European consensus statement on essential colposcopy.

This European consensus statement on essential colposcopy provides standards for the general colposcopist seeing women referred for colposcopy with an abnormal cervical screening test (including cytology and HPV tests) or with a clinically suspicious cervix. The article gives guidance regarding the aims and conduct of colposcopy. Recommendations are provided on colposcopy technique, the management of common colposcopy issues, treatment and follow-up of after treatment of CIN or early stage cervical. Colposcopists should make an informed decision on the management of each individual that is referred and organize appropriate follow-up. Cervical cancer is still a major health issue and the quality of care can only improve if there is a structured guidance for women with an abnormal smear or suspicious cervix.

Trophoblast Glycoprotein (TPGB/5T4) in Human Placenta: Expression, Regulation, and Presence in Extracellular Microvesicles and Exosomes.

BACKGROUND: Many parallels exist between growth and development of the placenta and that of cancer. One parallel is shared expression of antigens that may have functional importance and may be recognized by the immune system. Here, we characterize expression and regulation of one such antigen, Trophoblast glycoprotein (TPGB; also called 5T4), in the placenta across gestation, in placentas of preeclamptic (PE) pregnancies, and in purified microvesicles and exosomes. METHODS: Trophoblast glycoprotein expression was analyzed by real-time reverse transcription-polymerase chain reaction (RT-PCR), Western blot, and immunohistochemistry. Regulation of 5T4 in cytotrophoblast cells was examined under either differentiating conditions of epidermal growth factor or under varying oxygen conditions. Microvesicles and exosomes were purified from supernatant of cultured and perfused placentas. RESULTS: Trophoblast glycoprotein expression was prominent at the microvillus surface of syncytiotrophoblast and on the extravillous trophoblast cells, with minimal expression in undifferentiated cytotrophoblasts and normal tissues. Trophoblast glycoprotein expression was elevated in malignant tumors. In cytotrophoblasts, 5T4 was induced by in vitro differentiation, and its messenger RNA (mRNA) was increased under conditions of low oxygen. PE placentas expressed higher 5T4 mRNA than matched control placentas. Trophoblast glycoprotein was prominent within shed placental microvesicles and exosomes. CONCLUSION: Given the potential functional and known immunological importance of 5T4 in cancer, these studies reveal a class of proteins that may influence placental development and/or sensitize the maternal immune system. In extravillous trophoblasts, 5T4 may function in epithelial-to-mesenchymal transition during placentation. The role of syncytiotrophoblast 5T4 is unknown, but its abundance in shed syncytial vesicles may signify route of sensitization of the maternal immune system.

Angiogenic factors: potential to change clinical practice in pre-eclampsia?

Pre-eclampsia is a complex disease with significant maternal and fetal morbidity and mortality. Its syndromic nature makes diagnosis and management difficult. The field is rapidly evolving with the definition of pre-eclampsia being challenged by some organisations, with proteinuria no longer being essential in the presence of other features. In the last decade, angiogenic factors, in particular soluble fms-like tyrosine kinase 1 (sFlt-1), have emerged as important molecules in the pathogenesis of pre-eclampsia. Here we review the most recent evidence regarding the potential of these factors as biomarkers and therapeutic targets for pre-eclampsia. TWEETABLE ABSTRACT: A review of angiogenic factors, sFlt-1 and PlGF, in the diagnosis, prediction and management of pre-eclampsia.

Disclosing the results of the invasive cervical cancer review to patients: a survey of lead colposcopists across England.

