Video colposcopy improves adherence to follow-up compared to regular colposcopy: a randomized trial

Objective To assess and compare rates of adherence to follow-up in women undergoing video or regular colposcopy.Method Sixty patients with abnormal Pap smears were randomized to undergo video or regular colposcopy. All participants were given the same instructions and a follow-up appointment. If a patient did not keep her appointment and did not reschedule, this was considered a failure. Multivariate logistic regression was used for assessment of predictors of follow-up.Results The follow-up rate was significantly higher in the video colposcopy group compared to the regular colposcopy group (80 vs. 50%, p=0.014). After adjusting for results of previous and referral Pap smears, and previous treatment, multivariate analyses indicated that women undergoing video colposcopy were almost five times more likely to return for follow-up than women undergoing regular colposcopy (odds ratio=4.9, 95% confidence interval=[1.24, 19.39]).Conclusion Colposcopy clinics with patient population similar to ours may consider the use of video colposcope.     

阴道镜图像对宫颈疾病的诊断价值

目的　评价阴道镜图像对宫颈疾病尤其对宫颈上皮内瘤样病变 (CIN)的诊断价值。方法　 2 0 0 3年 4月至 2 0 0 4年 3月上海市黄浦区中心医院对 2 4 0例患者进行阴道镜检查 ,根据阴道镜图像定位取活组织送病理检查。结果　根据阴道镜拟诊与组织病理学结果进行对照 ,完全符合率是 6 1 2 5 %,包括相差一个级别在内者符合率为 95 %。对CIN诊断敏感性为 84 31 %、特异性 6 2 43%、阳性预测值 37 72 %、阴性预测值 93 6 5 %。结论　阴道镜图像对应阴道镜拟诊与组织病理学有较高的符合率 ,对CIN的诊断价值在于敏感性和阴性预测值高的优点 ,适合作为CIN的筛查方法。     

阴道镜对宫颈上皮内瘤变的诊断价值

目的：评价阴道镜检查对宫颈上皮内瘤样病变（CIN）的诊断价值。方法：对1991年5月至2002年4月进行阴道镜检查的患者1407例，行镜下定位取活组织病理检查。结果：近4年来CIN的发病例数呈上升趋势，发病年龄在30－39岁的病例占80．29％，经病理确诊CIN406例，包括CIN Ⅰ209例，CINⅡ104例和CINⅢ（包括CIS）93例；慢性宫颈炎625例，湿疣187例，息肉139例，其他50例（包括宫颈纳氏囊肿28例，子宫内膜异位症13例，乳头状瘤9例），阴道镜检查对CIN的诊断准确性为79．67％，敏感性为96．06％，特异性为73．03％，阳性预测值为59．095，阴性预测值为97．86％。CIN在阴道镜下的图像以醋酸白色上皮的出现率最高为83．50％，对CIN诊断的敏感性和阴性预测值高；与点状区和（或）镶嵌同时存在时，对CIN诊断的敏感性下降，特异性升高，结论：阴道镜检查对CIN的诊断价值在于其敏感性和阴性预测值高，在国内适合作为CIN的筛查方法，统一阴道镜的评分标准意义重大。     

Contribution of combined colposcopy and cytology in cervical pathology

Aim: The regular Papanicolaou (Pap) smear is the cornerstone of women’s preventive healthcare. The introduction of the regular Pap smear as a screening tool for cervical cancer has markedly decreased the number of deaths from cervical cancer. During the past decade, however, the rate of death from cervical cancer has remained relatively static. This screening method is known to have a high percentage of false negative results. To improve the detection of cervical lesions using the Pap smear in screening, a number of adjunct procedures have been developed. The purpose of this study is to evaluate the utility of a magnified chemoluminescent screening examination (Colposcopy) combined with the Pap smear in detecting cervical abnormalities. Methods: We investigated a cohort of 58 subjects who have been forwarded for colposcopic evaluation due to referral cytology suggestive of persistent inflammatory process not otherwise specified, and cervical intraepithelial or invasive neoplasia, in Chania Colposcopic clinic. Results: The higher the lesion detected by cytology, the more severe the corresponding colposcopic impression viewed. Conclusion: The data presented here are in harmony with previous reports and share our experience in a Regional Community Hospital Colposcopy Clinic. An integrated cytology–colposcopy program facilitates the assessment and identification of women harboring cervical pathological conditions.     

