Agreement Between Endocervical Brush and Endocervical

Agreement Between Endocervical
Brush and Endocervical Curettage in
Patients Undergoing Repeat
Endocervical Sampling
Meredith J. Alston MD
David W. Doo MD
Sara E. Mazzoni MD MPH
Elaine H. Stickrath MD
Denver Health Medical Center
University of Colorado
Department of Obstetrics and Gynecology
Background
• Women with abnormal Pap tests referred for
colposcopy frequently require sampling of the
endocervix
• ASCCP deems both the endocervical brush
(ECB) and the endocervical currette (ECC)
appropriate means of collecting endocervical
samples (1)
• Both have advantages and disadvantages, and it
is unclear if one modality is superior
Background
• ECB has good sensitivity for endocervical
lesions, it has poor specificity, ranging from 2638%2,3
• ECC has an excellent negative predictive value of
99.4% in women who had a satisfactory
colposcopy
• ECB is better tolerated by the patient, but runs
the risk of contamination from the ectocervix
• ECC is less likely to obtain an adequate sample
Background
• The results from the endocervical sample may
influence clinical management after colposcopy.
• Certain treatment options for high grade
squamous intraepithelial neoplasia are available
only to women with negative endocervical
sampling.
▫ Ablative techniques
▫ Expectant management
Background
• Over concerns related to potential complications
of excisional treatments, as well as overtreatment, there has been a push to re-introduce
ablative techniques and, in appropriate clinical
circumstances, expectant management, into the
routine treatment of patients with cervical
cancer precursors (12).
Background
• At our institution, it is our concern that due to
the possibility of contamination from the
ectocervix, a positive ECB may not represent a
true positive endocervical sample.
• We do not use a sleeve
• Positive ECBs return for ECC if otherwise a
candidate for ablative therapy or expectant
management
Objective
• To describe the agreement between these two
modalities of endocervical sampling.
• Aid clinicians in:
▫ counseling of patients
▫ interpretation of results
▫ selection of an endocervical sampling method in
varied clinical scenarios
Methods
• IRB approval was obtained through the
Colorado Multiple Institutional Review Board
• Retrospective cohort study
• April 1, 2013-June 15, 201
• ECB and returned for ECC
Methods
• ECB sampling results
▫ “Low-grade”
 LSIL
 ASCUS
▫ “High-grade”
 HSIL
 ASC-H
• ECC results: negative, LSIL, and HSIL
according to LAST terminology(13).
Methods
• Demographics:
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
Age
Gravidity
Parity
Insurance
primary language
Contraception
menopausal status
Weight
current drug or tobacco use
history of prior treatment for dysplasia (including type
of treatment)
Methods
• REDCap
• Percent agreement between ECB and ECC were
calculated based on “low-grade” and “high-grade”
classifications
• Chi-square and student’s t-test were used to
determine differences in dichotomous and
continuous variables
• Multivariate analyses, using logistic regression
modeling, were used to compare outcome measures
among the groups
• Statistical tests were considered significant at
P<0.05.
Results
Table 1. Patient Demographics and
Clinical Characteristics
Mean Age (years)
Gravidity
Parity
Primary Language
English
Spanish
Other
Insurance
Yes
No
Contraception Method
Condoms
Depo Provera
Implanon/Nexplanon
IUD
OCPs/Patch/Ring
Menopause
Sterilization
Tobacco Use
Yes
No
Drug Use
Yes
No
History of Prior Treatment
Yes
No
Not Documented
33.9 ± 10.3
2.27 ± 1.8
1.8 ± 1.5
56 (70.9%)
20 (25.3%)
3 (3.8%)
56 (70.9%)
23 (29.1%)
7 (8.9%)
4 (5.1%)
6 (7.6%)
19 (24.1%)
6 (7.6%)
7 (8.9%)
6 (7.6%)
14 (17.7%)
65 (82.3%)
2 (2.5%)
77 (97.5%)
4 (5.1%)
57 (72.2%)
18 (22.8%)
Results
Results
Table 2. Demographic and Clinical Predictors of Agreement Between
ECB and ECC
Variable
Mean Age (years)
Mean Parity
Mean weight (pounds)
Primary Language English
Insured
Progestin Only Contraception
Estrogen Contraception
Menopause
IUD
Tobacco
Drugs
Prior Excision
Atrophy
IUD = Intrauterine Device
Agreement
n=8
44.3 ± 13.3
1.5 ± 1.1
169 ± 36
5 (62.5%)
6 (75.0%)
1 (12.5%)
0
3 (37.5%)
0
2 (25.0%)
0
2 (25.0%)
1 (12.5%)
No Agreement
n=71
32.7 ± 9.3
1.9 ± 1.6
156 ± 39
51 (71.8%)
50 (70.4%)
22 (31.0%)
6 (8.5%)
4 (5.6%)
14 (19.7%)
12 (16.9%)
2 (2.8%)
1 (1.4%)
7 (9.9%)
P Value
0.049
0.38
0.37
0.59
0.78
0.24
1
0.02
0.07
0.59
1
0.03
1
Discussion
• There is poor agreement between ECB and ECC
results for both low-grade (7.4%) and high-grade
(16%) dysplasia at the time of colposcopy in our
patient population using an unsleeved
cytobrush.
