GYNECOLOGIC
ONCOLOGY
5, 134-141 (1977)
Cytology
C. Hsu, University
and Colposcopy in the Diagnosis of Cervical Neoplasia
J. C. K. PANG, B.Sc., DIP.MED., Departments of Hong
M.B.,
B.CHIR., M.R.C.O.G., AND K. M. KWAN-CHAU, C.M.(I.A.C.)
of Obstetrics and Gynaecology and Pathology, Kong, Queen Mary Hospital, Pokfulam Road, Hong
Kong
Received October 18, 1976 A total of 98 patients were referred to the Cervical Dysplasia Clinic for colposcopic evaluation. These included 52 patients with abnormal cytology and 46 with a grossly suspicious cervical lesion but negative cytology. None of the patients in the latter group showed any lesion on colposcopic examination. Of the 52 patients with abnormal cytology, cervical neoplasia was present in 47. The accuracy of cytology and colposcopy in predicting the degree of cervical neoplasia was 78.8 and 87.2%, respectively. The histology of the directed biopsy and that of the cone biopsy were within one histological grade of agreement in 88.5% of cases. The results also indicate that only 17.3% of the patients would require a cone biopsy for definitive diagnosis. It is concluded that colposcopy is a valuable adjunct to cytology in the diagnosis of cervical neoplasia, and the necessity for conization to establish a diagnosis can be markedly decreased.
The place of cytology in the routine screening of cervical cancer is now well established in clinical practice. It is also generally accepted that a cone biopsy is the ultimate procedure required to establish a definitive diagnosis. Most authorities agree, however, that conization is not a benign procedure for it can be complicated by severe postoperative bleeding or late cervical dysfunction. In the last few years, numerous reports have appeared in the literature advocating the use of colposcopy as a method for evaluating patients with abnormal cervical cytology 11-81. These studies established that it was possible to pinpoint accurately the area of abnormal epithelium by colposcopic examination for selection of the biopsy site, thus abolishing the need for conization in a large proportion of cases. The purpose of this paper is to report our experience in the first 12 months of combined use of cytology and colposcopy in the diagnosis of early cervical neoplasia, and to evaluate the individual and combined accuracy of these methods in predicting the histological diagnosis. MATERIALS
AND METHODS
The Cervical Dysplasia Clinic was established at the University Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong, in August 1975. Two groups of patients were referred to the clinic for evaluation: (1) those with abnormal or positive cytology, and (2) those with negative cytology but with clinically suspicious lesions on the cervix. The Moller colposcope was used for the examination, and we employed the 134 Copyright @ 1977 by Academic Press. Inc. All rights of reproduction m any form reserved.
DIAGNOSIS
OF CERVICAL
135
NEOPLASIA
clinical methods and criteria recommended by Kolstad and Stafl [9]. Each examination included the following: (1) careful gross examination of cervix, (2) repeat cytology smear, (3) colposcopic examination, (4) directed biopsy from the most significant part of the lesion seen. In order to assess the diagnostic accuracy of the colposcopically directed biopsy, conization was performed in all patients after the directed biopsy unless this showed invasive carcinoma. A cone biopsy was also done in those cases where no lesion was seen on colposcopy but the cytology was persistantly abnormal. In addition, in patients in whom the squamo-columnar junction was not fully visible, colposcopy was regarded as unsatisfactory since a more severe lesion higher up in the endocervical canal could not be excluded. In these cases, a cone biopsy was also performed. RESULTS
A total of 98 patients were referred to the Cervical Dysplasia Clinic from August 1, 1975 to July 31, 1976. Fifty-two patients were referred because of positive or atypical cytology; while in 46 patients, cytology was negative but a cervical lesion was thought to be present on direct visual examination. None of the patients in this latter group showed any lesion on colposcopic examination. The 52 patients in the first group form the basis of this report. Of these 52 patients, cervical neoplasia was present in 47. Patient
source
Thirty-three of the 52 patients were referred from the University Gynaecological Out-patient Department. Eleven were referred from the Family Planning Clinic, and 8 from the Social Hygiene Clinic.
