Download PDF
CC BY-NC-ND 4.0 · Rev Bras Ginecol Obstet 2017; 39(03): 123-127
DOI: 10.1055/s-0037-1599071
Original Article
Thieme-Revinter Publicações Ltda Rio de Janeiro, Brazil

Underdiagnosis of cervical intraepithelial neoplasia (CIN) 2 or Worse Lesion in Women with a Previous Colposcopy-Guided Biopsy Showing CIN 1

Subdiagnóstico de neoplasia intraepitelial cervical (NIC) 2 ou lesão mais grave em mulheres com biópsia dirigida por colposcopia prévia mostrando NIC 1
Carlos André Scheler de Souza
1   Department of Obstetrics and Gynecology, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
,
Michelle Garcia Discacciati
2   Laboratory of Cytopathology, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
,
Maria Gabriela d'Otavianno
1   Department of Obstetrics and Gynecology, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
,
Silvia Maria Bergo
3   Policlínica II, Campinas, São Paulo, Brazil
,
Markus Traue
3   Policlínica II, Campinas, São Paulo, Brazil
,
Liliana Aparecida Lucci de Angelo Andrade
4   Department of Pathology, Faculdade de Ciências Médicas, UNICAMP, Campinas, São Paulo, Brazil
,
Luiz Carlos Zeferino
1   Department of Obstetrics and Gynecology, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, Brazil
› Author Affiliations
Further Information

Publication History

15 September 2016

19 December 2016

Publication Date:
06 March 2017 (online)

   Permissions and Reprints

Abstract

Objective Expectant follow-up for biopsy-proven cervical intraepithelial neoplasia (CIN) 1 is the current recommendation for the management of this lesion. Nevertheless, the performance of the biopsy guided by colposcopy might not be optimal. Therefore, this study aimed to calculate the rate of underdiagnoses of more severe lesions in women with CIN 1 diagnosis and to evaluate whether age, lesion extent and biopsy site are factors associated with diagnostic failure.

Methods Eighty women with a diagnosis of CIN 1 obtained by colposcopy-guided biopsy were selected for this study. These women were herein submitted to large loop excision of the transformation zone (LLETZ). The prevalence of lesions more severe than CIN 1 was calculated, and the histological diagnoses of the LLETZ specimens were grouped into two categories: “CIN 1 or less” and “CIN 2 or worse.”

Results The prevalence of lesions diagnosed as CIN 2 or worse in the LLETZ specimens was of 19% (15/80). Three women revealed CIN 3, and 1 woman revealed a sclerosing adenocarcinoma stage I-a, a rare type of malignant neoplasia of low proliferation, which was not detected by either colposcopy or previous biopsy. The underdiagnosis of CIN 2 was not associated with the women's age, lesion extension and biopsy site.

Conclusions The standard methods used for the diagnosis of CIN 1 may underestimate the severity of the true lesion and, therefore, women undergoing expectant management must have an adequate follow-up.

Resumo

Objetivo O seguimento de mulheres com neoplasia intraepitelial cervical (NIC) 1 comprovada por biópsia é atualmente a recomendação de conduta para esta lesão. Entretanto, o desempenho da biópsia guiada por colposcopia pode falhar. Assim, este estudo teve como objetivo estimar a taxa de subdiagnóstico de lesões mais graves em mulheres com diagnóstico de NIC 1 e avaliar se a idade, a extensão da lesão e o local da biópsia são fatores associados à falha do diagnóstico.

Métodos Foram selecionadas 80 mulheres com diagnóstico de NIC 1 obtido por biópsia dirigida por colposcopia. Estas mulheres foram submetidas a excisão da zona de transformação por alça diatérmica (EZTAD). A prevalência de lesões mais graves do que NIC 1 foi calculada, e os diagnósticos histológicos feitos nas amostras obtidas por EZTAD foram agrupados em duas categorias: “NIC 1 ou menos grave” e “NIC 2 ou mais grave”.

Resultados A prevalência de lesões diagnosticadas como NIC 2 ou mais grave nas amostras de EZTAD foi de 19% (15/80). Três mulheres apresentaram NIC 3, e uma mulher revelou adenocarcinoma esclerosante estágio I-a, um tipo raro de neoplasia maligna de baixa proliferação, que não foi detectado por qualquer exame de colposcopia ou biópsia anterior. O subdiagnóstico de NIC 2 não foi associado à idade, à extensão da lesão ou ao local da biópsia.

Conclusão Os métodos de referência utilizados para o diagnóstico da NIC 1 podem subestimar a gravidade da lesão verdadeira e, portanto, as mulheres submetidas a conduta expectante devem ter um seguimento adequado.

Keywords

colposcopy - cervical intraepithelial neoplasia - colposcopic surgical procedures - uterine cervical neoplasms - biopsy

Palavras chaves

colposcopia - neoplasia intraepitelial cervical - procedimentos cirúrgicos colposcópicos - neoplasias do colo do útero - biópsia
 

