JAMA. 2002 May 8;287(18):2382-90.
Cost-effectiveness of alternative triage strategies for atypical squamous cells of undetermined significance.
Kim JJ, Wright TC, Goldie SJ. Department of Health Policy and Management, Harvard Center for Risk Analysis, 718 Huntington Ave, Second Floor, Boston, MA 02115, USA.
CONTEXT: Every year approximately 2 million US women are diagnosed as having a cervical cytological result of atypical squamous cells of undetermined significance (ASC-US). OBJECTIVE: To determine the most efficient and cost-effective management strategy for women in the United States diagnosed as having ASC-US. DESIGN AND SETTING: Cost-effectiveness analysis of data from clinical trials, prospective studies, and other published literature. A computer-based model was used to compare 4 management strategies for a cytological result of ASC-US: immediate colposcopy; human papillomavirus (HPV) triage, which includes colposcopy if high-risk HPV types are detected; repeat cytology, which includes follow-up cytology at 6 and 12 months and referral for colposcopy if a repeat abnormal result occurs; and reclassifying ASC-US as normal in which a cytological result of ASC-US is ignored. Reflex HPV DNA testing uses either residual liquid-based cytological specimens or samples co-collected at the time of the initial screening for conventional cytology. Another method, referred to as the 2-visit HPV DNA triage, requires a woman with an ASC-US result to return within 1 month to provide another speciman sample. MAIN OUTCOME MEASURES: Years of life saved (YLS), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. RESULTS: The least costly strategy for biennial screening was to reclassify ASC-US as normal, resulting in a reduction in total cancer incidence of 75% for conventional cytology and 84% for liquid-based cytology compared with no screening. The next least costly strategy was HPV DNA testing resulting in a reduction in total cancer incidence of 86% for conventional cytology and 90% for liquid-based cytology, followed by immediate colposcopy with a reduction of 87% and 91%, respectively. Compared with reflex HPV DNA testing, a strategy of repeat cervical cytology or delayed HPV testing costs more but is less effective. When all strategies were compared simultaneously, varying frequency and type of cytological test, biennial (vs every 3 years) liquid-based cytology with reflex HPV testing had a cost of 200 per YLS. In a similar comparison, liquid-based cytology with reflex HPV testing conducted every 3 years (vs every 5 years) had a cost of 600 per YLS and was more effective and less costly than a strategy of conventional cytology incorporating repeat cytology or immediate colposcopy conducted biennially. CONCLUSION: Reflex HPV DNA testing provides the same or greater life expectancy benefits and is more cost-effective than other management strategies for women diagnosed as having ASC-US.
Am J Clin Pathol. 2002 May;117(5):738-44.
Immunohistochemical localization of survivin in benign cervical mucosa, cervical dysplasia, and invasive squamous cell carcinoma.
Frost M, Jarboe EA, Orlicky D, Gianani R, Thompson LC, Enomoto T, Shroyer KR. Department of Pathology, University of Colorado Health Sciences Center, Denver 80262, USA.
Survivin is an inhibitor of apoptosis protein (IAP) that is expressed in fetal development and in cancer Survivin expression in premalignant lesions remains undefined. We obtained 73 samples of cervical squamous tissue, including 31 normal, 17 low- and 15 high-grade squamous intraepithelial lesions (LSILs, HSILs), and 10 squamous cell carcinomas (SCCs)from cone biopsy and hysterectomy specimens, and stained for survivin using an immunoperoxidase method. Nuclear staining was detected in normal mucosa, LSILs, and HSILs; staining intensity was greatest in cases with morphologic evidence of human papillomavirus (HPV) infection. In situ hybridization of serial sections demonstrated colocalization of HPV DNA and survivin. Cytoplasmic staining was observed in immature squamous metaplasia and in SCCs. Survivin expression in immature metaplastic squamous mucosa may reflect a rolefor survivin in normal squamous differentiation. However, the histologic correlation between nuclear staining and HPV infection suggests involvement of survivin in HPV-mediated disruption of normal cellular maturation.
West Indian Med J. 2002 Mar;51(1):37-9.
Analysis of cervico-vaginal (Papanicolaou) smears, in girls 18 years and under.