阴道镜诊断女性下生殖道湿疣的价值

目的 探讨阴道镜诊断女性下生殖道湿疣的价值。方法 采用阴道观察２５０例下生殖道湿疣的病变情况并与病理检查对照。结果 ２５０例湿疣患者子宫颈、阴道、外阴共发生湿疣病变３２２处,其中尖锐型湿疣２５８例（占８０．１２％）,扁平型湿疣５４例（占１６．７７％）,扁平型湿疣合并ＣＩＮ、ＶＩＮ１０例（占３．１０％）。宫颈湿疣的临床检出率为３４．４０％;阴道镜检出率为７６．８０％。阴道镜诊断尖锐型湿疣正确率为１     

影视阴道镜在子宫颈病变诊断中的应用

目的 评价影视阴道镜在子宫颈病变中的诊断价值及其临床意义。方法 应用影视阴道镜观察宫颈细胞病理学异常和尖锐湿疣患者共275例。在阴道镜指引下行宫颈活检术265例、宫颈管刮取术（ECC）8例、子宫颈环形电切术（LEEP）237例。结果 （1）影视阴道镜在诊断子宫颈病变中的敏感性为95.9%、特异性为77.7%、阳性预测值为84.5%。（2）影视阴道镜观察,93.8%正常转化区符合组织学诊断,有6.1%的假阴性;76.2%醋酸白上皮符合亚临床人乳头状瘤病毒（HPV）感染的诊断,有23.7%的假阳性,白嵌二联征、白嵌点三联征与宫颈癌的组织学诊断符合率为100.0%。结论 影视阴道镜诊断子宫颈病变的结果准确、可靠,有一定的临床应用价值,其诊断低度鳞状上皮内瘤变存在假阳性,而诊断高度鳞状上皮内瘤变有较高的敏感性。     

阴道镜下常规活检诊断宫颈上皮内瘤样病变108例分析

目的：通过阴道镜下常规活检，探讨宫颈上皮内瘤样癌变（CIN）的检查率、镜图像特征及诊断价值。方法：回顾分析5年来阴道镜检查834例中108例CIN的阴道镜检结果。结果：834例中CIN发现108例，占12．8％，CIN的异常阴道镜像主要为血管异常及腺口白环、白腺。结论：阴道镜是辅助诊断CIN的重要方法，初次阴道镜检可疑时应进行常规活检。     

Prenatal diagnosis of chromosomal abnormalities in a resource-poor setting

Objective

To compare the efficacy and efficiency of systematic, ultrasound-based risk adjustment using a published algorithm with that of a maternal age cutoff of 37 years for the prenatal detection of chromosomal abnormalities (especially autosomal trisomies).

Methods

These approaches were compared in a retrospective study of 136 chromosomal abnormalities confirmed by karyotyping prenatally (n = 46) or postnatally (n = 90). There were 114 autosomal trisomies.

Results

Maternal age was known for 103 fetuses with confirmed abnormalities. The ultrasound-based risk adjustment approach was more sensitive for autosomal trisomy (93.9% vs 44.1%), and karyotyping for younger women with abnormalities on ultrasound was more effective than routine karyotyping in older women (1 trisomy detected in 13.5 vs 42.8 samples, P < 0.001). A lack of screening was the main reason for the postnatal diagnosis.

Conclusion

Ultrasound-based risk adjustment was the more effective approach.     

阴道镜下子宫颈不典型转变区的远期观察

探讨阴道镜下子宫颈不典型转变区的远期演变规律。方法回顾总结本院防癌专科门诊阴道镜检查诊断为子宫颈不典型转变区患者的远期随诊资料。９８４例患者分成治疗组和观察组,Ａ组４９８例经物理方法治疗,Ｂ组４８６例未经治疗,均定期随诊３－５年,观察两组子宫颈不典型转转变区的转归。     

Evaluation of women presenting with postcoital bleeding by cytology and colposcopy

Objective

To evaluate women with postcoital bleeding (PCB) by clinical examination, cytology, colposcopy, and histopathology.

Methods

A cross-sectional study of 123 women with PCB, who were referred to the Colposcopy Clinic of Arash Hospital, Tehran, over a 2-year period.