The ages of the patients with cervical neoplasia ranged from 17 to 70 years. Table 1 shows the distribution of the various degrees of cervical neoplasia according to the different age groups. As can be seen, the degree of neoplasia became more severe as the patient’s age increased.
TABLE
1
AGES OF PATIENTS WITH VARIOUS OF CERVICAL NEOPLASIA
Age (years) 20 and under 21-30 31-40 41-50 51-60 Over 60
DEGREES
Mild to moderate dysplasia
Marked dysplasia to carcinoma
2 3 2 1 -
-
in situ
2 12 6 I -
Micro-invasive to invasive carcinoma 1 13 1 3
136
PANG,
HSU, AND KWAN-CHAU TABLE
PARITY
OF PATIENTS
WITH
VARIOUS
2 DEGREES
OF CERVICAL
NEOPLASIA
Parity
Patients (No.)
Percentage
0
3
6.3
1
4
2
9
3 93.7 4 5 6+
Parity
Table 2 shows the parity of the patients studied. 93.7% of the patients were parous, and 85.1% had had two or more pregnancies. Accuracy
of cytology
Table 3 shows the correlation between the cytological impression and the final histological diagnosis. The latter refers to the most advanced diagnosis obtained TABLE CORRELATION
BETWEEN
CYTOLOGY
AND
3 THE FINAL
HISTOLOGICAL
DIAGNOSIS
Final histological diagnosis
Negative
Mild dysplasia
Moderate dysplasia
Marked dysplasia
2
4
2
1
2
I
I
1
3
Carcinoma in situ
Microinvasive Invasive carcinoma carcinoma
Negative Mild 2 dysplasia 3 2 k dysplasia Moderate ,E
2
z Marked g dysplasia 0 ‘, U Carcinoma
3
in situ
II
I
5
5
Microinvasive carcinoma Invasive carcinoma
1
7
DIAGNOSIS
OF
CERVICAL
137
NEOPLASIA
either in the directed biopsy or the cone specimen. The central zone enclosed by the heavy lines represents those patients in whom the correlation was within one histological degree of neoplasia. Thus in 78.8% of cases the correlation was clinically accurate. Histology showed a more advanced lesion in 8 cases (15.4%) and a less advanced lesion in 3 (5.8%). In one of the latter patients, invasive cancer was diagnosed by cytology; but both directed and cone biopsies revealed no lesion. Accuracy
of colposcopy
The correlation between the colposcopic impression and the histological diagnosis of the directed biopsy is presented in Table 4. Of the 47 patients in whom a directed biopsy was taken, the correlation was within one histological grade in 41 (87.2%). Directed biopsy showed more advanced pathology in 4 cases (8.5%) and less advanced in 2 (4.3%). Three cases of early invasive carcinoma were underdiagnosed by colposcopic examination. All of these had large focal lesions involving the whole of the transformation zone. Multiple biopsies taken showed various grades of neoplasia, ranging from marked dysplasia to early invasive carcinoma. Accuracy
of combined
cytology
and colposcopy
Table 5 shows the correlation between the combined cytological and colposcopic impression and the final histological diagnosis. In 46 patients (88.5%), the TABLE CORRELATION THE
BETWEEN
THE
HISTOLOGY
4 COLPOSCOPIC
OF THE
Histology
of directed
IMPRESSION
DIRECTED
AND
BIOPSY
biopsy Micro-
Negative
,z
Negative
1
Mild dysplasia
3
Mild dysplasia
Moderate
Marked
dysplasia
dysplasia
Carcinoma
in situ
invasive carcinoma
Invasive carcinoma
I 3
I
2 5 ,s
Moderate dysplasia
1
.u 28
Marked dysplasia
1
1
I
2
2
6
1
5
6
1
B 2
Carcinoma
in situ
3
2
Microinvasive carcinoma Invasive carcinoma
7
PANG,
138
HSU, AND KWAN-CHAU TABLE
CORRELATION
BETWEEN IMPRESSION
THE COMBINED AND THE FINAL
5 CYTOLOGICAL HISTOLOGICAL
Final histological
Negative c 2 Negative 4 2 Mild .g dysplasia ‘% 2 $ g 4
2 3
Moderate dysplasia
diagnosis
Moderate dysplasia
Marked dysplasia
Carcinoma in sir14
Microinvasive Invasive carcinoma carcinoma
I 4
2 2
Marked dysplasia
9 5j Carcinoma
.i
Mild dysplasia
AND COLPOSCOPICAL DIAGNOSIS
1
I
I
3
I
I
I 44
in situ
11
5
4
-i; $j MicroD Invasive ,g carcinoma E Invasive u carcinoma
correlation was clinically more advanced pathology
8 4
accurate. The remaining than expected.
