History of colposcopy in the United States. Chronology of colposcopy development worldwide.

Colposcopy was initially developed by Professor Hinselmann of Germany and is now a procedure that is recognized the world over. Twenty-two countries now represent the International Federation for Cervical Pathology and Colposcopy. Additionally, individual societies representing several countries exist.

The management of cervical intraepithelial neoplasia: the use of the carbon dioxide laser.

This report concerns the experience of an abnormal Pap smear clinic in treating cervical intraepithelial neoplasia (CIN). The CO2 laser was the primary treatment method in 283 consecutive cases during 1977-1981, which fulfilled the criteria for conservative management. Seven percent of cases were performed in hospital as out-patients; the remainder were performed in the clinic without anesthesia. The location and shape of the defect was individualized in each case to conform to the topography of the cervix. The basic configuration, however, was the same for all cases; a dome-shaped defect with a curved apex and straight sides of at least 6 mm in height. Laser surgery was well tolerated; few post-operative complications arose. The squamocolumnar junction reappeared in each case at the level of the external os, facilitating follow-up. Eleven cases (3.9%) exhibited persistent disease within 3 months of primary treatment. Thereafter no primary laser failures occurred. Follow-up in this series ranged from 18 to 36 months. Failure rates for CIN grades are as follows: CIN I, 1.3%; CIN II, 2.0%; CIN III, 7.3%. No case of persistent disease was of greater severity than was originally diagnosed. Ten of the 11 cases were successfully managed with repeat laser surgery, yielding an overall therapeutic success rate of 99.6%. These data indicate that laser surgery is the most efficacious conservative method for eradicating this disease.

Age at time of first intercourse v. chronologic age as a basis for Pap smear screening.

The Walton Report on cervical cancer screening programs recently recommended a new program for screening for cervical cancer based on chronologic age, calling for 3- and 5-year intervals between examinations. It recommended that such examinations be discontinued after 60 years of age. In a group of 232 routinely examined women (aged 18 to 47 years) in whom cervical intraepithelial neoplasia developed the timing of onset of the disease and the implications for screening were studied. The average age at the time of diagnosis was 30 years; in 20% of the patients the diagnosis had been made after age 35. The screening program recommended in the Walton Report would have been effective in diagnosing most cases (80%) in this sample by age 35 and all by age 60. However, when the patients were grouped according to age at the time of first intercourse, the diagnosis had been made after age 35 in only 13% of those who started having intercourse at age 15 to 17 years, 20% of those who started at age 18 to 19 years and 33% of those who started at age 20 years of later. When the times of diagnosis were expressed by number of years of intercourse the distributions became uniform in the same three groups; in 72% of all the patients the diagnosis had been made within the first 15 years of intercourse, in 88% it had been made within 20 years and in 100% it had been made by 30 years. These data suggest that a program based on number of years of intercourse may be more uniform and more efficient than one based on chronologic age, and that cytologic examinations should be concentrated during the time when most cases develop -- 6 to 20 years after the time of first intercourse.

Age at beginning of coitus versus chronologic age as a basis for Papanicolaou smear screening: an analysis of 747 cases of preinvasive disease.

Disease onset in 747 routinely screened women who developed cervical intraepithelial neoplasia was analyzed. Average age at diagnosis was 30 years; the range was 16 to 71 years. In 19% diagnosis was made after age 35, and in 1% after age 60. Grouping cases by age at beginning of coitus produced significant differences (p less than 0.001) in cumulative proportions of patients with the diagnosis made at any age. In 11% of patients initiating intercourse between ages 15 and 17 diagnosis was made after age 35; the figure was 19% for the 18 to 19 age group and 36% for the 20+ group. Screening by chronologic age is effective for women initiating intercourse early. Screening by years of exposure to intercourse produced a uniform distribution regardless of age at beginning of coitus. In 75% the diagnosis was made within the first 15 years of intercourse, in 88% by year 20; and in 97% by year 30. In 70% the diagnosis was made between 6 and 20 years. Cytologic surveillance should be concentrated during the sixth through twentieth years when most cases develop.