OBJECTIVE: To survey lead colposcopists to explore the extent to which patients are currently being invited to discuss the results of their invasive cervical cancer review, the reasons why this might not be happening and the clinician experience. METHODS: An online survey was sent to lead colposcopists across England. They were asked whether they offered the review to patients, if they did how they did so and what their experience was and if they did not, why not. RESULTS: There was a 68.5% (N = 122) response rate, with 53% of respondents currently offering the review meetings. Patients were predominantly invited to the review meeting face to face and clinicians' experiences were mixed with a variety of positive and negative aspects of the meetings given. For those clinicians not currently offering a review meeting, there were a variety of reasons: 25% cited a lack of awareness of the guidelines, 19% time constraints, 12% a fear of causing additional distress and 2% a fear of litigation. Open-ended responses demonstrated a considerable amount of misunderstanding about the process. CONCLUSION: Despite National Health Service Cervical Screening Programme guidelines, not all clinicians offer review meetings to patients and those who do offer them do not always offer them to all women. Patient research needs to be conducted to explore the value of the meetings further, and there is a need to do more to engage clinicians in the process.

Awareness and knowledge of HPV and cervical cancer in female students: A survey (with a cautionary note).

We conducted a survey to explore levels of awareness and knowledge of human papillomavirus (HPV) and cervical cancer in 170 female students and whether mode of data collection (online vs. paper) affected the results. 27% of women named HPV as a cause of cervical cancer with online respondents more likely to do so. 75% of women had heard of HPV. More online respondents had heard of HPV than paper respondents. 127 women reported having heard of HPV, with a mean knowledge score of 2.989 (standard deviation [SD] 1.599). Online respondents scored higher (3.57, SD 1.316) than paper respondents (2.688, SD 1.591). Knowledge and awareness of HPV and its link to cervical cancer appear to have increased which may be related to the HPV vaccination programme. However, there is still a considerable number of women with little to no knowledge of HPV. Online surveys may result in an inflated estimation of awareness and knowledge.

Isolation of syncytiotrophoblast microvesicles and exosomes and their characterisation by multicolour flow cytometry and fluorescence Nanoparticle Tracking Analysis.

The human placenta releases multiple types and sizes of syncytiotrophoblast (STB) extracellular vesicles (EV) into the maternal circulation that exhibit diverse biological activities. The placental perfusion technique enables isolation of these STBEV, but conventional flow cytometry can only be used to phenotype EV down to ∼300 nm in size. Fluorescence Nanoparticle Tracking Analysis (fl-NTA) has the potential to phenotype EV down to ∼50 nm, thereby improving current characterisation techniques. The aims of this study were to prepare microvesicle and exosome enriched fractions from human placental perfusate (n=8) and improve fl-NTA STBEV detection. Differential centrifugation and filtration effectively removed contaminating red blood cells from fresh placental perfusates and pelleted a STB microvesicle (STBMV) fraction (10,000×g pellet - 10KP; NTA modal size 395±12 nm), enriched for the STB marker placental alkaline phosphatase (PLAP) and a STB exosome (STBEX) fraction (150,000×g pellet - 150KP; NTA modal size 147±6 nm), enriched for PLAP and exosome markers Alix and CD63. The PLAP positivity of 'standard' 10KP and 150KP pools (four samples/pool), determined by immunobead depletion, was used to optimise fl-NTA camera settings. Individual 10KP and 150KP samples (n=8) were 54.5±5.7% (range 17.8-66.9%) and 30.6±5.6% (range 3.3-51.7%) PLAP positive, respectively. We have developed a reliable method for enriching STBMV and STBEX from placental perfusate. We also standardised fl-NTA settings and improved measurement of PLAP positive EV in STBMV. However, fl-NTA is not as sensitive as anti-PLAP Dynabead capture for STBEX detection, possibly due to STBEX having lower surface expression of PLAP. These important developments will facilitate more detailed studies of the role of STBMV and STBEX in normal and pathological pregnancies.

Colposcopy training and assessment across the member countries of the European Federation for Colposcopy.