6 cases (11.5%) all showed
Accuracy of the directed biopsy Table 6 compares the histology of the directed biopsy with that of the cone specimen in 26 patients in whom the whole transformation zone could be seen in its entirety. Of the remaining 21 patients, 12 had invasive cancer on directed biopsy and therefore conization was not performed. In the other 9 patients (17.3%), the squamo-columnar junction was not visualized and thus colposcopic examination was regarded as unsatisfactory. The heavy lines in Table 6 again enclose those 23 patients (88.5%) in whom the diagnosis on directed biopsy and cone biopsy was within one histological grade of agreement. One patient (3.8%) showed less advanced pathology while 2 (7.7%) had more advanced disease in the cone specimen than in the directed biopsy. No case of invasive carcinoma was missed by directed biopsy. Final histological diagnosis The final histological diagnosis in the 52 patients is shown in Table 7. DISCUSSION
Until recently cone biopsy has been regarded as the only method of definitive diagnosis in patients with abnormal cervical smears. This procedure, however,
DIAGNOSIS
OF CERVICAL TABLE
CORRELATION
BETWEEN AND
THE THAT
6
HISTOLOGY OF THE
139
NEOPLASIA
OF THE
CONE
DIRECTED
BIOPSY
BIOPSY
Cone biopsy histology
Negative
Mild dysplasia
Moderate dysplasia
Marked dysplasia
Carcinoma in situ
Microinvasive Invasive carcinoma carcinoma
Negative B Mild o dysplasia z g Moderate 2 dysplasia E 5 Marked -KJ dysplasia Y 8 L Carcinoma ‘6 in situ
I
1
1
1
3
1
I
1
4
3 8
I
Microinvasive carcinoma Invasive carcinoma
requires hospitalization and has an early and late complication rate which cannot be ignored. Colposcopy, on the other hand, is a relatively simple procedure free from all the risks and disadvantages of conization. Although our experience with colposcopy is still rather limited, the results of the present study confirms the value of this procedure in the diagnosis of early cervical neoplasia. We endorse the view of others [l-3, 5, 7, 10, II] that this technique is complementary to cytology in the screening of cervical cancer and is
TABLE FINAL
HISTOLOGICAL
Diagnosis Benign Mild dysplasia Moderate dysplasia Marked dysplasia Carcinoma in situ Micro-invasive carcinoma Invasive carcinoma
7 DIAGNOSIS
Patients (No.) 5 4 4 6 1.5 6 12
140
PANG,
HSU,
AND
KWAN-CHAU
extremely helpful in determining the degree and site of lesion from which a directed biopsy may be taken. Our colposcopic impression was accurate in 87.2% of the cases. Our rate of error of 12.8% is in close agreement with the 15% reported by Stafl and Mattingly [5], and the 14% by Benedet and coworkers [8]. Our series, however, is much smaller than the two quoted, and more of our cases were underdiagnosed (8.5%) than overdiagnosed (4.3%). This is probably related to our initial inexperience with the technique. It is interesting to note that the three patients with early invasive carcinoma that were underdiagnosed by colposcopy had very large lesions involving the entire transformation zone. This study also confirms that colposcopically directed biopsies are reliably accurate provided the whole of the transformation zone can be visualized. The accuracy rate