Laser surgery for cervical intraepithelial neoplasia: principles and results.

Four hundred twenty-nine consecutive cases of cervical intraepithelial neoplasia were managed by one of three techniques of carbon dioxide laser surgery: dome-shaped vaporization of ectocervical lesions, cylinder-shaped excision of endocervical disease, or a combination of the two in the case of ectocervical disease that extended into the lower cervical canal. Ninety-two patients (21.5%) had grade 1, 137 (31.9%) had grade 2, and 200 (46.6%) had grade 3 cervical intraepithelial neoplasia. The success rates subsequent to one surgical intervention were 97.8% for grade 1, 94.9% for grade 2, and 94.5% for grade 3 of the disease. Success for the entire patient population was 95.3% after the first treatment. A second treatment was required in 20 cases: 18 laser procedures and two hysterectomies. The overall success of laser surgery (one or two procedures) approached 100%. Complications were negligible. These findings suggest that these techniques are very effective in eliminating cervical intraepithelial neoplasia of all degrees when a planned approach is followed.

Reliability of histopathologic diagnosis of cervical intraepithelial neoplasia.

A study was designed to measure the inter-pathologist consistency of histopathologic diagnosis of cervical intraepithelial neoplasia (CIN) among four pathologists. Intra-pathologist reliability over time was also determined. Between-pathologist comparisons resulted in agreement only 50% of the time; however, 81% of pairs were within one CIN grade of each other. Seventy-one percent of first and second diagnoses of the same pathologist were identical and 93% of pairs were within one CIN grade. In seven cases, however, pairs of evaluations of the same slide were remarkably disparate, two considered normal and CIN III by the same pathologist at different times. The findings of this study, using the CIN grading system, are consistent with other studies using different classification schemes. Inconsistency of diagnoses and discrepancies between pathologists must be considered when conservative therapy is elected for a patient with cervical intraepithelial neoplasia.

Laser cylindrical excision to replace conization.

This report describes the procedures and results of two techniques, which were developed by the senior author (V.C.W.), for eliminating cervical intraepithelial neoplasia involving, to some degree, the endocervical canal. These are excision by carbon dioxide laser of a tall cylinder of tissue for pure endocervical lesions and shallow excision of a similar specimen followed by peripheral vaporization. In 364 consecutive referred cases one of these two procedures was performed. A total of 15.9% of patients required attention for bleeding; most cases were managed in the clinic. Near-normal tissue mass and a squamocolumnar junction at the os were observed during 3 to 60 months of follow-up. In 95.9% of cases, over half of which were grade 3 cervical intraepithelial neoplasia, normal cytologic and colposcopic findings were demonstrated after one laser procedure. A repeat laser procedure was used to eliminate persistent disease identified at 3 or 6 months. Five hysterectomies were performed. These procedures appear to be therapeutically effective, appear to preserve organ function, and allow regeneration of cervical mass.

Carbon dioxide laser management of cervical intraepithelial neoplasia.

In this report we describe the use of the carbon dioxide laser for the outpatient management of cervical intraepithelial neoplasia (CIN). A comparison of treatment effectiveness for different grades of CIN is also included. Two hundred fifty-six cases were evaluated by colposcopy, cytology, and histopathology, treated by at least 5 to 6 mm of laser vaporization, and followed up for an average of 10.7 months. Follow-up examinations included cytology, colposcopy, and directed biopsy if a suspicious lesion was discovered. During the follow-up, 18 cases of persistent CIN were identified (7.0%). Most of these were successfully managed with repeat laser treatment. Overall success of laser surgery for CIN, one or two applications, was 97.6%. Few complications were encountered. Laser surgery appears to offer acceptable treatment effectiveness, early identification of persistent disease, and easy retreatment when required.