Results

Clinical examinations revealed cervical polyps in 18 women and ectropion in 14. Cervical cytology identified 13 patients with atypical squamous cells of undetermined significance, 2 with atypical glandular cells, 4 with low-grade squamous intraepithelial lesions, and 3 with high-grade squamous intraepithelial lesions. Colposcopy indicated invasive cancer in 1 patient. Transitional zones appeared normal in 39.8% of the cohort, were atypical grade 1 in 33.3%, and atypical grade 2 in 4.9%. Fourteen abnormalities were detected at histology, including 1 squamous cell carcinoma, 1 low-grade glandular neoplasm, 9 cervical intraepithelial neoplasia (CIN) grade 1, 2 CIN grade 2, and 1 CIN grade 3. The sensitivity and specificity of cytology were 50% and 86.5%, respectively. A total of 21.4% of abnormal pathologies were missed using colposcopy, which had a sensitivity of 79%.

Conclusion

Because of its higher sensitivity, colposcopy can be recommended for the investigation of persistent PCB, even in the presence of normal cytology.     

Psychological distress associated with colposcopy: patients' perception

OBJECTIVE: Cervical screening and colposcopy are associated with varying degrees of anxiety in women. Interventions are in place to reduce anxiety but the effectiveness of these needs examination. Our objective was to develop an understanding of factors associated with anxiety in relation to colposcopy and to seek women's opinion on interventions designed to reduce anxiety. STUDY DESIGN: Prospective, anonymised survey. Determination of anxiety level and effectiveness of interventions within the colposcopy experience, i.e. information leaflet, video-screen display, nursing and medical intervention and exploration of medical terms, i.e. 'CIN'. RESULTS: Prior to attendance 36% of patients felt they were very worried, 54% slightly worried and 10% not worried. All patients found the standardised NHS information leaflet helpful to a variable degree. During colposcopy 30% of patients found watching on a video-screen display very helpful, whilst a significant number (18%) found it increased their worry. Stratification of results showed that women with pre-existing high level of anxiety were least satisfied with indices examined. CONCLUSION: Our results indicate that the higher the index level of anxiety regarding colposcopy, the less likely women were to find either the leaflet or the video-screen display helpful. Research should focus on the 'very anxious' women, as they are least satisfied with existing measures in place to reduce anxiety. However, evidence is presented to imply this may not be possible.     

The increased detection of cervical intraepithelial neoplasia when using a second biopsy at colposcopy

Objective

It has been suggested that colposcopy can miss a significant percentage of high-grade cervical intraepithelial neoplasia (CIN2 +). Improved disease ascertainment was evaluated by taking multiple lesion-directed biopsies.

Methods

In a cross-sectional multicenter study in the Netherlands and Spain, 610 women referred to colposcopy following abnormal cervical cytology results were included. Multiple directed biopsies were collected from lesions and ranked according to impression. A non-directed biopsy of normal-appearing tissue was added if fewer than four biopsies were collected. We evaluated the additional CIN2 + yield for one and two directed biopsies. Colposcopic images were reviewed for quality control.

Results

In women with at least two lesion-directed biopsies the yield for CIN2 + increased from 51.7% (95%CI; 45.7–57.7) for one directed biopsy to 60.4% (95%CI; 54.4–66.2, p < 0.001) for two biopsies. The highest CIN2 + yield was observed in women who were HPV16-positive, had high-grade squamous intraepithelial lesion (HSIL) cytology, and high-grade colposcopy impression. The yield increased from 83.1% (95%CI; 71.5–90.5) with one directed biopsy to 93.2% (95%CI; 83.8–97.3) with two directed biopsies. Only 4.5% additional CIN2 + were detected in biopsies not targeting abnormal areas on the cervix.

Conclusions

A second lesion-directed biopsy is associated with a significant increase in CIN2 + detection. Performing a second lesion-directed biopsy and using a low threshold for abnormality of any acetowhitening should become the standard clinical practice of colposcopy.     

Assessing the accuracy of colposcopy at predicting the outcome of abnormal cytology in pregnancy

OBJECTIVE: To determine the accuracy of colposcopic and cytological assessment at predicting final histological diagnosis in women referred with abnormal cervical smears during pregnancy; to use this data as a basis for a follow up protocol for pregnant patients referred with abnormal cervical cytology. STUDY DESIGN: Retrospective analysis of women referred to Queens Medical Centre, Nottingham, UK with abnormal cytology whilst pregnant between 1994 and 2003. RESULTS: Forty-nine patients in total were included in the study. Colposcopic assessment in the antenatal period had a concordance with final histological diagnosis in 60% of patients and a concordance of 68% when undertaken in the post-natal period. Cytological concordance was lower at 58%. In only six percent of patients was a cervical biopsy undertaken and there were no complications as a result. There was a fall in colposcopically assessed high-grade cervical intraepithelial neoplasia between the antenatal and post-natal period. No cases of invasive cancers were diagnosed antenatally. CONCLUSION: A policy of conservative management of pregnant patients during the antenatal period is supported by this data. A suggested protocol of one colposcopic assessment at the time of the index abnormal smear followed by a post-partum colposcopy, and appropriate treatment is suggested.     

