| Abstract|| |
Background: The first 2 years' experience of a colposcopy clinic at our teaching hospital was analyzed. Establishment of the clinic was supervised by consultants trained in colposcopy. Objective: To review the performance of the clinic from its inception in 2010. Materials and Methods: A study of 90 patients who were referred for colposcopy was conducted. Data were extracted from patients' folders and records in the colposcopy and histopathology register and analyzed using EPI INFOTM 7. Results: Fifty-one women were referred on account of abnormal Papanicolaou (Pap) smears indicating either low grade squamous lesion (44%) or high grade lesion (12.2%). Thirteen patients (14.4%) had persistent inflammatory smears while 26 patients (28.9%) where referred on account of suspicious cervix. Abnormal colposcopic findings were reported in 48 patients who subsequently had colposcopically directed punch biopsy. The result of the biopsy showed that 18 patients had cervical intraepithelial neoplasia (CIN) I. Only two of these had high grade lesion; the remaining had low grade lesion (81% concordance). Nineteen women had either CIN II or CIN III. Only two cases were reported as low grade lesions and one case as suspected invasive cervical cancer on colposcopy. The remaining had high grade lesion (85% concordance %). Overall, the colposcopic impression was in agreement with the histological diagnosis in 87% of the cases. Conclusion: Our initial experience with colposcopy shows good correlation/agreement between colposcopic impression and histological diagnosis. This has improved the detection rate of premalignant and malignant disease of the cervix in our center.
Keywords: Biopsy, cervix, colposcopy, histology
|How to cite this article:|
Umar UA, Yakasai IA. Experience with colposcopy at Aminu Kano Teaching Hospital, Kano, North-Western Nigeria. Ann Trop Med Public Health 2016;9:180-3
|How to cite this URL:|
Umar UA, Yakasai IA. Experience with colposcopy at Aminu Kano Teaching Hospital, Kano, North-Western Nigeria. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Feb 22];9:180-3. Available from: http://www.atmph.org/text.asp?2016/9/3/180/179103
| Introduction|| |
Cervical cancer is the fourth most common cancer in women, and the seventh overall, with an estimated 528,000 new cases in 2012. Majority (around 85%) of the global burden occurs in the less developed regions where it accounts for almost 12% of all female cancers. There were an estimated 266,000 deaths from cervical cancer worldwide in 2012. Nine out of 10 of these deaths (87%) occur in less developed nations, accounting for 7.5% of all female cancer deaths.
Cervical cancer remains the leading cause of death in middle-aged women due to poor access to medical care and the unavailability of routine screening in many of these countries. In Nigeria, approximately 10,000 women will develop cervical cancer each year and 8,000 will die from the disease.
Cervical cancer is preventable and if it is diagnosed at an early stage; it can be cured with appropriate resources. In many developed countries, the introduction of cytologic screening and subsequent colposcopy for early detection of precancerous lesions into public health infrastructure has led to a remarkable reduction in cervical cancer incidence and mortality. Most women in developing countries have little or no access to cervical cancer prevention programs.
Cervical cancer can be prevented using various screening procedures such as Papanicolaou (Pap) smears, human papillomavirus (HPV) DNA testing, visual inspection with acetic acid (VIA), or Lugol's iodine (VILI). Pap smear has a false predictive rate ranging 10-50%. Colposcopy is corrective for false negative cytosmears in about 20-40% and is superior in grading dysplastic cervical smears. Therefore, colposcopy remains the reference standard for accessing the validity of all the screening procedures. Newer cervical screening strategies such as visual inspection base approaches as primary screening tests have been extensively studied in some developing countries in Africa and developing countries such as India. Although visual inspection with 5% acetic acid (VIA) is a test with good sensitivity, low specificity has been its limitation, which will result in excessive referrals and treatment of false-positive lesions.
Colposcopy is a visual technique that requires training and experience. Its limiting factor is that the accuracy of the method is directly related to the expertise of its operator. Moreover, the colposcopist will not be able to visualize the entire transformation zone (TZ) in type 3 TZ when it is located within the endocervical canal. Colposcopy allows identification, localization, and delineation of premalignant lesions of the cervix, vagina, and vulva, and directs the biopsy site.
| Materials and Methods|| |
The colposcopy clinic of the hospital was established in 2010. The clinic was run by a consultant gynecologist trained in colposcopy. Punched biopsy samples were examined in the pathology department of the hospital using Bethesda classification and reported using cervical intraepithelial neoplasia (CIN) terminologies.