Discussion
• Although the ASCCP recommends either
cytobrush or curettage for evaluation of the
endocervix(15), there has been a significant
amount of controversy over which is the
preferred method.
• Previous studies that have compared the relative
sensitivities and specificities of the two methods
have produced a wide range of results.
Discussion
• Our data suggests that ECB collected at the time
of colposcopy overestimates the presence of
endocervical disease when compared to ECC. We
suspect that this may be in a large part due to
atypical ectocervical cells adhering to the brush
at the time of ECB and thus giving false positive
results.
Discussion
• In our patient population, given the poor
agreement between the two modalities, we have
elected to perform endocervical sampling with
ECC in those patients who may be candidates for
expectant management or ablative therapies.
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
1.
Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain JM, et al. American Cancer Society, American Society for Colposcopy
and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. J Low
Genit Tract Dis. 2012 Jul;16(3):175–204.
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Holmstrom S. A prospective randomized comparison of the endocervical brush and endocervical curette. Obstet Gynecol. 2002 Apr;99(4):S4.
3.
Mogensen ST, Bak M, Dueholm M, Frost L, Knoblauch NO, Praest J, et al. Cytobrush and endocervical curettage in the diagnosis of dysplasia
and malignancy of the uterine cervix. Acta Obstet Gynecol Scand. 1997 Jan;76(1):69–73.
4.
Boardman LA, Meinz H, Steinhoff MM, Heber WW, Blume J. A randomized trial of the sleeved cytobrush and the endocervical curette. Obstet
Gynecol. 2003 Mar;101(3):426–30.
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Weitzman GA, Korhonen MO, Reeves KO, Irwin JF, Carter TS, Kaufman RH. Endocervical brush cytology. An alternative to endocervical
curettage? J Reprod Med. 1988 Aug;33(8):677–83.
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Andersen W, Frierson H, Barber S, Tabbarah S, Taylor P, Underwood P. Sensitivity and specificity of endocervical curettage and the
endocervical brush for the evaluation of the endocervical canal. Am J Obstet Gynecol. 1988 Sep;159(3):702–7.
7.
Klam S, Arseneau J, Mansour N, Franco E, Ferenczy A. Comparison of endocervical curettage and endocervical brushing. Obstet Gynecol.
2000 Jul;96(1):90–4.
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Dunn TS, Stevens-Simon C, Moeller LD, Miekle S. Comparing endocervical curettage and endocervical brush at colposcopy. J Low Genit
Tract Dis. 2000 Apr;4(2):76–8.
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Hoffman MS, Sterghos S, Gordy LW, Gunasekaran S, Cavanagh D. Evaluation of the cervical canal with the endocervical brush. Obstet
Gynecol. 1993 Oct;82(4 Pt 1):573–7.
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Gosewehr JA, Julian TM, O’Connell BJ. Improving the Cytobrush as an aid in the evaluation of the abnormal Papanicolaou test. Obstet
Gynecol. 1991 Sep;78(3 Pt 1):440–3.
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Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W, Paraskevaidis E. Obstetric outcomes after conservative treatment for
intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet Lond Engl. 2006 Feb 11;367(9509):489–98.
12.
Khan MJ, Smith-McCune KK. Treatment of cervical precancers: back to basics. Obstet Gynecol. 2014 Jun;123(6):1339–43.
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Darragh TM, Colgan TJ, Cox JT, Heller DS, Henry MR, Luff RD, et al. The Lower Anogenital Squamous Terminology Standardization Project
for HPV-Associated Lesions: Background and Consensus Recommendations From the College of American Pathologists and the American Society for
Colposcopy and Cervical Pathology. J Low Genit Tract Dis. 2012 Jul;16(3):205–42.