in our study (88.5%) is comparable to the 85 to 93% reported by other workers [3, 4, 81. Our results also indicate that of all the patients examined, only 17.3% required a cone biopsy for definitive diagnosis. In these patients, the squamo-columnar junction was not visualized. All the remaining patients had lesions diagnosed by colposcopically directed biopsies, and no case of invasive carcinoma was missed. It is interesting to note the extremely high incidence of invasive disease in our small series of patients. Eighteen of the 47 patients (38.3%) with cervical neoplasia had either microinvasive or invasive carcinoma. This incidence is much higher than the 2.3 to 13.5% reported in other series [4,5,8, 111. The reason for this is not entirely certain. One possible explanation may be that a large proportion of patients referred to our clinic belong to a population which runs a high risk of developing cervical carcinoma. Although we have only used colposcopy for only a year, our preliminary experience has led us to believe that this technique is a valuable adjunct to cytology in the diagnosis of cervical neoplasia, and that the need for a cone biopsy for definitive diagnosis can be dispensed with in a high percentage of cases. REFERENCES 1. Townsend, D. E., Ostergard, D. R., Mischel, D. R., and Hirose, F. M. Abnormal Papanicolaou smears: Evaluation by colposcopy, biopsies, and endocervical curettage, Amer. J. Obsret. Gynecol.
108, 429-434
(1970).
2. Crapanzano, J. T. Office diagnosis in patients with abnormal cervicovaginal cytosmears: Correlation of colposcopic biopsy and cytologic findings, Amer. J. Obstet. Gynecol. 113, 967-972 (1972). 3. Thompson, B. H., Woodruff, J. D., Davis, H. J., Julian, C. G., and Silva, F. G. Cytopathology, histopathology, and cytology in the management of cervical neoplasia, Amer. J. Obstet. Gynecol.
114, 329-338
(1972).
4. Donohue, L. R., and Merriweather, W. Colposcopy as a diagnostic tool in the investigation of cervical neoplasia, Amer. J. Obstet. Gynecol. 113, 107-110 (1972). 5. Stafl, A., and Mattingly, R. F. Colposcopic diagnosis of cervical neoplasia, Obstet. Gynecol. 41, 168-176 (1973). 6. Boelter, W. C., and Newman, R. L. The correlation between colposcopic grading, directed punch biopsy, and conization, Amer. J. Obstet. Gynecol. 122, 945-946 (1975). 7. Tovell, H. M. M., Banogan, P., and Nash, A. D. Cytology and colposcopy in the diagnosis and management of preclinical carcinoma of the cervix uteri: A learning experience, Amer. J. Obstet.
Gynecol.
124, 924-934
(1976).
DIAGNOSIS
OF
CERVICAL
NEOPLASIA
141
8. Benedet, J. L., Boyes, D. A., Nichols, T. M., and Miller, A. Colposcopic evaluation of patients with abnormal cervical cytology, Brir. J. Obsret. Gynaecol. 83, 177-182 (1976). 9. Kolstad, P., and Statl, A. Atlas of Colposcopy, University Park Press, Baltimore (1972). 10. Navratil, E., Burghardt, E., Bajardi, F., and Nash, W. Simultaneous colposcopy and cytology used in screening for carcinoma of the cervix, Amer. J. O&et. Gynecol. 75, 1292-1297 (19.58). 11. Hollyock, V. E., and Chanen, W. The use of the colposcope in the selection of patients for cervical cone biopsy, Amer. J. Obstet. Gynecol. 114, 185-189 (1972).
