| INTRODUCTION |
Last century has seen the control of several
diseases. However, some diseases have eluded us even in the
new millennium, cancer being one of them.
In the worldwide
scenario, cancer of the uterine cervix is the second most
common cancer in women (breast cancer
topping the list), accounting for 68.5% of all gynaecological
malignancies. The disturbing fact is 80% of all the cases
occur in developing countries, India accounting for 18%
of them.1 As more than 75% cases are diagnosed in the late
stages, no curative treatment is possible leading to high
morbidity and mortality.
High risk factors like teenage
pregnancy, low socio-economic status etc. are responsible
for the high incidence of invasive
carcinoma of the cervix (20-45/1,00,000 women).1 For all
these reasons it is extremely essential to diagnose these
cases at the earlier stages.
The aim of the present study
is an effort in this direction with an attempt to assess
the predictive value of colposcopy
in cervical cancer detection programmes.
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| Material and Methods |
Study comprises colpohistopathological and cytohistopathological
analysis of 70 cases from 254 colposcopy examinations performed
at the cytology clinic at JJ Hospital in the department of
obstetrics and gynaecology of Grant Medical College over
a period of 5 years.
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| Colposcopy indications |
1. Suspicious symptoms like persistent
leucorrhoea, postcoital or intermenstrual bleeding and postmenopausal
bleeding.
2. Suspicious cervix such as hypertrophied and unhealthy cervix
and cervix with erosion which bleeds on touch
3. Abnormal cytology report
Colposcopy was carried out in the oestrogenic phase of the
menstrual cycle except in postmenopausal patients after fulfilling
the prerequisites. Reagents used for the colposcopy were 3%
acetic acid and Schiller’s iodine. After colposcopy examination,
the findings were recorded using Hammond’s graph. |
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Colposcopy findings are classified
as
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1. Normal
2. Abnormal : a) Atypical transformation zone
b) Suspected invasive disease
3. Indecisive findings : Squamo-columnar junction not visible.
4. Miscellaneous : Inflammatory changes, atrophic changes etc.
Grading2 was done as per the typical colposcopic appearance shown in Table 1. |
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| Table 1 : Grading (Colposcopy findings) |
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Grade
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Finding on colposcopy |
Suspicion of |
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| I |
Flat white epithelium with or without
a regular pattern of fine caliber vessels |
CIN-I |
| II |
Flat, White epithelium with or
without an irregular pattern of
coarse caliber vessels |
CIN-II |
| III |
Very white epithelium with an
irregular pattern of coarse caliber,
coiled or bizarre branching vessels,
usually wide intercapillary distance
and irregular surface contour |
CIN-III |
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Evidence of abnormal blood vessels
and/or irregular surface contour |
Invasion |
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Patients with evidence of infection from the miscellaneous
and abnormal group were advised repeat examination after 2
to 4 weeks of antimicrobial therapy. Patients with indecisive
findings with atrophic changes were advised repeat colposcopy
examination after low dose oestrogen therapy.
Colposcopy directed biopsy was taken from the most suspicious
acetowhite areas and/or iodine negative epithelium and sent
for histopathological examination.
Colpohistopathological correlation2 was done as shown in Table
2. |
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| Table 2 : Colposcopic grading correlated
with histopathology |
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Grade
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Correlation |
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| I |
Normal to CIN I |
| II |
CIN II |
| III |
CIN III, Early invasion to
frank malignancy |
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Results and Analysis
The study group had maximum patients 27 (38.57%) in the age
group of 31-40 years followed by 17 (24.29%) in the age group
of 41-50 years. Most of the patients were grand multiparas
with parity four and above. |
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Indications for colposcopy (Table 3)
The commonest indication for colposcopy was suspicious symptoms 23 (45.71%) followed
by suspicious cervix. |
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| Table 3 : Indications for colposcopy |
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Indications
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No. of patients |
% |
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Suspicious cervix
Suspicious symptoms
a) White discharge
b) Postmenstrual bleeding
c) Postcoital bleeding
Abnormal cytology findings
a) CIN I
b) CIN II
c) CIN III
d) Malignancy |
26
32
30
1
1
12
6
4
1
1 |
37.14
45.71
42.85
1.43
1.43
17.14
8.57
5.71
1.43
1.43 |
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Cytology findings (Table 4)
Cytology showed 6, 4, and 1 case of CIN I, CIN II and CIN III
respectively while 1 case of malignancy was reported by Pap
smear. Cytology showed majority of the patients [54 (77.14%)]
having inflammatory smear. |
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| Table 4 : Cytology findings |
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Cytology finding
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No. |
% |
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Normal
Inflammatory
CIN I
CIN II
CIN III
Malignancy |
4
54
6
4
1
1 |
5.71
77.14
8.57
5.71
1.43
1.43 |
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Histopathology findings (Table 5)
Histopathology showed 10 cases of CIN vs 11 cases of CIN by
cytology. Histopathology also reported 7 cases of metaplasia
and 45 cases of inflammatory changes (chronic cervicitis).