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Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology
and workflow process for providing translational research informatics support. J Biomed Inform. 2009 Apr;42(2):377–81.
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Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al. 2012 updated consensus guidelines for the management of
abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2013 Apr;17(5 Suppl 1):S1–27.
• Thank you!
Are Women With Abnormal Pap
Smears Being Discharged from
Colposcopy Too Soon?
Rachel Kupets MD, MSc,
Anna Kone PHD, Julia Gao, Li Wang
Ontario Cervical Screening Program,
Cancer Care Ontario
Verbal Disclosure
• No Disclosures
Introduction
• Research has found that more than half of women
referred for abnormal cervical cytology are exited from
colposcopy with out undergoing treatment
• Concern that lesions may have been missed in untreated
women who may continue to be at elevated risk of
developing cervical cancer
• Mcredie et al. published that 50% of women with
untreated CIN III progressed into invasive cancer
• Concern whether colposcopy has adequately excluded
high grade cervical dysplasia
Kupets, R et al, J Obstet Gynaecol Can. 2014 Dec;36(12):1079-84.
McCredie MR, et al Lancet Oncol. 2008 May;9(5):425-34. doi: 10.1016/S1470-2045(08)70103-7
Objective
• To determine the subsequent cervical cancer risk
of women discharged from colposcopic care with
out treatment as compared to those who under
go treatment
• To determine if any clinical factors or colposcopic
practices were associated with cervical cancer
risk
Setting and Study Design
• This study is carried out in the province of
Ontario, Canada which has 4.3 million screen
eligible women aged 21-69
• Given the universal health care, all residents
have a unique health care number which allows
for linkage of multiple data bases which reflect
health care utilization and cervical smear results
• This study is a population based retrospective
cohort design carried out with the use of
administrative data
Methods
• Cytobase: Pap smear results;
• RPDB: age, socioeconomic characteristics;
• CHDB: services provided by physicians;
• OCR: cancer registry; and
• PIMS: cancer information
Methods
• Study Cohort: women with a first time cytologic
abnormality between 2007-2010 who were
referred to colposcopy with one year of pap. No
prior history of abnormal pap, colposcopy or
treatment for dysplasia or cancer in 3 years prior
• Colposcopic episode end: no activity for 14
months
• Cohort followed until 2015
• Treatment status was determined with in
colposopic episode and cancer incidence was
determined post episode
Methods
• Logistic Regression assessed impact of
colposcopic care, patient factors and screening
post discharge on subsequent cervical cancer
risk
• Results are stratified by initial cytology diagnosis
Characteristics of Women in the Cohort, by Initial Cytology
% of Women Exiting After an Initial Colposcopy and No
Treatment, by Initial Cytology and Women’s Characteristics
Percentage of Women with Treatment During Episode, by
Characteristics
Percentage of Women with Cancer After Episode, by
Characteristics
What impacts Risk of Cervical Cancer After Exit?
High grade Initial Cytology
What Impacts Risk of Cervical Cancer After Exit?
Low grade Initial Cytology
Conclusions
• This study represents a cohort of 56,703 women who
initiated a colposcopic episode of care between 20072010
• Women referred to colposcopy for a high grade pap
smear and are discharged with out treatment are at
elevated risk of cervical cancer; 1.1% vs. 0.3% for those
who under go treatment
• Mean time to the development of cervical cancer in this
group was 588 days +/- 689 days (1-2609) post exit from
colposcopy
• Women referred for a low grade dysplasia who are
discharged with out treatment are NOT at elevated risk
Conclusions
• Currently due to the fragmented screening program in many
jurisdictions in the US and Canada, there is not an integrated
cervical cancer screening program which allows women to
transition easily between screening, colposcopy, surveillance
and back to screening again
• This study raises the importance of the establishing an
adequate number of evaluations per colposcopic episode and
having strategies of stratifying risk for women in whom a lesion
is not detected
• Proper exit strategies from colposcopy need to be established
for treated and untreated women
• Appropriate recommendations need to be provided by
colposcopists regarding follow up , frequency of screening post
colposcopy to primary care physicians and women
Thank You
To my co-authors
This Study was initiate and supported by Cancer Care Ontario. We gratefully
acknowledge the support of the Ministry of Health and Long-Term Care. The
views expressed in this study are those of Cancer Care Ontario and do not
necessarily reflect those of the Ontario Ministry of Health and Long-Term Care
or the Government of Ontario.
Folate Receptor-Mediated
Staining Solution (FRDTM) For
Detecting CIN2+
Yun Zhao MD
Department of Gynecology
Peking University People’s Hospital
Estimated cervical cancer incidence
worldwide, 2012
effective screening, early diagnosis and treatment for precancer and early cancer is imperative.