OBJECTIVES: Colposcopy training and assessment is not uniform across Europe with individual countries determining their own required standards and regulations. In light of the significant changes in colposcopic practice that have occurred over the past decade and the expansion of the European Federation for Colposcopy (EFC) membership, a study was conducted firstly, to assess the current requirements for training in each of the member countries and secondly, to review an EFC-approved core training curriculum for colposcopy. STUDY DESIGN: A questionnaire survey of the EFC representatives from all member countries investigating their country's current practices/requirements with regard to training, assessment and accreditation for colposcopy. A two-round Delphi consultation with representation from the full, associate and three potential member countries was conducted using a 5-point Likert scale for scoring opinions. The results were analysed with respect to each country's population size and World Bank economic classification. RESULTS: For the questionnaire survey, responses were received from 31/34 countries invited to participate. Training programmes were reported to be in place in 21 of the 31 countries but only 17 of the 21 countries had a committee overseeing the training programme. An assessment was part of the training programme in 20 countries with multiple choice questions and portfolios the most common assessment tools. Countries with a population size less than 2 million have a statistically significant lower probability of having a structured training/assessment programme, 1/5 compared to 20/26 for a populations greater than 2 million, p=0.013. For the Delphi study, responses were received from 34/39 countries invited to participate. Of the 51 competencies previously identified only 2 did not receive full support: 'perform bacterial swabs' and 'provide data to national body'. There was no significant difference in the responses given by member, associate member or potential member countries. CONCLUSIONS: There is considerable variation in colposcopy training and assessment across Europe. This study has enabled consensus opinion with the EFC on the contents of an EFC core curriculum. The revised curriculum has a mandate from the EFC member countries to be implemented across Europe as the standard for colposcopic training.

Interleukin-1 family cytokines and their regulatory proteins in normal pregnancy and pre-eclampsia.

Maternal systemic inflammation is a feature of pre-eclampsia, a condition in pregnancy characterized by hypertension and proteinuria. Pre-eclampsia is caused by the placenta; many placental factors contribute to the syndrome's progression, and proinflammatory cytokines have been identified previously as one such mediator. The interleukin (IL)-1 family of cytokines are key regulators of the inflammatory network, and two naturally occurring regulatory molecules for IL-1 family cytokines, IL-1RA and sST2, have been found previously to be elevated in maternal blood from women with pre-eclampsia. Here we investigate more recently identified IL-1 family cytokines and regulatory molecules, IL-1RAcP, IL-37, IL-18BP, IL-36α/ß/γ/Ra and IL-38 in pre-eclampsia. Pregnant women have more circulating IL-18BP and IL-36Ra than non-pregnant women, and sIL-1RAcP is elevated from women with pre-eclampsia compared to normal pregnancies. The placenta expresses all the molecules, and IL-37 and IL-18BP are up-regulated significantly in pre-eclampsia placentas compared to those from normal pregnancies. Together, these changes contribute to the required inhibition of maternal systemic cytotoxic immunity in normal pregnancy; however, in pre-eclampsia the same profile is not seen. Interestingly, the increased circulating levels of sIL-1RAcP and increased placental IL-18BP and IL-37, the latter of which we show to be induced by hypoxic damage to the placenta, are all factors which are anti-inflammatory. While the placenta is often held responsible for the damage and clinical symptoms of pre-eclampsia by the research community, here we show that the pre-eclampsia placenta is also trying to prevent inflammatory damage to the mother.

Cytological follow-up after hysterectomy: is vaginal vault cytology sampling a clinical governance problem? The University Hospital of North Staffordshire approach.

OBJECTIVES: Vaginal vault cytology sampling following hysterectomy is recommended for specific indications in national guidelines. However, clinical governance issues surround compliance with guidance. Our first study objective was to quantify how many patients undergoing hysterectomy at the University Hospital of North Staffordshire (UHNS) had vault cytology advice in their histology report and, if indicated, whether it was arranged. The second was to devise a vault cytology protocol based on local experience and national guidance. METHODS: The local cancer registry was searched. Clinical, clerical and histological data for all patients undergoing hysterectomy were collected. RESULTS: In total, 271 patients were identified from both the gynae-oncology and benign gynaecology teams. Of these, 24% (65/271) were gynae-oncology patients with a mean age of 69 years. The benign gynaecology team had 76% (206/271) of patients with a mean age of 55 years. Subsequently, 94% (256/271) had cytology follow-up advice in their histopathology report. Ultimately, from both cohorts, 39% (18/46) had follow-up cytology performed when indicated. CONCLUSION: A high proportion of cases complied with national guidance. However, a disappointingly high number did not have vault cytology sampling when this was indicated. This is probably a result of the complex guidance that is misunderstood in both primary and secondary care. Vault follow-up of patients after hysterectomy rests with the team performing the surgery. Vault cytology, if indicated, should be performed in secondary care and follow-up should be planned. The protocol set out in this article should be followed to avoid unnecessary clinical governance failings.

