colposcopy
DESCRIPTION
COLPOSCOPY. Accuracy of Colposcopy Histopathologic basis for false negative and false positive colposcopic impressions Ramifications both clinical and scientific of using the iron (rather than gold) standard of colposcopically directed biopsy for ≥ CIN 2 P.O.I. 5-biopsy standard - PowerPoint PPT PresentationTRANSCRIPT
COLPOSCOPY
• Accuracy of Colposcopy• Histopathologic basis for false negative and
false positive colposcopic impressions• Ramifications both clinical and scientific of
using the iron (rather than gold) standard of colposcopically directed biopsy for ≥CIN 2
• P.O.I. 5-biopsy standard
INITIAL COLPOSCOPISTS’ AND REVIEWERS’ COLPOSCOPIC
IMPRESSIONS IN ALTS
Weighted kappa: 0.237
Ferris DG et. al. Am J Obstet Gynecol 2004;191:1934-41
INITIAL IMP REVIEW IMP
NORMAL
REVIEW IMP
CIN 1
REVIEW IMP
CIN 2/3
NORMAL 322 28 4CIN 1 767 568 86CIN 2/3 77 146 87
COLPOSCOPIC IMPRESSION OF WOMEN WITH ECTOCERVICAL CIN 2 OR WORSE
SCPMG-FONTANA, 4/96 – 11/99
•
Pretorius RG et. al. J Reprod Med 2001;46:724-8
NORMAL HPV OR CIN 1 CIN 2 OR
WORSE
146/642 (22.7%) 359/642 (55.9%) 137/642 (21.3%)
I
II
IV
III
PROPORTION OF WOMEN WITH CIN 2, CIN 3, OR CANCER DIAGNOSED BY
A COLPOSCOPICALLY DIRECTED BIOPSY
CIN 2
OR WORSE
CIN 3
OR WORSE
SPOCCS I 65/86 (75.6%)1 36/43 (83.7%)2
SPOCCS II 211/375 (56.3%)1 117/202 (57.9%)2
175.6% vs. 56.3%, Chi-Square=10.8, df=1, p<.001283.7% vs. 57.9%, Chi-Square=10.1, df=1, p<.01
Pretorius RG et al. Int J Cancer 2007;121(10):2218-24
MEASUREMENT OF THICKNESS AND DENSITY OF EPITHELIUM
MEAN AVERAGE THICKNESS OF SQUAMOUS EPITHELIUM (µm) AS FUNCTIONS OF
HISTOLOGY AND COLPOSCOPIC IMPESSION
HISTOLOGY COLPO NORMAL
COLPO LOW
COLPO HIGH
COLPO CANCER
TOTAL
NORMAL/CIN 1
366b [327-405]
358b [316-453]
453b [388-517]
310b [one slide]
387c [358-416]
CIN2/CIN3
184a [151-216]
250a [220-282]
352a [309-396]
410a
[335-485]290c [265-314]
a184 vs. 250 vs. 352 vs. 410, p<.0001, GLMMb366 vs. 358 vs. 453 vs. 310, p=0.04, GLMMc387 vs. 290, p<.001, WRST
Yang B et al. Gynecol Oncol 2008;110:32-6
POOR CLINICAL DECISIONS FROM USING A COLPOSCOPIC DIRECTED BIOPSY ‘GOLD
STANDARD’ FOR ≥CIN 2
1. Q 6-month follow-up of women with colposcopic diagnosis of ≤CIN 1
Not a good plan as many women are lost to follow-up
Pretorius RG et al.Am J Obstet Gynecol 2006;195(5):1260-5
2. Performing LEEP or cone on a young woman with CIN 2 to avoid missing CIN 3Many women with CIN 2 will resolve their infections without treatment, so if you knew the diagnosis was CIN 2, you might follow them.
ACOG Committee Opinion #330 Obstet Gynecol 2006;107:963-8
POOR SCIENCTIFIC CONCLUSIONS FROM USING A COLPOSCOPIC DIRECTED BIOPSY ‘GOLD
STANDARD’ FOR ≥CIN 2
1. CIN is more frequent on the anterior lip of the cervix.Though colposcopically detected lesions are more common on the
anterior lip, CIN (and microinvasive squamous cervical cancer) are radially distributed on the cervix.
Pretorius RG et al. J Lower Genital Tract Disease 2006;10:45-50
2. The sensitivity of acetic acid aided visual inspection (VIA) for ≥CIN2 is about 65%.
VIA and colposcopy are correlated (ie. they detect and miss many of the same lesions). When colposcopy is the ‘gold-standard’ in VIA screening studies, the sensitivity of VIA for ≥CIN 2 (and ≥CIN 3) is inflated. The actual sensitivity of VIA for ≥CIN 2 is closer to 45%.
Pretorius RG et al. Int J Cancer 2007;121(10):2218-24
METHOD OF DIAGNOSING WOMEN WITH CIN 2 OR WORSE (SPOCCS II)
Colpo biopsy 208/364 (57.1%)
Colpo biopsy + 2 o’clock 256/364 (70.3%)
Colpo biopsy + 2, 4 o’clock 297/364 (81.6%)
Colpo biopsy + 2, 4, 8 o’clock 329/364 (90.4%)
Colpo biopsy + 2, 4, 8, 10 o’clock 344/364 (94.5%)
Colpo biopsy + 2, 4, 8, 10 + ECC 364/364 (100%)
57.1% vs. 70.3% vs. 81.6% vs. 90.9% vs. 94.5% vs. 100%, Chi-Square = 326, df=5, p<.001
SENSITIVITY OF COLPOSCOPY FOR CIN 2 OR WORSE AND RATE OF CIN 2
OR WORSE
SENSITIVITY CIN 2
OR WORSE
RATE CIN 2
OR WORSE
SPOCCS I 65/86 (75.6%) 86/1997 (4.3%)
SPOCCS II 211/375 (56.3%) 375/8497 (4.4%)
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