Source: Comprehensive Cervical Cancer Control, A guide to essential practice, WHO 2014
What’s FRD?
 Folate Receptor-Mediated Staining Solution
(FRDTM ) is designed for rapid visualization of
the cervical neoplastic epithelia to early detect
abnormal lesions (CIN2+). Test results are
determined immediately (within 60 sec) after
staining of the entire cervical epithelia. FRDTM
is capable of detecting abnormal lesions of
both squamous and column epithelia.
Characteristics of Tumor Cells
 Folate receptors over-expressed on tumor cell
membranes [1,2]
 Reactive oxygen species (ROS) accumulated in
tumor cells [3,4] .
 High demand for iron [5-7] :
Fe2++H2O2→Fe3++OH-+·OH
How to detect cervical lessions?
 Conjugates binds to
folate receptor and
trigger endocytosis.
 Oxidation reaction.
 Reaction product
exits.
Reference
[1] Zhao XB, Lee RJ. Tumor-selective targeted delivery of genes
and antisen seo ligo deoxyribonuc leo tides via the folate
receptor [J].Adv Drug Deliv Rev,2004,56(8):191-193
[2] Reddy JA, Allagadda Vm, Leamon CP. Targeting therapeutic
and imaging agents to folate receptor positive tumors
[J].Current Pham Biotech,2005,6,131-150
[3]Goncalves TL, Erthal F, Corte CL, et al. (2005) Involvement of
oxidative stress in the pre-malignant and malignant states of
cervical cancer in women. Clin Biochem 38: 1071-1075
[4] Beevi SS, Rasheed MH, Geetha A ,et al. (2007) Evidence of
oxidative and nitrosative stress in patients with cervical squamous
cell carcinoma. Clin Chim Acta 375: 119-123
[5] Canto MI, Setrakian S, Willis J, et al, Methylene blue-directed
biopsies improve detection intestinal metaplasia and
dysplasia in Barrett’s esophagus [J].Gastrointest Endosc,
000,5:560
[6]Link EM, Blower PJ,Costa DC, et al, Early detection of melanoma
metastases with radioiodinated methylene blue[J].Eur J Nuclear
Med, 1998,25(9):1322
[7]Kakhlon O,Cabantchik Z . The labile iron pool: characterization,
measurement, and participation in cellular processes. Free Radic
Biol Med,2002,33(8):1037-1046
FRD test procedure
1.Dip to get solution
2.Smear on the cervix
3.Observe color change
FRD Staining Test
Multi-center study in the Beijing
Cervical cancer screening
Cytology
NILM
HR-HPV
≥ASCUS
+
FRD staining
Colposcopy
Histopathology
-
FRD Staining Test
Multi-center study in the Beijing
 Cytology and HPV test: Patients underwent routine cervical
cancer screening.
 FRD cervical staining: Patients who were returning for
evaluation based on an abnormal cervical cytology result
and/or HPV results, underwent FRD staining test before they
refer to colposcopy.
 Colposcopy: Colposcopy was performed on patients who had
a cytology result of ASCUS or greater, and/or had a positive
high-risk HPV result.
 Biopy: directed or random multiple biopsies and endocervical
curettage (ECC)
* The multi-center study was approved by the ethical committee of Peking University People’s Hospital, which played the
leading role in directing this research.
Shaanxi GaoYuan in-vitro diagnostic reagents Co., Ltd only donated FRD staining solution and trained.
The excluded standard :
Pregnant before examination.
Acute inflammation of cervix and/or vaginitis.
Women with total hysterectomy.
Cervical surgeries, including the conization of
cervix, ablative therapy.
Patients who has been diagnosed as CIN2+.