  • References

  • 1 Vale DB, Westin MC, Zeferino LC. High-grade squamous intraepithelial lesion in women aged <30 years has a prevalence pattern resembling low-grade squamous intraepithelial lesion. Cancer Cytopathol 2013; 121 (10) 576-581
    CrossrefPubMedGoogle Scholar
  • 2 Zuna RE, Wang SS, Rosenthal DL, Jeronimo J, Schiffman M, Solomon D. ; ALTS Group. Determinants of human papillomavirus-negative, low-grade squamous intraepithelial lesions in the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesions triage study (ALTS). Cancer 2005; 105 (05) 253-262
    CrossrefPubMedGoogle Scholar
  • 3 Elit L, Levine MN, Julian JA. , et al. Expectant management versus immediate treatment for low-grade cervical intraepithelial neoplasia : a randomized trial in Canada and Brazil. Cancer 2011; 117 (07) 1438-1445
    CrossrefPubMedGoogle Scholar
  • 4 Saslow D, Solomon D, Lawson HW. , et al; American Cancer Society; American Society for Colposcopy and Cervical Pathology; American Society for Clinical Pathology. 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. Am J Clin Pathol 2012; 137 (04) 516-542
    CrossrefPubMedGoogle Scholar
  • 5 Ostör AG. Natural history of cervical intraepithelial neoplasia: a critical review. Int J Gynecol Pathol 1993; 12 (02) 186-192
    CrossrefPubMedGoogle Scholar
  • 6 Wright Jr TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. ; 2006 American Society for Colposcopy and Cervical Pathology-sponsored Consensus Conference. 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol 2007; 197 (04) 340-345
    CrossrefPubMedGoogle Scholar
  • 7 Wright Jr TC, Cox JT, Massad LS, Carlson J, Twiggs LB, Wilkinson EJ. ; American Society for Colposcopy and Cervical Pathology. 2001 consensus guidelines for the management of women with cervical intraepithelial neoplasia. Am J Obstet Gynecol 2003; 189 (01) 295-304
    CrossrefPubMedGoogle Scholar
  • 8 Saslow D, Runowicz CD, Solomon D. , et al; American Cancer Society. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002; 52 (06) 342-362
    CrossrefPubMedGoogle Scholar
  • 9 Austoker J, Bankhead C, Davey C. . Cervical screening results explained: a guide for primary care. London: National Health System (NHS); 2003
  • 10 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 2006; 367 (9509): 489-498
    CrossrefPubMedGoogle Scholar
  • 11 Arbyn M, Kyrgiou M, Simoens C. , et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ 2008; 337: a1284
    CrossrefPubMedGoogle Scholar
  • 12 Stoler MH, Schiffman M. ; Atypical Squamous Cells of Undetermined Significance-Low-grade Squamous Intraepithelial Lesion Triage Study (ALTS) Group. Interobserver reproducibility of cervical cytologic and histologic interpretations: realistic estimates from the ASCUS-LSIL Triage Study. JAMA 2001; 285 (11) 1500-1505
    CrossrefPubMedGoogle Scholar
  • 13 Mustafa RA, Santesso N, Khatib R. , et al. Systematic reviews and meta-analyses of the accuracy of HPV tests, visual inspection with acetic acid, cytology, and colposcopy. Int J Gynaecol Obstet 2016; 132 (03) 259-265
    CrossrefPubMedGoogle Scholar
  • 14 Gage JC, Schiffman M, Hunt WC. , et al; New Mexico HPV Pap Registry Steering Committee. Cervical histopathology variability among laboratories: a population-based statewide investigation. Am J Clin Pathol 2013; 139 (03) 330-335
    CrossrefPubMedGoogle Scholar
  • 15 Cox JT, Schiffman M, Solomon D. ; ASCUS-LSIL Triage Study (ALTS) Group. Prospective follow-up suggests similar risk of subsequent cervical intraepithelial neoplasia grade 2 or 3 among women with cervical intraepithelial neoplasia grade 1 or negative colposcopy and directed biopsy. Am J Obstet Gynecol 2003; 188 (06) 1406-1412
    CrossrefPubMedGoogle Scholar
  • 16 Boonlikit S, Asavapiriyanont S, Junghuttakarnsatit P, Tuipae S, Supakarapongkul W. Correlation between colposcopically directed biopsy and large loop excision of the transformation zone and influence of age on the outcome. J Med Assoc Thai 2006; 89 (03) 299-305
    PubMedGoogle Scholar
  • 17 Sideri M, Garutti P, Costa S. , et al. Accuracy of colposcopically directed biopsy: results from an online quality assurance programme for colposcopy in a population-based cervical screening setting in Italy. BioMed Res Int 2015; 2015: 614035
    CrossrefPubMedGoogle Scholar
  • 18 Pretorius RG, Zhang WH, Belinson JL. , et al. Colposcopically directed biopsy, random cervical biopsy, and endocervical curettage in the diagnosis of cervical intraepithelial neoplasia II or worse. Am J Obstet Gynecol 2004; 191 (02) 430-434
    CrossrefPubMedGoogle Scholar
  • 19 Moss EL, Hadden P, Douce G, Jones PW, Arbyn M, Redman CW. Is the colposcopically directed punch biopsy a reliable diagnostic test in women with minor cytological lesions?. J Low Genit Tract Dis 2012; 16 (04) 421-426
    CrossrefPubMedGoogle Scholar
  • 20 Gage JC, Hanson VW, Abbey K. , et al; ASCUS LSIL Triage Study (ALTS) Group. Number of cervical biopsies and sensitivity of colposcopy. Obstet Gynecol 2006; 108 (02) 264-272
    CrossrefPubMedGoogle Scholar
  • 21 Nam K, Chung S, Kwak J. , et al. Random biopsy after colposcopy-directed biopsy improves the diagnosis of cervical intraepithelial neoplasia grade 2 or worse. J Low Genit Tract Dis 2010; 14 (04) 346-351
    CrossrefPubMedGoogle Scholar