GYNECOLOGIC ONCOLOGY 3, 114- 116 (1975)

Diagnosis of Cervical Neoplasia by the Nonspecialized Colposcopistl

GREGORIO DELGADO, M.D. ANDJULIAN P. SMITH, M.D.

M.D. Anderson Hospital and Tumor Institute, Houston, Texas

Received March 18, 1975

Forty-five patients with abnormal Papanicolau smears referred to M.D. Anderson Hos- pital and Tumor Institute underwent colposcopic selected biopsies and endocervical curet- ting in the regular Gynecologic Clinic, by nonspecialized colposcopists. Thirty-two of these patients had cone biopsies; the other 13 had normal colposcopically directed punch biopsies and normal repeated Papanicolau smears. In none of these patients was the conization spec- imen more than one histologic degree more significant than the directed biopsies. In 2 1 pa- tients the histopathology was the same in both specimens. Seven others had severe dys- plasia with directed biopsies and foci of carcinoma in situ in the cone, with no residual disease in the hysterectomy specimen. Two patients with carcinoma in situ in the endocer- vital curetting had microinvasive cancer in the cone biopsy. The need of further investiga- tion was recognized. Even if the numbers are small, these results are comparable with others in the literature, suggesting that this examination may be done by the general gynecologist.

Colposcopy had proved to be a useful procedure in the screening and early de- tection and treatment of cancer of the cervix when it is done by specially trained personnel. In many cases of patients with abnormal Papanicolau smears, col- poscopy alone is a sufficient diagnostic tool; a cone biopsy can be avoided and the patient can receive final treatment in the physician’s office. At the present time, patients with abnormal Pap smears are usually referred to colposcopy clinics where trained colposcopists perform this procedure. In addition, many pa- tients also receive cone biopsies in hospitals, incurring attendant risks and ex- penses.

This study evaluates whether a general gynecologist without any special training in colposcopy can adequately perform colposcopic examinations. If col- poscopy is available to every gynecologist, it can substantially improve the diagnosis of early cervical cancers, reduce the rate of cone biopsies and the resulting hospitalization, and permit final treatment of some patients in the physician’s office.

METHODS

Forty-five patients with abnormal Pap smears referred to M.D. Anderson Hospital and Tumor Institute, Houston, Texas, underwent colposcopic examina- tions and colposcopically directed punch biopsies of the cervix, and endocervical curettings by fellows and residents without special colposcopic training. The

’ Presented to the IV District ACOG, October 15, 1974, Baltimore, Maryland.

114 Copyright 0 1975 by Academic Press, Inc. All rights of reproduction in any form reserved.

DIAGNOSIS OF CERVICAL NEOPLASIA BY NONSPECIALIZED COLPOSCOPIST 115

results of the colposcopically directed biopsies were compared with the histo- logical results of the cone biopsies, and correlation was established.

The participating gynecology fellows had completed full obstetrics and gyne- cology residency training, and some were already board-certified obstetrician- gynecologists. The participating residents were usually Chief Residents from the hospitals of the city. These physicians had no specific colposcopic training, but rather, regular residency training in their respective OB-GYN programs. In some cases, an informal 2 or 3 hr of instruction in colposcopic patterns and use of the colposcope was given. Any abnormal epithelium was biopsied regardless of the colposcopic pattern. In every case endocervical curettings were also done. All the patients that had had abnormal colposcopic biopsies received cone biopsies also and results of the two procedures were correlated.

RESLILTS

Thirteen of the 45 patients had normal colposcopically directed biopsies, and subsequently repeated normal Pap smears. These patients did not receive further work-up, but close follow-up.

The remaining 32 patients underwent cone biopsies and dilatation and curet- tage; histological results of the cones, curettage and directed biopsies were then correlated. When hysterectomies were performed, surgical specimens were also compared.

In 21 patients, the histopathology was the same in both the colposcopically directed biopsy and the cone biopsy, as shown in Table I.

In 11 patients the histopathology was different: in nine cases, with the cone biopsy revealing more serious disease, in two cases, the reverse. In seven of the nine patients, severe dysplasia was found in the directed biopsies, and foci of carcinoma in situ in the cone biopsies; no residual disease was found in the hys- terectomy sections. In two patients, carcinoma in situ in the endocervical curet- tings of the cone biopsy was diagnosed as microinvasive cancer in the cone biopsy. Although the histopathology was different in these cases, the need for further investigation was clearly revealed by the endocervical biopsy.

TABLE I COMPARISON OF Co~posco~~c AND CONIZATION BIOPSIES

Colposcopic biopsy Cone biopsy

Cervicitis Carcinoma

Dysplasia in situ Microinvasive Invasive Total

Cervicitis Dysplasia Carcinoma in situ Microinvasive Invasive Total

4 4 9 7 16 2 6 2 10

2 2 4 11 13 2 2 32

116 DELGADO AND SMITH

DISCUSSION

The accuracy of colposcopy in the clinical diagnosis of cervical cancers has been well documented in the recent literature [ 1,4,7,8]. Colposcopy reduces the number of false negatives produced by Pap smears alone. In many cases, it avoids the use of the cone biopsy with its attendant risks and expense [2,3,4,6]. It is a good diagnostic tool in the case of the pregnant patient for whom cone biopsy presents particular hazards. Physiological eversion of the pregnant cervix affords an excellent colposcopic visualization of the entire squamocolumnar junction.

Every effort should be made to put this important tool in the hands of the gen- eral gynecologist for the use as a routine office procedure. As Emil Reis pointed out as early as 1932, “A colposcopic examination must come to be part of every periodic health examination, of every examination for life insurance, and should be as familiar and routine as a urinalysis and a blood examination.” Unless col- poscopy is performed by the general gynecologist, the majority of patients with abnormal Pap smears (or patients with normal Pap smears who undergo colopos- copy) will continue having diagnostic cone biopsies because it is not possible for them to attend special colposcopic clinics.

The results of our study suggest that colposcopic examination may be per- formed adequately by the general gynecologist with an incidence of diagnostic conizations somewhat higher than would be required with specially trained col- poscopists. In no patient for whom a cone biopsy was indicated was the co’niza- tion specimen more than one histologic degree from the directed biopsies; in over half, the histopathology was the same in both specimens. The general gynecologist may find himself relying on cone biopsies more often, but even so, the number of patients who have cone biopsies will be considerably reduced and some patients will be able to receive final diagnosis and treatment in the physi- cian’s office.

REFERENCES

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2. Fowler, W. C., and Shigleton, H. Impact of dysplasia clinic on cervical conization rates. Obstei. Gynecol. 38, 609-612 (1972).

3. Hollyock, V. E., and Chanen, W. The use of the colposcope in the selection of patients for cer- vical cone biopsy. Amer. J. Obstet. Gynecol. 114, I85- 189 (1972).

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6. Stafl, A., Mattingly, R. F. Colposcopic diagnosis of cervical neoplasia. Obsret. Gynecol. 41, 168-176 (1973).

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