进行比较分析。结果单用巴氏涂片法检测的敏感度、特异度、准确度及约登指数分别为68．9％、90．1％、88．8％和0．589;单用LCT检测分别为73．8％、89．5％、88．5％和0．630;LCT联合巴氏涂片法检测分别为85．3％、89．6％、89．2％和0．747;单独使用LCT检测与单独使用巴氏涂片法比较其敏感度、特异度与准确度差异均无统计学意义（均P＞0．05）。LCT联合巴氏涂片法检测方法的敏感度与单独使用LCT检测或巴氏涂片法检测比较均有提高（均P＜0．05）,而特异度和准确度比较差异均无统计学意义（均P＞0．05）。同时单用LCT检测判断正确的比例比单用巴氏涂片法高,其重分类改善指标（net reclassification improvement,NRI）为0．042。LCT联合巴氏涂片法检测判断正确的比例比单用巴氏涂片法和单用LCT法均高,其NRI值分别为0．818和0．861。结论巴氏涂片法联合LCT能准确地检测出子宫颈癌病变,数据较准确可靠,有较高的临床应用价值。     

Association of Abnormal Pap Smear with Occult Cervical Stromal Invasion in Patients with Endometrial Cancer

Objective: The purpose of this study was to determine the association between abnormal preoperative Pap smearresults and occult cervical stromal invasion in endometrial cancer patients. Methods: Medical records were reviewed ofpatients with endometrial cancer who had undergone surgical staging at Srinagarind Hospital. Patients with gross cervicalinvolvement, with an unsatisfactory Pap smear, without available Pap smear results, with no cervical intraepitheliallesion/invasive cervical cancer, or who had previously undergone pelvic radiation therapy were excluded. The patientswere assigned to one of two groups according their Pap smear results (negative and epithelial cell abnormalities).Logistic regression was used to determine the independent association between an abnormal Pap smear and the riskof cervical stromal invasion. Results: All cervical smears in this study were performed as conventional Pap smears.Smears were abnormal in 50 (21.0%) of the 238 patients enrolled and normal in the remaining 188 (79.0%). The typesof Pap smear abnormalities included adenocarcinoma (n=22); atypical endometrial cells (n=2); atypical glandular cells(n=17); high-grade squamous intraepithelial lesions (n=4); atypical squamous cells, cannot exclude high-grade squamousintraepithelial lesions (n=2); and atypical squamous cells of undetermined significance (n=3). After controlling for type ofendometrial cancer, abnormal Pap smear results were found to be a significant independent factor that indicated cervicalstromal invasion (adjusted OR 2.65; 95% CI 1.35 to 5.21). Conclusion: Endometrial cancer patients with abnormalPap smears were strongly and independently associated with histopathologically diagnosed cervical stromal invasion.     

DNA ploidy compared with human papilloma virus testing (Hybrid Capture II) and conventional cervical cytology as a primary screening test for cervical high-grade lesions and cancer in 1555 patients with biopsy confirmation

BACKGROUND: Because 80% of cervical cancers arise in low-resource settings, many inexpensive strategies are being tested. In that spirit, the authors are testing large-scale genomic or DNA ploidy measurements as an inexpensive and semiautomated strategy. METHODS: Patients entered either a screening or diagnostic study of several optical technologies: quantitative cytology, quantitative histopathology, and fluorescence and reflectance spectroscopy using a point probe, a multispectral digital colposcope, or a combination of the two. We calculated sensitivities, specificities, positive and negative predictive values, and their confidence interval testing conventional cytology, Hybrid Capture (HC) II testing, and DNA ploidy measured on the Feulgen-stained quantitative Pap smear. RESULTS: The current investigation reports on 1555 patients for whom colposcopically directed biopsies were read 3 times by study pathologists. The final histopathologic diagnosis was high grade (cervical intraepithelial neoplasia [CIN] 2, CIN 3, carcinoma in situ [CIS], and cancer) in 16% of patients. Using high-grade squamous intraepithelial lesions (SILs) histopathology as the threshold and gold standard, the sensitivity and specificity, respectively, were: 0.47 and 0.96 for conventional cytology, 0.91 and 0.80 for HC II, and 0.59 and 0.93 for DNA ploidy. The positive and negative predictive values (PPV, NPV) for conventional cytology were 0.70 and 0.90, 0.46 and 0.98 for HC II, and 0.63 and 0.92 for DNA ploidy. CONCLUSIONS: DNA ploidy shows comparable sensitivity, specificity, PPV, and NPV values to conventional cytology and HC II. Unlike conventional cytology, DNA ploidy is semiautomated and can be performed in less than 8 hours. Cost effectiveness studies are under way, but in the authors' laboratory DNA ploidy is inexpensive.