The invasive cervical cancer review: psychological issues surrounding disclosure.

An audit of the screening history of all new cervical cancer cases has been a requirement since April 2007. While NHS cervical screening programmes (NHSCSP) guidance requires that women diagnosed with cervical cancer are offered the findings of the audit, as yet there has been no research to investigate the psychological impact that meeting to discuss the findings might have on patients. This is in spite of the fact that cytological under-call may play a role in as many as 20% of cervical cancer cases. This review draws on the literature concerning breaking bad news, discussing cancer and disclosing medical errors, in order to gain insight into both the negative and positive consequences that may accompany a cervical screening review meeting. We conclude that while patients are likely to experience some distress at disclosure, there are also likely to be positive aspects, such as greater trust and improved perception of care.

Accuracy of colposcopy-directed punch biopsies: a systematic review and meta-analysis.

BACKGROUND: The colposcopy-directed punch biopsy is widely used in the management of women with abnormal cervical cytology; however, its accuracy compared with definitive histology from an excision biopsy is not well established. OBJECTIVES: To assess the accuracy of the colposcopy-directed punch biopsy to diagnose high-grade cervical intraepithelial neoplasia (CIN) by performing a systematic review and meta-analysis. SEARCH STRATEGY: A systematic search of MEDLINE, EMBASE and the Cochrane Library was performed. SELECTION CRITERIA: Articles that compared the colposcopically directed cervical punch biopsy with definitive histology from an excisional cervical biopsy or hysterectomy. DATA COLLECTION AND ANALYSIS: Random effects and hierarchical summary receiver operating characteristic regression models were used to compute the pooled sensitivity and specificity applying different test cut-offs for outcomes of high-grade CIN. MAIN RESULTS: Thirty-two papers comprising 7873 paired punch/definitive histology results were identified. The pooled sensitivity for a punch biopsy defined as test cut-off CIN1+ to diagnose CIN2+ disease was 91.3% (95% CI 85.3-94.9%) and the specificity was 24.6% (95% CI 16.0-35.9%). In most of the studies, the majority of enrolled women had positive punch biopsies. Pooling of the four studies where the excision biopsy was performed immediately after the punch biopsy, and where the rate of positive punch biopsies was considerably lower, yielded a sensitivity of 81.4% and specificity of 63.3%. AUTHOR'S CONCLUSION: The observed high sensitivity of the punch biopsy derived from all studies is probably the result of verification bias.

Review of invasive cervical cancers and uptake of disclosure of results: an audit of procedures and response.

OBJECTIVE: To audit the process and outcome of case reviews performed for invasive cervical cancers diagnosed between 2003 and 2007, and the timely disclosure of results to the respective patients. METHODS: Invasive cervical cancer reviews were performed on all cases of cervical cancer diagnosed between 2003 and 2007. Following the review, women were classified into two categories: a group who developed invasive cancer despite adherence to the screening programme or in whom a management or diagnostic decision was determined to have been a principal factor in the development of their disease (Group A), and a second group who either had never undergone a cervical smear or had been established defaulters from the screening programme (Group B). RESULTS: Ninety-seven of the 98 cases of invasive cervical cancer diagnosed in the 4-year study period were reviewed. Sixty of the 61 women in Group A were sent an invitation to discuss the results of their case review. Thirty-six (37%) were classified as Group B, and it was deemed neither appropriate nor possible to invite the patients for a review consultation. Of the women sent an invitation, only 24 (40%) chose to attend. CONCLUSION: A policy of selective invitation for the disclosure of invasive review results is feasible. Less than one-half of patients diagnosed with cervical cancer appear to want to know how they developed cervical cancer despite previously participating in a screening programme.