 1,504 women, aged 20 – 76(Mean 40.29± 10.17 )
Age
Case number
20-29
214( 14.23%)
30-39
562( 37.37%)
40-49
409( 27.19%)
50-65
309( 20.55%)
>65
10( 0.66%)
Total
1504
Results
Histologic Diagnosis
NILM
Case Number（%）
503( 33.44%)
CIN1
440( 29.26%)
CIN2
254( 16.89%)
CIN3
257( 17.09%)
SCC
50( 3.32%)
Total
1504
 Sensitivity, Specificity, Positive Prediction Value (PPV), Negative
Prediction Value (NPV) of Cytology ( ≥ASCUS), High-Risk HPV, and
FRD staining for CIN2+ (n =1504)
Characteristic
Coincidence rate,
%(95%CI)
KAPPA, %(95%CI)
Cytology
HPV
FRD
48.87 (46.34-51.40) 45.01（42.50-47.53） 66.62 (64.24-69.01)
8.77 (5.06-12.48)
8.20（5.90-10.49）
34.59 (30.16-39.03)
Sensitivity, %(95%CI)
80.39 (77.11-83.68) 95.54（93.84-97.25） 77.72 (74.27-81.16)
Specificity, %(95%CI)
30.12 (27.19-33.04) 14.95（12.68-17.23） 60.02 (56.89-63.15)
PPV, %(95%CI)
40.63 (37.74-43.52) 40.06（37.43-42.69） 53.63 (50.20-57.06)
NPV, %(95%CI)
72.08 (67.65-76.51) 84.94（79.50-90.38） 81.91 (79.04-84.78)
PLR, (95%CI)
1.15(1.08-1.22)
1.12（1.09-1.16）
1.94(1.78-2.13)
NLR, (95%CI)
0.65(0.54-0.79)
0.30（0.20-0.45）
0.37(0.32-0.44)
 Sensitivity, Specificity, Positive Prediction Value (PPV), Negative Prediction
Value (NPV) of Cytology ( ≥ASCUS), High-Risk HPV, and FRD staining for CIN3+
(n =1504)
Characteristic
Coincidence rate,
%(95%CI)
KAPPA, %(95%CI)
Cytology
HPV
FRD
39.96 (37.48-42.44) 29.72（27.41-32.03） 60.90（58.44-63.37）
6.31 (3.76-8.86)
3.80（2.43-5.18）
25.39（21.75-29.03）
Sensitivity, %(95%CI)
83.71 (79.58-87.84) 95.77（93.51-98.02） 86.64（82.84-90.45）
Specificity, %(95%CI)
28.74 (26.17-31.30) 12.78（10.89-14.67） 54.30（51.48-57.12）
PPV, %(95%CI)
23.15 (20.67-25.63) 21.97（19.75-24.19） 32.72（29.49-35.94）
NPV, %(95%CI)
87.31 (84.02-90.60) 92.17（88.08-96.26） 94.07（92.31-95.83）
PLR, (95%CI)
1.17(1.11-1.25)
1.10（1.06-1.13）
1.90（1.76-2.05）
NLR, (95%CI)
0.57(0.43-0.74)
0.33（0.19-0.58）
0.25（0.18-0.33）
The Results of FRD and Histologic
Diagnosis by Cytologic Negative
Histologic Diagnosis
FRD
NILM
CIN1
-
114( 63.69%)
67( 63.81%)
26( 43.33%) 10( 21.28%)
+
65( 36.31%)
38( 36.19%)
34( 56.67%) 37( 78.72%) 3(100.00%) 177( 44.92%)
Total
179
105
CIN2
60
CIN3
47
SCC
Total
0( 0.00%) 217( 55.08%)
3
394
• FRD staining Association with Different Age
Groups for the Detection of CIN2+
FRD
Characteristic
20-29
30-39
40-49
50-65
Coincidence rate,
%(95%CI)
65.42（59.05-71.79） 62.99（59.00-66.98） 65.77（61.17-70.37） 75.08（70.26-79.90）
KAPPA, %(95%CI)
31.65（19.82-43.49） 27.65（20.18-35.13） 33.70（25.38-42.01） 50.12（40.85-59.39）
Sensitivity, %(95%CI)
75.34（65.45-85.23） 73.42（67.61-79.23） 79.87（73.43-86.30） 84.68（77.98-91.38）
Specificity, %(95%CI)
60.28（52.21-68.36） 56.18（50.90-61.45） 57.69（51.69-63.70） 69.70（63.30-76.10）
PPV, %(95%CI)
49.55（40.25-58.85） 52.24（46.70-57.79） 51.97（45.49-58.44） 61.04（53.34-68.74）
NPV, %(95%CI)
82.52（75.19-89.86） 76.40（71.14-81.66） 83.33（77.89-88.78） 89.03（84.11-93.95）
PLR, (95%CI)
1.90（1.49-2.42）
1.68（1.45-1.94）
1.89（1.60-2.22）
2.79（2.23-3.50）
NLR, (95%CI)
0.41（0.27-0.62）
0.47（0.37-0.60）
0.35（0.25-0.49）
0.22（0.14-0.34）
• Cytology (≥ASCUS) Association with Different
Age Groups for the Detection of CIN2+
Cytology
Characteristic
Coincidence rate,
%(95%CI)
KAPPA, %(95%CI)
20-29
30-39
43.93（37.28-50.57） 48.40（44.27-52.53）
2.35（-7.32-12.02）
40-49
50-65
47.43（42.5952.27）
