Video monitoring of smear-taking at colposcopy: relationship to cytology.

OBJECTIVE: To investigate the reasons why cervical smears occasionally fail to reflect the underlying pathology in the cervix even when the smear is taken at colposcopy. DESIGN: A randomised study of three different smear-taking devices. SETTING: A colposcopy clinic. POPULATION: Women attending the colposcopy clinic. METHODS: A smear was taken from 172 nulliparous and 100 multiparous women at colposcopy and the procedure was monitored on a video-imaging system. The cytological findings were compared with the biopsy report in 147 nulliparous and 85 multiparous women. MAIN OUTCOME MEASURES: Accuracy of cytology and the effect of a range of variables on the accuracy of cytology. RESULTS: Sampling of the transformation zone was incomplete in 15% of nulliparous women and 8% of multiparous women. Univariate analysis of a range of variables including parity, type of sampling devices, completeness of sampling of the transformation zone, size of the transformation zone, size of the lesion (aceto-white area) and location of the squamo-columnar junction showed that the accuracy of cytology was influenced by all these factors except for parity and smear-taking devices. Multivariate analysis showed that the location of the squamo-columnar junction, the size of the transformation zone area, the size of the aceto-white area and the ratio of the aceto-white area to the area of the transformation zone influenced the accuracy of cytology. CONCLUSIONS: Women with large transformation zone areas (>30.03 mm(2)) and/or small aceto-white lesions (<7.01 mm(2)) are more likely to have an inaccurate cytology reports than women with small transformation zone and women with larger aceto-white areas. A ratio of the aceto-white area to the area of the transformation zone of 0.22 or less increases the risk of disagreement between the cytological and histological findings.

Endometriosis arising during estrogen and testosterone treatment 17 years after abdominal hysterectomy: a case report.

OBJECTIVE: To report the possible association between the use of oestrogen replacement therapy and endometriosis in a postmenopausal woman. METHODS: We present a case of a postmenopausal, previously hysterectomised, woman who received hormonal replacement therapy and developed a large broad ligament cyst. Two years prior to her presentation she had been complaining of pelvic pain and deep dyspareunia. RESULTS: Pelvic ultrasound showed an adnexal cyst that was increasing in size. CA-125 was normal. Laparoscopy revealed multiple endometriotic deposits and a broad ligament cyst. Cystectomy and oophorectomy were done. Histology confirmed a diagnosis of endometriosis including the broad ligament cyst. CONCLUSIONS: Hormonal replacement therapy can be associated with de novo endometriosis including at sites, which are unusual.

Measurement of Brn-3a levels in Pap smears provides a novel diagnostic marker for the detection of cervical neoplasia.

OBJECTIVES: We have previously demonstrated that Brn-3a cellular transcription factor activates transcription of the human papillomavirus (HPV) E6 and E7 oncogenes in human cervical cancer cells and that Brn-3a levels are dramatically elevated in biopsies from women with high-grade cervical neoplasia. The aim of this study was to establish the relationship between Brn-3a levels in Pap smears and the histological diagnoses. We also analysed whether Brn-3a levels can be used in combination with Pap smear to predict the presence of cervical intraepithelial lesion. METHODS: Two hundred thirty-eight women who were referred with abnormal Pap smear underwent a diagnostic colposcopy, repeat in-study Pap smear, colposcopically directed biopsy, and assessment of Brn-3a and HPV-16 E6 m-RNA levels. Data were analysed to assess the association between Brn-3a levels and the histological diagnosis. RESULTS: Brn-3a was readily measured in smears and showed a statistically significant correlation with the grade of cervical abnormality. Positive Brn-3a is associated with increased relative risk of higher-grade lesion. Moreover, measurement of Brn-3a levels in smears can be used to detect a significant proportion of cervical lesions that were missed by Pap smear. CONCLUSION: Measurement of Brn-3a levels in routinely taken Pap smears is a feasible technique that correlates with the severity of the epithelial abnormality and is a useful adjunct to cytology. Brn-3a appears to have great promise since it detects activation of oncogenic HPVs rather than simply detecting their presence, as is currently being done.

Triage by HPV-DNA testing: is it useful in women with persistent minor smear abnormalities?

BACKGROUND: This study was carried out to evaluate the efficacy of HPV-DNA (Human Papilloma Virus) testing as a triage strategy for persistent borderline and mild cytological abnormalities. METHODS: A prospective cross-sectional study involving 321 women registered between January and December 2001 with two smears showing borderline or mild dyskaryosis, taken 6 months apart. This study was undertaken in a colposcopy unit in a large district general hospital in central London. RESULTS: Three hundred and twenty-one women referred with persistent borderline and mild dyskaryosis were recruited in this study. HPV-DNA testing was positive in 194 women (60.4%). Histology of colposcopically directed biopsy showed CIN2/3 in 57 women (18%). Fifty-one of these 57 women were detected by HPV-DNA testing (sensitivity for high-grade disease 89.5%). Specificity for high-grade disease was 45.8%. Negative predictive value was 95.3%. Women with a positive HPV-DNA result had a 7.2 times higher risk of having a high-grade cervical cancer precursor lesion. CONCLUSION: Negative predictive value of HPV-DNA testing for high-grade cervical lesion is very high. Hence, it can be used as a triage strategy for persistent borderline changes and mild dyskaryosis.

Visualization techniques (colposcopy, direct visual inspection, and spectroscopic and other visual methods). Summary of task force 7.

Visual screening techniques include both low-technology approaches, such as direct visual inspection (DVI), and high-technology approaches, such as those that utilize electrooptical detectors to identify cervical cancer precursors and invasive cervical cancer. Simple visual screening techniques, such as DVI, consist of washing the cervix with a solution of 5% acetic acid (e.g., vinegar) and then inspecting it using either the naked eye or with a low-power magnifying device to identify areas of acetowhitening, which frequently correspond to cervical squamous intraepithelial lesions (SILs). The simple visual screening methods are being evaluated as an alternative to cytology in low-resource settings where screening using cervical cytology is not feasible. Multiple studies have shown DVI to have sensitivity similar to that of cervical cytology for identifying women with high grade SIL but much lower specificity. The novel high-technology visual screening methods that utilize electrooptical sensors to identify cervical abnormalities are still in the developmental phases but offer considerable potential.