Implementing the national invasive cervical cancer audit: a local perspective.

OBJECTIVE: To monitor the effectiveness of the cervical screening programme and identify suboptimal management in order to improve patient care. DESIGN: Retrospective study. SETTING: A university hospital serving a population of 1 million people. POPULATION: All women diagnosed with a cervical cancer between 2003 and 2006. METHODS: Analysis of data from invasive cervical cancer reviews. MAIN OUTCOME MEASURE: Categorisation of cervical cancer cases according to the Invasive Cervical Cancer Audit classification. RESULTS: Eighty-seven women were diagnosed with cervical cancer during the 3-year study period. The 'lapsed attender' group accounted for the greatest number of cases (30%), followed by screen detected (26%), interval cancers (13%), never attended (12%), lost to follow-up (10%) and never invited (9%). Women who had never attended for cytology presented with higher stage disease, stage-II or above, compared with the screen-detected cases: 60% were stage II or above, compared with 13.0%, Chi-square P = 0.018. The most frequently identified screening programme problem was patient compliance, which was determined to be the principle contributing factor in 39 cases (45%) and a secondary factor in a further ten cases. CONCLUSIONS: The categorisation of cervical cancer cases has the potential of yielding invaluable information for improving programme effectiveness. Patient compliance is the greatest challenge to the screening programme, and the need for regular screening and adherence to follow-up regimens needs to be reinforced in order to maximise the efficacy of the national screening programme.

Cervical cytology/histology discrepancy: a 4-year review of patient outcome.

OBJECTIVE: To investigate the diagnosis, review and management of women identified as having a cytology/histology discrepancy. METHODS: A review of all patients diagnosed with a discrepancy between referral smear and cervical histology was performed between January 2003 and December 2004. Cases were followed for a minimum of 4 years and patient management and outcome reviewed. RESULTS: A significant discrepancy was identified in 79 cases, 0.1% of all smears (n = 80,926) analysed during the study period. A discrepancy between cytology and histology, obtained from large loop excision of the transformation zone (LLETZ), was confirmed by multidisciplinary review in 42 cases (53.2%). In 37 cases (46.8%) the cytological and/or histological diagnosis was revised; the cytology was significantly more likely than the histology to be amended (chi square P = 0.005), most often because cytology had been overcalled. Of the confirmed discrepancy cases, 33 (78.6%) were due to high-grade squamous cell or glandular abnormalities on cytology with a negative, inflammatory or human papillomavirus (HPV) infection on histology (HGC/NH). HGC/NH cases were managed by cytological follow-up in 29 (87.9%), of which 72.4% of the smears were negative when performed at least 6 months post-excision. During the 4-year follow-up period six women with a confirmed HGC/NH underwent a repeat cervical excision (hysterectomy or LLETZ), and of these, HPV effect was seen in two cases but no cervical intraepithelial neoplasia was detected in any of the histological specimens. CONCLUSION: Cytology overcall was responsible for the majority of cytology/histology discrepancies. A confirmed discrepancy is not an indication for a further excisional biopsy but follow-up is essential because a small percentage of patients may have disease that has been missed.

Implementing the national invasive cervical cancer audit: correlation between local and regional classification.