54.37（48.82-59.92）
6.63（0.45-12.82） 6.69（-0.44-13.82） 19.00（11.15-26.84）
Sensitivity,
%(95%CI)
75.34（65.45-85.23） 79.73（74.44-85.02）
78.52（71.9385.12）
87.39（81.21-93.56）
Specificity,
%(95%CI)
27.66（20.28-35.04） 27.94（23.17-32.71）
29.62（24.0735.17）
35.86（29.18-42.54）
PPV, %(95%CI)
35.03（27.57-42.49） 41.94（37.23-46.65）
39.00（33.4844.52）
43.30（36.81-49.79）
NPV, %(95%CI)
68.42（56.35-80.49） 67.86（60.12-75.59）
70.64（62.0979.19）
83.53（75.64-91.41）
PLR, (95%CI)
1.04（0.88-1.23）
1.11（1.01-1.22）
1.12（0.99-1.25）
1.36（1.20-1.55）
NLR, (95%CI)
0.89（0.55-1.44）
0.73（0.53-0.99）
0.73（0.51-1.04）
0.35（0.21-0.59）
Conclusion 1
Another way for cervical lesion detecting
 FRD has a clinical sensitivity of 86.64%
and a specificity of 54.30% for detection of
lessions(CIN3+)
Conclusion 2
FRD Staining-Rapid and intuitive visual results
1 minute
Conclusion 3
FRD Staining-Full fill entire cervix
During the procedure, the two cotton swab
will cover the entire cervix including the
ecto and endocervix
Visualization of FRD Staining
Acknowledgments
We thank all 13 research centers for providing their study
data, and the center names and experts in charge of each
center were as follows:
 Peking University People's Hospital (Lihui Wei);
 Chinese PLA General Hospital (Yali Li);
 Beijing Anzhen Hospital, Capital Medical University (Bin Li);
 Beijing Chao-Yang Hospital (Zhenyu Zhang);
 Beijing Tian Tan Hospital, Capital Medical University
(Limin Feng);
 Fu Xing Hospital, Capital Medical University (Ailuan Lai)
 Xuanwu Hospital, Capital Medical University (Fengying Wang)
 Beijing Hospital (Qiubo Lv)
 Beijing Obstetrics and Gynecology Hospital, Capital
Medical University (Dan Lu)
 Peking University Third Hospital (Hongyan Guo)
 Beijing Tongren Hospital, Capital Medical University
(Jianjun Zhai)
 Peking Union Medical College Hospital (Yang Xiang)
 Beijing Shijitan Hospital, CMU (Hongxia Li)
Thanks for your interest
and attention !
p16 expression in colposcopy-directed
and random cervical biopsies of CIN 2
and CIN 3
Cynthia Arvizo, MD
April 14, 2016
Cleveland Clinic
Colposcopy training focuses on
sampling visible lesions
POI micro-biopsy protocol
• Designed by Belinson et al to standardize
colposcopy and reduce verification bias in
clinical trials
• First employed in a large population based
study in 1997 - Shanxi Province Cervical
Cancer Screening Study (SPOCCS I)
POI micro-biopsy protocol
1. Divide cervix into 4
quadrants and
evaluate by quadrant
2. Biopsy abnormal
lesions
3. Biopsy all negative
quadrants at the
squamocolumnar
junction
4. Perform ECC
Colposcopy Instruments
POI micro-biopsy instrument
Tischler biopsy forceps
Ongoing debate
• Should we biopsy more than what we see?
(random biopsies in negative quadrants)
• Do positive biopsies of nonvisible lesions even
matter?
Sensitivity of Colposcopy for CIN2+
Sensitivity
Massad et al 2003
56%
Pretorius et al 2004
57.1%
Gage et al 2006
69.9%
One additional random biopsy can detect up to 20%
more CIN 2 or greater*
Massad, et al. Gynecologic Oncology, 89(3), 424–8.
Pretorius et al. Am J Obstet Gynecol. Aug;191(2):430-4., 191(2), 430–434
Gage el al. Obstetrics and Gynecology, 108(2), 264–72.
*Huh et al. Obstetrics and Gynecology, 124(4), 670–8.
Ongoing debate
• Should we biopsy more than what we see?
