Jeffrey H.J. Tan

Colposcopy performance in the new primary HPV screening in Australia: How to determine colposcopy competency?

AimsTo assess colposcopic performance and determine indicators for competency within the new Australian primary human papillomavirus (HPV) cervical screening program.Materials and methodsA retrospective observational study of 4542 women seen at The Royal Women's Hospital Colposcopy Clinic in Melbourne, from 1 December 2017 to 31 July 2020 after a higher‐risk cervical screening test (CST) result.ResultsHistological CIN2+ was detected in 25.1% up to two years from first colposcopy visit (FCV). The majority (86.7%) of CIN2+ was detected early within the first six months of presentation. Biopsy rate overall was 96.1% with abnormal colposcopic impression. Of four colposcopists with a lower biopsy rate, only one was able to achieve this early detection rate. Biopsy was also taken in over 30% of cases with negative reflex cytology and normal colposcopy, with CIN2+ detected in 5.0% among positive HPV16/18 and 3.8% with non‐16/18 HPV. Positive predictive value of high‐grade colposcopic impression at FCV averaged 66.4% (range: 54.9–81.6% among our colposcopists) and is poorly correlated with early detection rate of CIN2+. Overall accuracy of colposcopy is 84.5% (range: 78.7–90.3%), buoyed by high true negative colposcopic predictions secondary to high rates of negative reflex cytology referral with the new screening algorithm and is also unlikely to be a useful colposcopy indicator.ConclusionsEarly detection rate of CIN2+ within the first six months of presentation is a useful measure of colposcopy competency and we would encourage our National Cancer Screening Register to explore this with the participating colposcopists.

Outcomes of women with positive oncogenic HPV and reflex cytology showing possible high‐grade squamous intraepithelial lesion

AimTo examine outcomes in women following cervical screening detection of oncogenic human papillomavirus (HPV), with reflex cytology showing possible high‐grade squamous intraepithelial lesion (pHSIL).Materials and methodsA retrospective observational study of 523 women seen in the Royal Women’s Hospital Colposcopy Clinic from 1 January 2018 to 31 July 2020.ResultsTwo hundred eighty‐two (53.9%) women had histology‐confirmed HSIL, encompassing CIN2 or worse (CIN2+), including seven cancers (1.3%) and two adenocarcinoma in situ (AIS) (0.4%). In 81.2% (229/282) of women with CIN2+, this was detected on cervical biopsy at initial colposcopy, with another 8.9% (25/282) of CIN2+ detected at cervical excision following initial colposcopy and the remaining 9.9% (28/282) at follow‐up colposcopy thereafter. When discordant cervical biopsy results were discussed at multidisciplinary meeting (MDM), 66.7% of women with pHSIL cytology upgraded to definite HSIL were found to have CIN2+, but only 20.8% when pHSIL cytology was retained and none when downgraded to low‐grade (LSIL) or normal. No significant difference was found in the proportion of CIN2+ based on patient age above or below 40, HPV16 and/or 18 versus non 16/18, or whether discordant findings were reviewed at MDM.ConclusionsWe propose a pathway for management of women with positive oncogenic HPV and reflex pHSIL cytology. MDM review is recommended when CIN2+ is not identified on cervical biopsy at initial colposcopy. Conservative management is safe with low risk of CIN2+ when LBC prediction of pHSIL is confirmed or downgraded at MDM with no high‐grade change on colposcopy or repeat cytology.

Recurrent post‐coital bleeding: Should colposcopy still be mandatory?

BackgroundColposcopy has been recommended for all women with recurrent post‐coital bleeding (PCB) even if their cervical cytology or co‐test (involving oncogenic human papillomavirus (HPV) DNA testing and cytology) are negative.AimsTo determine the risk of cervical cancer and its precursors among women with recurrent PCB with negative cytology or co‐test.Materials and MethodsA retrospective analysis of two cohorts of women with PCB referred to a tertiary colposcopy clinic. Cohort (1) (n = 1846) between 1 January 2000 and 31 December 2016 (cytology‐based screening) and Cohort (2) (n = 215) from 1 January 2018 to 31 December 2019 after introduction of primary HPV screening.ResultsIn 1217 (65.9%) women in Cohort (1) referred with negative cytology, there was one cancer (0.08%) and 22 high‐grade squamous intraepithelial lesions (HSIL (cervical intraepithelial neoplasia 2/3)) on histopathology. In Cohort (2), there was no cancer or HSIL in 83 women with negative co‐tests (negative for oncogenic HPV and cytology). False‐negative cytology after a negative referral cytology or co‐test was low with 2% of repeat cytology at initial colposcopy showing possible HSIL or worse.ConclusionsWomen presenting with PCB and negative cytology alone have a low risk of cancer and could have HPV testing before being triaged to colposcopy. We showed that with the assurance of a negative co‐test and the low likelihood of false‐negative cytology, these women could avoid colposcopy unless cervical cancer is clinically suspected. There is a need for a larger cohort study to substantiate our findings with more precision.

Management and long‐term outcomes of women with adenocarcinoma in situ of the cervix: A retrospective study

BackgroundAdenocarcinoma in situ of cervix is increasingly managed by local excision rather than hysterectomy and this study will ascertain if conservative management by excision alone is adequate.AimsTo evaluate the long‐term outcomes of conservative management of adenocarcinoma in situ of cervix, particularly in relation to excisional margin status.Materials and MethodsRetrospective analysis of women diagnosed with adenocarcinoma in situ and their management between 1992 and 2010 retrieved from the Victorian Cervical Cytology Registry, Australia. Failure of conservative treatment is defined by histologically proven adenocarcinoma in situ or adenocarcinoma at follow‐up after negative excisional margins.Resultsadenocarcinoma in situ of the cervix was managed primarily with cold knife cone biopsy or loop electrosurgical excision of the cervix. Most excisions were in one piece (83.4%) with average depth of 16.1 mm and 21.9% had involved excisional margins. Women with adenocarcinoma in situ on any excisional margin were more likely to have residual or recurrent disease (28.7%) compared with negative excisional margins (4.3%). Residual adenocarcinoma in situ was twice as common if adenocarcinoma in situ was present at endocervical (29.6%) and stromal (23.1%) margins compared with an ectocervical margin (13.6%). Cancer incidence at follow‐up was 2.3% for women with positive excisional margins compared to 1.3% with negative margins.ConclusionsWomen with adenocarcinoma in situ of cervix can be managed with local excisional procedures, best in single pieces to provide the important information on excisional margins. Adenocarcinoma in situ at endocervical and stromal excisional margins needs re‐excision or where appropriate, hysterectomy, while negative excisional margins have a low rate of recurrence and can be followed up with test of cure.