ONCOLOGY
5, 134-141 (1977)
Cytology
C. Hsu, University
and Colposcopy in the Diagnosis of Cervical Neoplasia
J. C. K. PANG, B.Sc., DIP.MED., Departments of Hong
M.B.,
B.CHIR., M.R.C.O.G., AND K. M. KWAN-CHAU, C.M.(I.A.C.)
of Obstetrics and Gynaecology and Pathology, Kong, Queen Mary Hospital, Pokfulam Road, Hong
Kong
Received October 18, 1976 A total of 98 patients were referred to the Cervical Dysplasia Clinic for colposcopic evaluation. These included 52 patients with abnormal cytology and 46 with a grossly suspicious cervical lesion but negative cytology. None of the patients in the latter group showed any lesion on colposcopic examination. Of the 52 patients with abnormal cytology, cervical neoplasia was present in 47. The accuracy of cytology and colposcopy in predicting the degree of cervical neoplasia was 78.8 and 87.2%, respectively. The histology of the directed biopsy and that of the cone biopsy were within one histological grade of agreement in 88.5% of cases. The results also indicate that only 17.3% of the patients would require a cone biopsy for definitive diagnosis. It is concluded that colposcopy is a valuable adjunct to cytology in the diagnosis of cervical neoplasia, and the necessity for conization to establish a diagnosis can be markedly decreased.
The place of cytology in the routine screening of cervical cancer is now well established in clinical practice. It is also generally accepted that a cone biopsy is the ultimate procedure required to establish a definitive diagnosis. Most authorities agree, however, that conization is not a benign procedure for it can be complicated by severe postoperative bleeding or late cervical dysfunction. In the last few years, numerous reports have appeared in the literature advocating the use of colposcopy as a method for evaluating patients with abnormal cervical cytology 11-81. These studies established that it was possible to pinpoint accurately the area of abnormal epithelium by colposcopic examination for selection of the biopsy site, thus abolishing the need for conization in a large proportion of cases. The purpose of this paper is to report our experience in the first 12 months of combined use of cytology and colposcopy in the diagnosis of early cervical neoplasia, and to evaluate the individual and combined accuracy of these methods in predicting the histological diagnosis. MATERIALS
AND METHODS
The Cervical Dysplasia Clinic was established at the University Department of Obstetrics and Gynaecology, Queen Mary Hospital, Hong Kong, in August 1975. Two groups of patients were referred to the clinic for evaluation: (1) those with abnormal or positive cytology, and (2) those with negative cytology but with clinically suspicious lesions on the cervix. The Moller colposcope was used for the examination, and we employed the 134 Copyright @ 1977 by Academic Press. Inc. All rights of reproduction m any form reserved.
DIAGNOSIS
OF CERVICAL
135
NEOPLASIA
clinical methods and criteria recommended by Kolstad and Stafl [9]. Each examination included the following: (1) careful gross examination of cervix, (2) repeat cytology smear, (3) colposcopic examination, (4) directed biopsy from the most significant part of the lesion seen. In order to assess the diagnostic accuracy of the colposcopically directed biopsy, conization was performed in all patients after the directed biopsy unless this showed invasive carcinoma. A cone biopsy was also done in those cases where no lesion was seen on colposcopy but the cytology was persistantly abnormal. In addition, in patients in whom the squamo-columnar junction was not fully visible, colposcopy was regarded as unsatisfactory since a more severe lesion higher up in the endocervical canal could not be excluded. In these cases, a cone biopsy was also performed. RESULTS
A total of 98 patients were referred to the Cervical Dysplasia Clinic from August 1, 1975 to July 31, 1976. Fifty-two patients were referred because of positive or atypical cytology; while in 46 patients, cytology was negative but a cervical lesion was thought to be present on direct visual examination. None of the patients in this latter group showed any lesion on colposcopic examination. The 52 patients in the first group form the basis of this report. Of these 52 patients, cervical neoplasia was present in 47. Patient
source
Thirty-three of the 52 patients were referred from the University Gynaecological Out-patient Department. Eleven were referred from the Family Planning Clinic, and 8 from the Social Hygiene Clinic.