• Do positive biopsies of nonvisible lesions
even matter?
Random biopsies of CIN 2 and 3 are
thinner than targeted biopsies
Average Thickness (microns)
600
500
400
COLPO IMP NORMAL
300
COLPO IMP HIGH
200
100
0
NORMAL
CIN 1
CIN 2
Yang B, el al. Gynecol Oncol. 2008;110(1):32-36.
CIN 3
p16 overexpression is associated with
progression to CIN3
http://www.nature.com/bjc/journal/v112/n6/fig_tab/bjc201559f1.html
Virchows Arch. 2004;445(6):616-620.
Hypothesis
p16 expression of colposcopy-directed and
random biopsies of CIN 2 and CIN 3 is similar
Study specimens
• Tissue blocks from patients with CIN 2 or
greater were identified from SHENCCAST II
database
– 10,000 patient population based clinical trial
conducted in China that evaluated self sampling
and three HPV testing technologies
Study design
• Selected biopsies were re-cut and stained for
p16
• Diffuse overexpression of p16 was considered
“p16 positive”
• Pathologist blinded to initial colposcopic
interpretation and whether biopsies were
directed or random
Results of biopsies showing CIN 2
89 patients with CIN2
and complete data
21 patients without
CIN2 on recut
10 patients with
new CIN3 on recut
55 patients diagnosed
with CIN2 on recut
3 patients without
CIN2 on IHC slides
220 individual
biopsies
94 Normal
50 CIN1
76 CIN2
p16 positivity of colposcopy-directed and
random biopsies of CIN 2 is similar
p16 positive (%) p16 negative (%)
Colpo-directed 46 (86.8)
Random
19 (82.6)
Total
65
7 (13.2)
4 (17.4)
11
Total
53
23
76
Chi square p = 0.73
Results of biopsies showing CIN 3
138 patients with
complete data
11 patients CIN3 on
ECC only
2 patients cancer only
(no CIN3)
125 patients
included
500 individual biopsies
recut and reviewed
155 Normal
79 CIN1
21 CIN2
232 CIN3
9 Cancer
2 AIS
2 insufficient tissue
p16 positivity of colposcopy-directed and
random biopsies of CIN 3 is similar
Colpo-directed
Random
p16 positive (%)
168 (97.7)
55 (91.7)
p16 negative (%) Total
4 (2.3)
172
5 (8.3)
60
Total
223
9
232
Fisher’s exact p=0.052
Random lesions of CIN 3 involve less quadrants
No. quadrants Colpo-directed
1
24
2
3
4
22
16
6
Random
20
Both
0
1
1
0
10
8
8
Conclusions
• Should we biopsy more than what we see?
– Additional biopsies increase detection of CIN 2 or
greater
• Do positive biopsies of nonvisible lesions even
matter?
– Colposcopy-directed and random biopsies
similarly overexpress p16, suggesting they have
similar biology and both should be part of
colposcopy protocols
Acknowledgments
Qing Chen, MD; Chun Wang, MD; Bin Yang, MD,
PhD; Robert G. Pretorius, MD; Ruifang Wu, MD,
Guixiang Wang, MD; Jerome L. Belinson, MD
Office Hysteroscopy In The
Diagnosis Of Endocervical
Intra-epithelial Neoplasia
Ahmad Sameer Sanad
Minia Maternity University Hospital
Egypt
 Cervical glandular intraepithelial neoplasia (CGIN) is
considered as a precursor for adenocarcinoma in-situ
(AIS)
and
subsequently
invasive
cervical
adenocarcinoma.
 The diagnosis of CGIN faces many challenges at both
clinical and pathological level. The lesion may present
high in the cervical canal so it may not be seen during
colposcopic examination
Aim of the Study
 The aim of this study is to evaluate the role of
office hysteroscopy in diagnosis of CGIN in
patients with CIN
Patients & Methods
 This study was an observational cross-sectional study
involving 124 patients with abnormal Pap smear or
positive VIA in the period between May 2013 and Nov
2014.
 The study was approved by scientific ethical committee
of the Department of Ob & Gyn, Minia University in Jan
2013. And from the Institutional Review Board of the
Faculty of Medicine; Minia University in Feb 2013.
Patients & Methods
 The inclusion criteria of the study were
 Age > 18 years,
 Negative pregnancy test and
 Positive PAP smear or positive VIA
Patients & Methods
 The inclusion criteria of the study were
 Age > 18 years,
 Negative pregnancy test and
 Positive PAP smear or positive VIA
Patients & Methods
 Exclusion Criteria
 Current cervicitis or PID.