Histopathology confirmed 4 cases of invasive carcinoma. |
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| Table 5 : Histopathology findings |
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Histopathology
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No. |
% |
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Normal
Chronic cervicitis
Metaplasia
CIN I
CIN II
CIN III
Invasive carcinoma |
4
45
7
7
3
—
4 |
5.71
64.29
10
10
4.29
—
5.71 |
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Meta and M - Metaplasia, N - Normal, Inflamm - Inflammatory,
Miscell - Miscellaneous;
*Overall correlation obtained is 81.3%; *7.1% cases were reported
as higher grade than actual disease (False positive); *7.6%
cases were reported as lower grade than actual disease (False
negative) |
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Inflamm - Inflammatory, Malig - Malignancy;
*Overall correlation is 58.8%; *8.5% cases were reported as
higher cytology than the actual disease (False positive);
*24.2% cases were reported as lower cytology than the actual
disease (False negative) |
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| Discussion |
The population screened in the study has included maximum
patients (> 60%) in the age group of 31-50 years, majority
of whom are grand multiparas with parity four and above. In
this study colpohistopathological correlation and thus the
predictive value of colposcopy is found to be 81.3%. It is
comparable to that of Matingly et al (1973)3 - 85%, Singh et
al (1989)4 - 86.2% and Kusittagi et al (1995) 5 - 78%. However,
Usha Agrawal et al (1989)6 and Wills Shiela et al (1991)7 have
reported higher correlation than the present study, 89.69%
and 92% respectively. Sensitivity of colposcopy prediction
increases with the experience.
Cytohistopathological correlation obtained in this study is
58.8%, considerably lower than the colpohistological correlation
of 81.3%. The error in collection technique, fixation and also
presence of infection and tissue necrosis interfere in correct
cytology reading. In the present study, cytology has under-reported
some of the higher grade lesions (high rate of false negatives)
as compared to the colposcopy. No significant difference has
been observed in false positive reports for colposcopy (7.1%)
and cytology (8.5%) in this study. However, false negative
reports of cytology (24.2%) are much more as compared to colposcopy
(7.6%). Same observation has been reported by Singh et al (2000)
in their study which mentions comparable false positive rates
for colposcopy and cytology.8 It also confirms a high sensitivity
of colposcopically directed biopsy (95%).8
Ambiye et al (1989) on screening 800 patients found that, cytology
and colposcopy when combined can detect early cases missed
by any single method. They also observed that the use of colposcope
enabled them to perform target cytology to reduce false negative
smears.9 It is a well accepted fact that, colposcopically directed
biopsy is the best biopsy sample in terms of accuracy than
the random four quadrant biopsy. Usha Saraiya et al (1986)
stated that, cytology and colposcopy are complementary to each
other and should be used simultaneously as both methods mutually
and continually control each other.10 |
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| Conclusion |
| In conclusion, the sensitivity of colposcopy
is more than cytology, specially for grade III lesions. Hence,
colposcopy should be encouraged along with the routine cytology
screening. Abnormal cytology as well as inflammatory smears
need further evaluation by colposcopy. Attention to follow-up
is mandatory to overcome the limitations of these screening
methods. |
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| References |
| 1. |
Miniello G, Saraiya UB. Colour
Atlas of Cytology and Colposcopy, First Edition, CBC
Publishers, New Delhi, India, XV, 205, 1999. |
| 2. |
Ananth R. Technique of Colposcopy, Ascon
Medical Instruments Pvt. Ltd., Madras, India. 1999 :
1-28 |
| 3. |
Matingly RF, Stafl A. Colposcopic diagnosis
of cervical neoplasia. Obstet Gynecol 1973; 41 : 168. |
| 4. |
Singh V, Das DK, Murthy NS, et al. Colposcopic
observations in precancerous and early cancerous lesions
of uterine cervix. The Journal of Obstetrics and Gynaecology
of India 1989; 39 : 392. |
| 5. |
Kusittagi P, Rao R, Downstaging of carcinoma
of uterine cervix in South Indian women on Vestcost.
The Journal of Obstetrics and Gynaecology of India 1995;
45 (5) : 666-70. |
| 6. |
Agrawal U, Kaur M, Kharakwal S, et al.
Role of cytology and colposcopically directed biopsies
in various lesions of cervix. The Journal of Obstetrics
and Gynaecology of India 1989; 39 : 548. |
| 7. |
Wills S, Azhagammai, Kanthamani PN, et
al. Histo-cyto-colposcopic evaluation of 39 cases of
postmenopausal bleeding. The Journal of Obstetrics and
Gynaecology of India 1991; 41 (1) : 99-102. |
| 8. |
Singh SL, Dastur NA, Nanavati MS. A comparison
of colposcopy and papanicolaou smear: Sensitivity, specificity
and predictive value. The Bombay Hospital |
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