Prevalence of pathology in women attending colposcopy for postcoital bleeding with negative cytology

Objective To determine the frequency of cervical pathology and the incidence of cervical neoplasia in women presenting with PCB at the colposcopy clinic with negative cytology. Design A retrospective study. Setting A district general hospital. Population Eighty-seven women with postcoital bleeding and negative cytology were seen in the colposcopy unit during 1 January 2003 to 31 December 2005. Methods Women were identified from computer records and details were extracted from the case notes. Main outcome measure Histopathological diagnosis. Results Six women (6.9%) had cervical intraepithelial neoplasia. There were no cases of invasive cancer. Thus in our study 6.9% women with postcoital bleeding had abnormal histology even though they had normal smears. Other identifiable causes were cervical polyp (12.5%), ectopy (33.6%) and Chlamydia (2.3%). No pathology was found in 50% of women. Conclusion Women with postcoital bleeding even with normal smears appear to be at much greater risk of cervical neoplasia than the general population. Unfortunately there is no general consensus for management of these patients. Hence further research is needed to standardise the management of women with PCB. Patients should be reassured that in vast majority of cases no serious pathology is detected.     

Ten-year outcomes of a one-stop colposcopy clinic: a unique service for low grade cytology

Objective

To determine patient acceptance of treatment, and treatment default rate, at a one-stop clinic, and to establish the concordance of punch and loop histology for high grade cervical intraepithelial neoplasia (CIN) by date of excisional treatment.

Study design

Retrospective review of computerised data and clinic files of 2090 women with low grade cytology undergoing cervical punch biopsies between 2001 and 2011 at the colposcopy clinic, Northern Gynaecological Oncology Centre, Gateshead, UK. Punch biopsies were micro-wave processed and reported within 2 h, and women were offered immediate loop biopsy if high grade CIN was confirmed. Data were collected regarding patients’ choice for immediate or deferred treatment and default rate. Histological outcomes were compared between those undergoing immediate and deferred loop biopsies.

Results

Of the 360 women (17%) with high grade CIN on punch biopsy, 259 (72%) opted to have immediate loop treatment at the first visit. Of these women, 190 (73%) had high grade CIN on loop histology. Of 97 women (27%) who had deferred loop biopsy after a median of 28 days (range 7–112), 65 (67%) had high grade CIN on loop histology. The default rate at return for treatment appointments was 0% amongst all patients.

Conclusion

This one-stop colposcopy clinic reduces defaulting from treatment. It has proven to be a sustainable service and the majority of women, when given the choice, opt for immediate loop treatment at their first visit.     

Diagnostic accuracy of colposcopy in relation to human papillomavirus genotypes and multiple infection

Objective

The aim of this study is to evaluate the diagnostic accuracy of colposcopy for cervical intraepithelial neoplasia grade 3 or worse (CIN3 +) in relation to the detection of human papillomavirus (HPV) type 16 and multiple HPV infection.

Methods

A cohort study of 2526 subjects attending a colposcopic service because of cytological abnormalities. HPV genotypes were identified using the INNO–LIPA genotyping system.

Results

The final colposcopic/pathological diagnoses were as follows: 1282 (50.8%) negative, 709 (28.1%) CIN1, 169 (6.7%) CIN2, 318 (12.6%) CIN3 and 48 (1.9%) invasive cervical cancer, respectively. Among women with ASCUS/LSIL, assuming any colposcopic abnormality as a cut-off, there were no significant differences in the sensitivities (83.8%, 95% CI = 76–89.6 as compared to 84.1%, 95% CI = 73.2–91.1, p = 0.9) and ROC curves (0.61, 95% CI = 0.58–0.65 as compared to 0.59, 95% CI = 0.54–0.64, p = 0.5) in the detection of CIN3 + lesions between subjects with single and multiple high-risk infection, and between subjects infected by HPV16 (83.1%, 95% CI = 73.7–89.7, ROC = 0.59, 95% CI = 0.54–063) or other high-risk HPVs (84.7%, 95% CI = 75.6–90.8, ROC = 0.62, 95% CI = 0.58–0.66, p = 0.8 and p = 0.6 compared to HPV16). After correction for confounders, the odds ratios of CIN3 + associated with any abnormal colposcopic findings were 2.47 (95%CI = 1.44–4.23, p = 0.001) among HPV16 positive, 3.34 (95% CI = 2.16–5.42, p < 0.001) among other high-risk HPVs and 1.3 (95% CI = 0.72–2.48, p = 0.36) among subjects with negative/low-risk HPVs.