The ages of the patients with cervical neoplasia ranged from 17 to 70 years. Table 1 shows the distribution of the various degrees of cervical neoplasia according to the different age groups. As can be seen, the degree of neoplasia became more severe as the patient’s age increased.
TABLE
1
AGES OF PATIENTS WITH VARIOUS OF CERVICAL NEOPLASIA
Age (years) 20 and under 21-30 31-40 41-50 51-60 Over 60
DEGREES
Mild to moderate dysplasia
Marked dysplasia to carcinoma
2 3 2 1 -
-
in situ
2 12 6 I -
Micro-invasive to invasive carcinoma 1 13 1 3
136
PANG,
HSU, AND KWAN-CHAU TABLE
PARITY
OF PATIENTS
WITH
VARIOUS
2 DEGREES
OF CERVICAL
NEOPLASIA
Parity
Patients (No.)
Percentage
0
3
6.3
1
4
2
9
3 93.7 4 5 6+
Parity
Table 2 shows the parity of the patients studied. 93.7% of the patients were parous, and 85.1% had had two or more pregnancies. Accuracy
of cytology
Table 3 shows the correlation between the cytological impression and the final histological diagnosis. The latter refers to the most advanced diagnosis obtained TABLE CORRELATION
BETWEEN
CYTOLOGY
AND
3 THE FINAL
HISTOLOGICAL
DIAGNOSIS
Final histological diagnosis
Negative
Mild dysplasia
Moderate dysplasia
Marked dysplasia
2
4
2
1
2
I
I
1
3
Carcinoma in situ
Microinvasive Invasive carcinoma carcinoma
Negative Mild 2 dysplasia 3 2 k dysplasia Moderate ,E
2
z Marked g dysplasia 0 ‘, U Carcinoma
3
in situ
II
I
5
5
Microinvasive carcinoma Invasive carcinoma
1
7
DIAGNOSIS
OF
CERVICAL
137
NEOPLASIA
either in the directed biopsy or the cone specimen. The central zone enclosed by the heavy lines represents those patients in whom the correlation was within one histological degree of neoplasia. Thus in 78.8% of cases the correlation was clinically accurate. Histology showed a more advanced lesion in 8 cases (15.4%) and a less advanced lesion in 3 (5.8%). In one of the latter patients, invasive cancer was diagnosed by cytology; but both directed and cone biopsies revealed no lesion. Accuracy
of colposcopy
The correlation between the colposcopic impression and the histological diagnosis of the directed biopsy is presented in Table 4. Of the 47 patients in whom a directed biopsy was taken, the correlation was within one histological grade in 41 (87.2%). Directed biopsy showed more advanced pathology in 4 cases (8.5%) and less advanced in 2 (4.3%). Three cases of early invasive carcinoma were underdiagnosed by colposcopic examination. All of these had large focal lesions involving the whole of the transformation zone. Multiple biopsies taken showed various grades of neoplasia, ranging from marked dysplasia to early invasive carcinoma. Accuracy
of combined
cytology
and colposcopy
Table 5 shows the correlation between the combined cytological and colposcopic impression and the final histological diagnosis. In 46 patients (88.5%), the TABLE CORRELATION THE
BETWEEN
THE
HISTOLOGY
4 COLPOSCOPIC
OF THE
Histology
of directed
IMPRESSION
DIRECTED
AND
BIOPSY
biopsy Micro-
Negative
,z
Negative
1
Mild dysplasia
3
Mild dysplasia
Moderate
Marked
dysplasia
dysplasia
Carcinoma
in situ
invasive carcinoma
Invasive carcinoma
I 3
I
2 5 ,s
Moderate dysplasia
1
.u 28
Marked dysplasia
1
1
I
2
2
6
1
5
6
1
B 2
Carcinoma
in situ
3
2
Microinvasive carcinoma Invasive carcinoma
7
PANG,
138
HSU, AND KWAN-CHAU TABLE
CORRELATION
BETWEEN IMPRESSION
THE COMBINED AND THE FINAL
5 CYTOLOGICAL HISTOLOGICAL
Final histological
Negative c 2 Negative 4 2 Mild .g dysplasia ‘% 2 $ g 4
2 3
Moderate dysplasia
diagnosis
Moderate dysplasia
Marked dysplasia
Carcinoma in sir14
Microinvasive Invasive carcinoma carcinoma
I 4
2 2
Marked dysplasia
9 5j Carcinoma
.i
Mild dysplasia
AND COLPOSCOPICAL DIAGNOSIS
1
I
I
3
I
I
I 44
in situ
11
5
4
-i; $j MicroD Invasive ,g carcinoma E Invasive u carcinoma
correlation was clinically more advanced pathology
8 4
accurate. The remaining than expected.