OBJECTIVE: To determine the accuracy of information recorded regionally and locally on the screening classification of cervical cancer cases using the national invasive cervical cancer audit categories. METHODS: Comparison of the audit categorization of all cervical cancer cases diagnosed at the University Hospital of North Staffordshire (UHNS) between January 2003 and December 2006 with the classification assigned by the West Midlands Cervical Screening Quality Assurance Reference Centre (WMQARC). RESULTS: Eighty-seven cases of cervical cancer were diagnosed during the three-year study period. There was agreement between the UHNS and WMQARC classification of cases in 52 cases (59.7%), moderate agreement κ = 0.51 (95% CI 0.39-0.63). The greatest disparity was seen in the classification of lapsed attenders, with nine of the 26 cases categorized as 'lapsed' by the UHNS being assigned to the 'lost to follow-up' category by WMQARC. Three cases were deemed unclassifiable by WMQARC using the national classification since the women were over the age of 70 years but had previously been enrolled in the screening programme, and currently there is no national category for these women. CONCLUSIONS: Accurate and consistent classification of invasive cervical cancer cases is essential in order to obtain useful information on the efficiency of the national screening programme at a local, regional and national level. The use of a national algorithm would provide reassurance that all data used in the national evaluation of the NHS Cervical Screening Programme are consistent, meaning that robust conclusions could then be drawn from the data.

Placental stress and pre-eclampsia: a revised view.

In pre-eclampsia, poor placentation causes both oxidative and endoplasmic reticulum stress of the placenta. It is believed placental hypoxia stimulates excessive production of soluble fms-like tyrosine kinase 1 (sFlt-1), which binds and deactivates circulating vascular endothelial growth factor (VEGF). When maternal endothelium is deprived of VEGF it becomes dysfunctional hence leading to the clinical syndrome of the mother. In this paper the previous claim that poor placentation may predispose more to placental oxidative stress than hypoxia is reiterated. We show why pre-eclampsia is not only an endothelial disease, but also a disorder of systemic inflammation. We question that hypoxia is the only or indeed the main stimulus to release of sFlt-1; and emphasise the role of inflammatory mechanisms. Hypoxia cannot be assumed simply because hypoxia-inducible transcription factors (HIF) are upregulated. Concurrent assessments of nuclear factor-kappaB (NF-kappaB), a transcription factor for inflammatory responses are desirable to obtain a more complete picture. We point out that the pre-eclampsia placenta is the source of bioactive circulating factors other than sFlt-1 in concentrations that are much higher than in normal pregnancy. These may also contribute to the final inflammatory syndrome. We propose a modified version of the two-stage model for pre-eclampsia.

Identifying the performance criteria for appraisal of colposcopists: benchmarking Delphi.

BACKGROUND: Colposcopy forms an essential part of National Health Service Cervical Screening Programme (NHSCSP). With an increased emphasis on accountability and improved performance, there is a need to identify the performance criteria that are essential to be satisfied by the colposcopists at the time of appraisal. OBJECTIVE: To identify the performance criteria essential for appraisal of colposcopists by two-generational Delphi survey. DESIGN: Delphi survey. SETTING: Annual British Society for Colposcopy and Cervical Pathology conference (BSCCP 2005, Edinburgh, UK). POPULATION: Four hundred and ninety-nine delegates attending the above conference. METHOD: A two-generational Delphi survey was undertaken to identify the criteria needed for appraisal. The participants were asked to rate the relevance of quality items that might be considered necessary for appraisal of performance of colposcopists. After the first round, the results were presented, and the respondents were given the chance to reflect on their response and change it if necessary. MAIN OUTCOME MEASURES: Criteria considered to be essential for appraisal of colposcopists in areas of training, diagnostic and therapeutic aspects and communication. RESULTS: In the first round, 306/499 (61%) participants returned the completed questionnaire. Sixty percent (187/306) of participants returned their questionnaire in the second round. In addition to BSCCP certification, four other criteria were identified, which were quality of recorded findings, biopsy rate when atypia noted, proportion of biopsies histologically adequate and proportion of normal initial posttreatment follow-up smears. CONCLUSION: This Delphi survey has been the first to identify criteria to be used in the annual appraisal of professionals. It has resulted in a number of criteria that could be considered for the appraisal and possible revalidation of colposcopists practising in UK.