Adenocarcinoma in situ of the cervix-controversies in diagnosis and treatment.

Adenocarcinoma in situ (AIS) of the uterine cervix is a rare condition. Pap smear screening is unsatisfactory, and the disease has no morphologic reliable colposcopic features. Diagnosis is often made by chance during the treatment of squamous pre-invasive disease, which commonly coexists with AIS. Although the entire endocervical canal can be the site of disease, most lesions lie within 1 cm of the squamocolumnar junction. Skip lesions are rare, making fertility-sparing surgery a possibility under certain conditions. Recurrent disease occurs in 14% of cases when cone margins are free of disease and rise to more than 50% if the margins are involved. The method of conization is immaterial provided a large enough specimen is taken and that the endocervical margins can be evaluated by the pathologist. Follow-up of conservatively managed women is not defined; however, we recommend that regular endocervical cytology be performed in addition to conventional cytology and colposcopy.

Response of vulvar lichen sclerosus and squamous cell hyperplasia to graduated topical steroids.

OBJECTIVE: To determine whether symptomatic remission could be obtained equally effectively in patients with vulvar lichen sclerosus, squamous cell hyperplasia or mixed disease in response to a standardized course of graduated topical steroids. STUDY DESIGN: A retrospective analysis of 137 patients with biopsy-proven lichen sclerosus (84), squamous cell hyperplasia (42) or mixed disease (11) treated between 1990 and 1997 with a standard, three-month regimen of graduated topical steroids was carried out. Presence or absence of symptoms and side effects of treatment were recorded three and six months following induction of the initial graduated topical steroid regimen. RESULTS: On completion of the graduated topical steroid course, 59% of patients were asymptomatic (P = .035), and at six months, 58% were asymptomatic (P = .11). Remission of symptoms was more easily achieved in patients with lichen sclerosus as compared to patients with squamous cell hyperplasia and mixed disease at both three and six months (P = .09 at three and P = .035 at six). Four cases of local reactions to the steroids were recorded, as were two cases of vulvar malignancy. CONCLUSION: Symptomatic remission was significantly easier to achieve in patients with vulvar lichen sclerosus as compared to those with squamous cell hyperplasia following treatment with graduated topical steroids.

Histologic and immunologic associations of an HPV16 variant in LoSIL smears.

BACKGROUND: Human papillomavirus type 16 variants have been described and may have different biologic activities: this has implications for the design of HPV vaccines. OBJECTIVES: The aim of this study was to see if the HPV16 variant E-G 131 can be detected in women with preinvasive disease and to consider the histological and immunological implications of such infection. DESIGN: A prospective observational cross-sectional study on a cohort of women with minor cervical cytological abnormalities was performed. METHODS: Samples were tested for HPV DNA by polymerase chain reaction and restriction enzyme digestion. Blood samples were tested for antibodies to HPV16 virus-like particles (VLP) and to determine class I HLA types. Women found to have abnormal colposcopy were treated by large-loop excision of the transformation zone on a see-and-treat basis. RESULTS: Two hundred forty-one women were included in the study. Infection with the variant was detected in 20. 9% of cases and was not associated with any specific HLA type. These cases were more likely to have high-grade CIN than those with wild-type HPV16 or no HPV16 (chi2 = 18.85, P < 0.001). There were significant differences in seropositivity to HPV16 virus-like particles between the three groups (chi2 = 32.43, P < 0.001). CONCLUSIONS: The E-G 131 variant may have increased oncogenic potential by evading host immune responses, but its identification is only weakly predictive of high-grade disease in stepwise logistic regression. The lack of seropositivity to HPV16 VLP has implications for the design of prophylactic vaccines based on VLP to HPV16.

Cytological prediction of cervical intraepithelial neoplasia grade 3: does size of the lesion matter?

OBJECTIVE: Our objective was to test the hypothesis that accurate cytological prediction of cervical intraepithelial neoplasia grade 3 (CIN3) is related to the size of the atypical transformation zone. PATIENTS AND METHODS: Data on 340 women in whom CIN3 was diagnosed after large-loop excision of the transformation zone were recorded prospectively on a computerized database. These data were studied with regard to such variables as lesion size, age, parity, contraception use, and smoking status. RESULTS: No association was demonstrated between cytological findings and lesion size in accurately predicting CIN3 lesions. A weak association between cytological findings and age was demonstrated: Cytology is more likely to predict CIN3 accurately in women 25 years or older than in women younger than 25 years. CONCLUSIONS: Accurate cytological prediction of CIN3 is not related to the size of the atypical transformation zone seen at colposcopy. The CIN3 lesions may be present as discrete foci within a background of low-grade changes.

Video colpography: a new technique for secondary cervical screening.

OBJECTIVE: To assess the diagnostic accuracy of a new technique of cervical imaging and to consider its potential as a secondary cervical screening method. DESIGN: A prospective cross-sectional study with each case acting as its own control, comparing video colpography with colposcopy. SETTING: University of Birmingham colposcopy clinics, City Hospital and Birmingham Women's Hospital. PARTICIPANTS: Fifty women referred for colposcopy. INTERVENTIONS: The women had a video colpogram recording made prior to colposcopy. MAIN OUTCOME MEASURES: The proportion of technically suitable colpograms obtained and the level of agreement between colposcopist and video screener. RESULTS: The images were satisfactory or good in 94% cases, and there was a very high level of agreement between colposcopist and video screener (kappa = 0.79). If the technique had been used in a primary health care setting as a secondary screening method for women with low grade cervical smear abnormalities, 61% would have avoided referral for colposcopy. CONCLUSIONS: Video colpography is an accurate, portable and quick method of cervical imaging. It combines the simplicity of a video camera with the versatility of computerised digital imaging and has great potential in the fields of teaching, audit and screening of low grade smear abnormalities.

Observer variability among colposcopists from the West Midlands region.

OBJECTIVE: To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy. DESIGN: A two-part video questionnaire study. PARTICIPANTS: Colposcopists from West Midlands Region. METHODS: Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart. RESULTS: Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (chi 2 = 19.45, P < 0.0001) but not where the histology was CIN 1 or less (chi 2 = 2.64, P = 0.10). Overall interobserver agreement improved slightly from kappa = 0.169 to kappa = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been overtreated. CONCLUSION: There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy.

Reagent strip testing of antenatal urine specimens for infection.

OBJECTIVE: To compare reagent strip testing (RST) with microscopy and culture in identifying significant bacteriuria, and secondly, to consider potential cost savings if RST screening proved to be reliable. DESIGN: Prospective descriptive study. SETTING: Antenatal Clinic, Bristol Maternity Hospital. SUBJECTS: Eight hundred and ninety-eight women having urine testing in pregnancy for microscopy and culture either routinely or because of a clinical infection. INTERVENTIONS: The midstream specimens of urine had RST examination using Ames Multistix 8SG prior to being sent to the laboratory. MAIN OUTCOME MEASURE: Significant culture (> 10(5) colonies/ml) of a single organism in culture. RESULTS: The highest predictive value for a negative result of the urine culture (99.7%) was obtained when using four RSTs in combination. The RST for nitrite had a high predictive value for a positive urine culture (90%). The samples which gave a false negative result with RST screening were mainly infected with low grade urinary pathogens or genital tract contaminants. CONCLUSION: RST screening for bacteriuria provides a reliable and cheap alternative to culture of all urine specimens.