6 cases (11.5%) all showed
Accuracy of the directed biopsy Table 6 compares the histology of the directed biopsy with that of the cone specimen in 26 patients in whom the whole transformation zone could be seen in its entirety. Of the remaining 21 patients, 12 had invasive cancer on directed biopsy and therefore conization was not performed. In the other 9 patients (17.3%), the squamo-columnar junction was not visualized and thus colposcopic examination was regarded as unsatisfactory. The heavy lines in Table 6 again enclose those 23 patients (88.5%) in whom the diagnosis on directed biopsy and cone biopsy was within one histological grade of agreement. One patient (3.8%) showed less advanced pathology while 2 (7.7%) had more advanced disease in the cone specimen than in the directed biopsy. No case of invasive carcinoma was missed by directed biopsy. Final histological diagnosis The final histological diagnosis in the 52 patients is shown in Table 7. DISCUSSION
Until recently cone biopsy has been regarded as the only method of definitive diagnosis in patients with abnormal cervical smears. This procedure, however,
DIAGNOSIS
OF CERVICAL TABLE
CORRELATION
BETWEEN AND
THE THAT
6
HISTOLOGY OF THE
139
NEOPLASIA
OF THE
CONE
DIRECTED
BIOPSY
BIOPSY
Cone biopsy histology
Negative
Mild dysplasia
Moderate dysplasia
Marked dysplasia
Carcinoma in situ
Microinvasive Invasive carcinoma carcinoma
Negative B Mild o dysplasia z g Moderate 2 dysplasia E 5 Marked -KJ dysplasia Y 8 L Carcinoma ‘6 in situ
I
1
1
1
3
1
I
1
4
3 8
I
Microinvasive carcinoma Invasive carcinoma
requires hospitalization and has an early and late complication rate which cannot be ignored. Colposcopy, on the other hand, is a relatively simple procedure free from all the risks and disadvantages of conization. Although our experience with colposcopy is still rather limited, the results of the present study confirms the value of this procedure in the diagnosis of early cervical neoplasia. We endorse the view of others [l-3, 5, 7, 10, II] that this technique is complementary to cytology in the screening of cervical cancer and is
TABLE FINAL
HISTOLOGICAL
Diagnosis Benign Mild dysplasia Moderate dysplasia Marked dysplasia Carcinoma in situ Micro-invasive carcinoma Invasive carcinoma
7 DIAGNOSIS
Patients (No.) 5 4 4 6 1.5 6 12
140
PANG,
HSU,
AND
KWAN-CHAU
extremely helpful in determining the degree and site of lesion from which a directed biopsy may be taken. Our colposcopic impression was accurate in 87.2% of the cases. Our rate of error of 12.8% is in close agreement with the 15% reported by Stafl and Mattingly [5], and the 14% by Benedet and coworkers [8]. Our series, however, is much smaller than the two quoted, and more of our cases were underdiagnosed (8.5%) than overdiagnosed (4.3%). This is probably related to our initial inexperience with the technique. It is interesting to note that the three patients with early invasive carcinoma that were underdiagnosed by colposcopy had very large lesions involving the entire transformation zone. This study also confirms that colposcopically directed biopsies are reliably accurate provided the whole of the transformation zone can be visualized. The accuracy rate