Conclusion

In routine clinical practice, multiple infection or HPV16 positivity did not affect colposcopic accuracy in the diagnosis of CIN3 + lesions. The sensitivity of colposcopy was poor among subjects who were uninfected or infected by low-risk HPV genotypes.     

2468例阴道镜检查与病理学诊断结果分析

用阴道镜活检２４６８例妇科门诊患者，在异常阴道镜图像中，白色上皮、腺口白环、白斑、点状血管、异形血管、镶嵌、明显癌及非典型增生的检出率分别为５．６％、１０．４％、１６．０％、１６．０％、１７．４％、２０．３％和７９．２％。腺口白环的癌及非典型增生的检出率为１０．４％。阴道细胞涂片中的Ⅲ、Ⅳ和Ⅴ级涂片中癌的检出率分别为２１．７％、６５．５％和９２％。涂片的级别与异常阴道镜图像有明显的关系。     

Prevalence of high-grade squamous intraepithelial neoplasia (HiSIL) in symptomatic women referred to the colposcopy clinic with negative cytology

Objective We have evaluated patients who were referred to the colposcopy clinic with postcoital and/or intermenstrual bleeding and suspicious looking cervix with normal smear tests (negative cytology) mainly to establish the incidence of underlying high-grade squamous intraepithelial neoplasia in these groups and also to look at our intervention rate. Design Retrospective study. Setting Colposcopy clinic in a District General Hospital in the United Kingdom. Population A total of 134 patients out of 812 new referrals to our colposcopy clinic during the study period were due to clinical indications only. Results Main indication for referral with negative cytology was post coital bleeding (47.8%). The main causes of postcoital and intermenstrual bleeding were cervical ectropions and polyps. The incidence high-grade squamous intraepithelial neoplasia (HiSIL) was 2.2% out of all the patients, which was determined after 66 biopsies. Conclusion In the majority of cases the pathology is benign. However the underlying prevalence of high-grade cervical disease in symptomatic women with normal smears necessitates colposcopy in selected cases. Prior assessment in the gynaecology clinic, to rule out common pathology like polyps and ectropions would reduce patient anxiety and inappropriate referrals to the clinic.     

Accuracy of colposcopy in the diagnostic setting compared with the screening setting

OBJECTIVE: To estimate the accuracy of colposcopy to identify cervical precancer in screening and diagnostic settings. METHODS: As part of a larger clinical trial to evaluate the diagnostic accuracy of optical spectroscopy, we recruited 1,850 patients into a diagnostic or a screening group depending on their history of abnormal findings on Papanicolaou tests. Colposcopic examinations were performed and biopsies specimens obtained from abnormal and normal colposcopic sites for all patients. The criterion standard of test accuracy was the histologic report of biopsies. We calculated sensitivities, specificities, likelihood ratios, receiver operating characteristic curves, and areas under the receiver operating characteristic curves. RESULTS: The prevalence of high-grade squamous intraepithelial lesions (HSIL) or cancer was 29.0% for the diagnostic group and 2.2% for the screening group. Using a disease threshold of HSIL, colposcopy had a sensitivity of 0.983 and a specificity of 0.451 in the diagnostic group when the test threshold was low-grade squamous intraepithelial lesions (LSIL), and a sensitivity of 0.714 and a specificity of 0.813 when the test threshold was HSIL. Using the same HSIL disease threshold, in the screening group, colposcopy had a sensitivity of 0.286 and a specificity of 0.877 when the test threshold was LSIL, and a sensitivity of 0.191 and a specificity of 0.961 when the threshold was HSIL. The colposcopy area under the receiver operating characteristic curve was 0.821 (95% confidence interval 0.79-0.85) in the diagnostic setting compared with 0.587 (95% confidence interval 0.56-0.62) in the screening setting. Changing the disease threshold to LSIL demonstrated similar patterns in the tradeoff of sensitivity and specificity and measure of accuracy. CONCLUSION: Colposcopy performs well in the diagnostic setting and poorly in the screening setting. Colposcopy should not be used to screen for cervical intraepithelial neoplasia. LEVEL OF EVIDENCE: II.