Prussia PR, Gay GH, Bruce A. School of Clinical Medicine and Research, University of the West Indies, Queen Elizabeth Hospital, Cave Hill, Barbados. prussia@cariaccess.com
This study was conducted retrospectively at the Queen Elizabeth Hospital and a private laboratory in Barbados to determine the types of epithelial abnormalities in cervico-vaginal Papanicolaou (Pap)-stained smears, and their clinical implications in Barbadian girls, 18 years and under, during the five-year period January 1995 to December 1999. Two hundred and sixty-five Pap smears from 236 patients were examined and the gynaecological history, initial and repeat Pap smear diagnoses, and histology reports of these patients were analyzed. Of the 236 first-visit smears, 94 (39.8%) were abnormal with 36 (15.3%) displaying cytologic features of squamous intra-epithelial lesions (SIL), (33 low grade and 3 high grade). A diagnosis of atypical squamous cells of undetermined significance (ASCUS) was reported in the remaining 58 (24.5%) abnormal smears, of which 35 (60.3%) were suspected to be related to human papillomavirus (HPV) infection. Twenty-two (23.4%) of these 94 patients, who had abnormal smears of either ASCUS or low grade squamous intra-epithelial lesions (LSIL) were re-evaluated within six to twelve months of the initial abnormal Pap smear diagnosis. Eight of these 22 patients (36.4%) had histological diagnosis of LSIL inclusive of cervical intra-epithelial neoplasia grade 1 (CIN 1) and condylomata. High-risk HPV DNA types were detected in two of these eight patients (25%). The study confirms that sexually active teenage girls are at risk of developing SIL and high-risk HPV infection. Screening of sexually active teenaged girls by Pap smears followed by other appropriate investigative procedures is recommended.
Minerva Ginecol. 2002 Jun;54(3):263-9.
Cervical cytologic reports of ASCUS and LSIL. Cyto-histological correlation and implication for management
HPV Virus Infections - Article in Italian
Fallani MG, Penna C, Fambrini M, Marchionni M. Centro di Fisiopatologia del Basso Tratto Genitale e Laser Terapia, Dipartimento di Ginecologia, Perinatologia e Riproduzione Umana, Universita degli Studi, Firenze, Italy. maxfambrini@libero.it
BACKGROUND: The purpose of this retrospective study is to evaluate the appropriate management of ASCUS and LSIL pap smears by correlating the histological findings obtained by punch biopsy or excised specimens. METHODS: The study group included 584 women with abnormal pap smear: 358 with ASCUS and 226 with LSIL cytological abnormalities. All patients underwent colposcopy and, if necessary, directed-punch biopsy. In case of biopsy-proven dysplasia a destructive or excisional treatment was performed, as indicated. RESULTS: The prevalence of HPV-CIN histological lesions in ASCUS patients was 36.3% and in LSIL patients was 67.7%. High grade CIN was observed in 15.7 and 20.8% respectively. In one ASCUS patients an invasive lesion was diagnosed on punch biopsy and two LSIL patients showed stromal invasion on the final histopathologic report on excised specimens. CONCLUSIONS: Patients with ASCUS or LSIL pap smear exhibit a wide spectrum of histological findings ranging from no pathologic abnormality to frequent high grade CIN and invasive carcinoma in rare cases. Because of the histological assessment by directed-punch biopsy and its therapeutical indications, colposcopic examination is recommended for all women with a cytologic diagnosis of ASCUS and LSIL.
Ginekol Pol. 2002 Apr;73(4):320-4.
Pregnancy and delivery course with pregnant women with abnormal cervical cytology
HPV Virus Infections - Article in Polish
Gajewska M, Jabiry-Zieniewicz Z. I Katedry I Kliniki Poloznictwa i Ginekologii AM w Warszawie.
DESIGN: The aim of this study was the analyze of pregnant women procedure with abnormal cervical cytology, the estimate of pregnancy and delivery course. MATERIALS AND METHODS: The study group consisted of two pregnant women with abnormal cervical cytology, treated in I Clinic Medical Academy in Warsaw in 1996-1999. RESULTS: With the first women in 7 week of pregnancy in mikroscopical examination carcinoma praeinvasivum was found. After histological control-study in 36 week of pregnancy, the caesarean section as result of obstetrical indications was conducted. In the puerperium the therapeutic-diagnostical conisation of colli uteri was done. With the second patients in the first trimester in microscopical examinations cervical dysplasia was found. In 39 week of pregnancy the caesarean section as result obstetrical indications was conducted. In puerperium control cytology was done. CONCLUSIONS: No impact of pregnancy for cervical dysplasia or cervical praeinvasivum carcinoma was diagnosed, but in two patients infection of HPV occurred.
Publication Types: - Case Reports
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