in our study (88.5%) is comparable to the 85 to 93% reported by other workers [3, 4, 81. Our results also indicate that of all the patients examined, only 17.3% required a cone biopsy for definitive diagnosis. In these patients, the squamo-columnar junction was not visualized. All the remaining patients had lesions diagnosed by colposcopically directed biopsies, and no case of invasive carcinoma was missed. It is interesting to note the extremely high incidence of invasive disease in our small series of patients. Eighteen of the 47 patients (38.3%) with cervical neoplasia had either microinvasive or invasive carcinoma. This incidence is much higher than the 2.3 to 13.5% reported in other series [4,5,8, 111. The reason for this is not entirely certain. One possible explanation may be that a large proportion of patients referred to our clinic belong to a population which runs a high risk of developing cervical carcinoma. Although we have only used colposcopy for only a year, our preliminary experience has led us to believe that this technique is a valuable adjunct to cytology in the diagnosis of cervical neoplasia, and that the need for a cone biopsy for definitive diagnosis can be dispensed with in a high percentage of cases. REFERENCES 1. Townsend, D. E., Ostergard, D. R., Mischel, D. R., and Hirose, F. M. Abnormal Papanicolaou smears: Evaluation by colposcopy, biopsies, and endocervical curettage, Amer. J. Obsret. Gynecol.
108, 429-434
(1970).
2. Crapanzano, J. T. Office diagnosis in patients with abnormal cervicovaginal cytosmears: Correlation of colposcopic biopsy and cytologic findings, Amer. J. Obstet. Gynecol. 113, 967-972 (1972). 3. Thompson, B. H., Woodruff, J. D., Davis, H. J., Julian, C. G., and Silva, F. G. Cytopathology, histopathology, and cytology in the management of cervical neoplasia, Amer. J. Obstet. Gynecol.
114, 329-338
(1972).
4. Donohue, L. R., and Merriweather, W. Colposcopy as a diagnostic tool in the investigation of cervical neoplasia, Amer. J. Obstet. Gynecol. 113, 107-110 (1972). 5. Stafl, A., and Mattingly, R. F. Colposcopic diagnosis of cervical neoplasia, Obstet. Gynecol. 41, 168-176 (1973). 6. Boelter, W. C., and Newman, R. L. The correlation between colposcopic grading, directed punch biopsy, and conization, Amer. J. Obstet. Gynecol. 122, 945-946 (1975). 7. Tovell, H. M. M., Banogan, P., and Nash, A. D. Cytology and colposcopy in the diagnosis and management of preclinical carcinoma of the cervix uteri: A learning experience, Amer. J. Obstet.
Gynecol.
124, 924-934
(1976).
DIAGNOSIS
OF
CERVICAL
NEOPLASIA
141
8. Benedet, J. L., Boyes, D. A., Nichols, T. M., and Miller, A. Colposcopic evaluation of patients with abnormal cervical cytology, Brir. J. Obsret. Gynaecol. 83, 177-182 (1976). 9. Kolstad, P., and Statl, A. Atlas of Colposcopy, University Park Press, Baltimore (1972). 10. Navratil, E., Burghardt, E., Bajardi, F., and Nash, W. Simultaneous colposcopy and cytology used in screening for carcinoma of the cervix, Amer. J. O&et. Gynecol. 75, 1292-1297 (19.58). 11. Hollyock, V. E., and Chanen, W. The use of the colposcope in the selection of patients for cervical cone biopsy, Amer. J. Obstet. Gynecol. 114, 185-189 (1972).