 Current uterine bleeding.
 Evidence of invasive cervical lesions with naked eye or
colposcopic examination
The study procedure:
 The study was conducted through 3 steps
 Colposcopy and colposcopy-directed cervical
biopsies using (1DL Leisegang Colposcopy with Optic-2
Med Inc Germany). Punch biopsies were taken from any
suspicious region.
The study procedure:
 Cervical hysteroscopy:
 3-mm continuous-flow office hysteroscopy with an
operative channel.
 The light intensity used was as low as possible.
 The outer sheath was connected to infusion pump that
allowed distension of the uterus with fluid medium 0.9%
saline.
The study procedure:
 Vaginoscopic approach.
 Distension of the endocervix was obtained using an
irrigation-suction electronic device (Hystromat; Karl Storz).
 When the external uterine orifice was visualized, the
irrigation of saline was stopped and a syringe with 5 mL of
5% acetic acid was connected to the inflow channel of the
hysteroscopy.
The study procedure:
 A panoramic view of the ectocervix, the transformation zone and the endocervix
was noticed for the changes induced by the application of the acetic acid.
 The anterior and posterior walls of the endocervix were carefully examined
 The lateral walls were examined while gently rotating the tip of the scope within
the endocervix, following the principles of an open oblique vision.
 Longitudinal crests of the endocervical mucosa were seen protruding into the
cavity as the plicae palmatae.
 Secondary oblique branching of the mucosa appeared as a tree and constituted
the arbor vitae
The study procedure:
 Once an epithelial lesion was suspected, magnify the image
on the monitor.
 During the examination a biopsy was performed using 5Frgrasping forceps with teeth.
 The
endocervical
mucosa
was
evaluated
for
both
vascularization, and morphology.
 The
procedure
was
completed
examination of the uterine cavity
with
hysteroscopic
Grading of results
1. Positive if there was: atypical TZ, acetowhite epithelium
appeared as sharp, distinct, well defined and dense,
mosaicism, punctuation, iodine positivity and atypical
vessels,
2. Presence of benign lesion as mucous polyp, adenomatous
polyp, masses, immature metaplasia.
3. Negative if there was normal cervix that remained pale and
pink in color.
4. Doubt results and the tests were repeated one week later
Results
 Distribution of the patients according to
results of referral cytology
Referral
Cytology
Number of patients
(n=124)
Percentage
LSIL
94
75.8%
HSIL
22
17.7%
AGC
5
4%
SIL+AGC
3
2.5%
Results
 Distribution of the patients according to results of
colposcopy and histopathology
Colposcopy & histopathology
Number of patients
Percentage
No lesion
74
59%
Benign lesion (n=25)
- Cervicitis
- Metaplasia
6
19
4.8%
15.3%
Pre-malignant lesion (n=25)
- CIN I
- CIN II
- CIN III
Total
15
7
5
124
12.1%
5.6%
4%
Results
 Distribution of the patients according to
hysteroscopic findings of the endocervix
Hysteroscopic findings of the
endocervix
No lesion
Benign lesions:
- Mucinous polyp
- Adenomatous polyp
- Metaplasia
Atypical lesions: (n=9)
- Acetowhite epithelium
- Punctation
- Mosaicism
Total
No. of patients
Percentage
97
78.2%
8
7
3
6.5%
5.7%
2.4%
7.3%
4
3
2
124
Results
 Results of hysteroscopy in comparison with the
results of biopsy
Hysteroscopic findings
of the endocervix
Biopsy
Negative biopsy
Positive biopsy
No Lesions (n=97)
97
0
Benign lesion (n=18)
17
1
Atypical lesion (n=9)
3
6
117
7
Total (n=124)
Results
 Diagnostic performance of hysteroscopy in
detecting endocervical lesions
%
Sensitivity (SE)
95% confidence
interval
86
0.773 - 0.996
Specificity (SP)
98
0.963 - 0.994
Positive predictive value (PPV)
67
0.576 - 0.848
99
0.984 - 0.999
97.1
0.959 - 0.987
43
39.63 – 46.35
0.14
0.128 – 0.167
Negative predictive value (NPV)
Diagnostic accuracy (DA)
Positive likelihood ratio (LR+)
Negative likelihood ratio (LR-)
In conclusion
 Hysteroscopy appears to be a safe and effective
diagnostic tool that can help to increase the detection
of CGIN. We recommend office hysteroscopy to be
done in all cases with abnormal cervical cytology or
positive VIA referred for colposcopic examination