Indications for referral to the clinic include any CIN lesion on cytology [low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL)] persisting abnormality on Pap smear (for example, chronic inflammation), history of postcoital bleeding, history of recurrent vaginal discharge, cervical polyp, suspicious lesion (warts, plaque, ulcers) on the genital tract (vulva, vagina, cervix), intermenstrual bleeding, and previous treatment for CIN.
The colposcopy was performed by any of the three gynecologists trained in colposcopy using a video colposcope SLC 2000B series (Goldway Industrial Inc. 2008, China). Strict adherence to the essential steps involved in colposcopy was ensured. The procedure was explained to all patients and consent was obtained. Normal saline was first applied to the cervix with cotton balls for the removal of mucous secretions. This is followed by preliminary inspection of the surface of the cervix for abnormalities. The examination of the blood vessels was aided by using the green filter. Acetic acid (5%) was then applied using cotton balls to conduct another inspection of the entire transformation zone (TZ) and evaluate any areas of acetowhite lesion or atypical TZ. Schiller test was also conducted using Lugol's iodine.
The colposcopic diagnosis of cervical neoplasia depends on the recognition of four main features: Intensity of acetowhitening, margin and surface contour of the acetowhite areas, vascular features (punctations and mosaics), and color changes after iodine application. Biopsies were obtained from the worst of any abnormal areas under colposcopic guidance. Biopsy specimens were immediately fixed in formalin and sent to the histopathology department for processing and reporting.
The colposcopy is said to be satisfactory when the whole TZ is visualized. Where the examination is unsatisfactory, endocervical curettage is performed and the sample is sent for histology.
Data were retrospectively analyzed using EPI INFO ™ 7 developed (Centers for Disease Control and Prevention 1600 Clifton Rd., Atlanta, GA 30333, USA) by the US center for disease control. Quantitative variables were analyzed by mean and standard deviation, whereas qualitative data were analyzed by percentage and frequency. Colposcopic accuracy was defined as the proportion of patients in whom the correlation between colposcopic impression and histologic diagnosis was within one histologic degree of neoplasia. Concordance was defined as the proportion of cases in which colposcopic impression was in exact agreement with histologic diagnosis.
| Results|| |
During the first 2 years of establishing the clinic, a total of 106 patients were referred for colposcopy. Ninety folders were retrieved and analyzed, given a retrieval rate of 84.9%. The patients' ages ranged 22-67 years with a mean age of 36 ± 9.4 [standard deviation (SD)]. See [Table 1].
Of the 90 women analyzed, 51 (56.7%) were referred on account of abnormal Pap smears indicating either LSIL or HSIL. Thirteen (14.4%) patients had persistent inflammatory smears while 26 patients (28.9%) were referred on account of suspicious cervix. See [Table 2].
[Table 3] shows the finding at colposcopy. Low grade lesions were detected in 22 patients (24.1%) while high grade lesions were detected in 18 patients (20%). Four patients (4.4%) had colposcopic features suggestive of invasive cancer. The entire TZ could not be visualized in patients (4.4%) and were categorized as unsatisfactory colposcopy. No cervical abnormality was detected in 42 patients (46.7%) and they were thus, reported as normal.
[Table 4] shows the result of biopsy in the 48 patients who had abnormal colposcopic findings. Histologic findings were reported as normal in 4 (8.3%) patients, CIN I in 18 (37.5%) patients, CIN II in 12 (25%) patients, CIN III in 7 (14.6%) patients, and invasive cancer in 3 (6.3%) patients. Four specimens were returned as “inadequate.”
The agreement between colposcopic impression and histopathology is shown in [Table 5]. Of the 18 cases of biopsy proven CIN I, 2 (4.5%) were reported as high grade lesion on colposcopy and 16 (36.4%) cases were accurately diagnosed. Of the 19 biopsy proven cases of either CIN II or CIN III, two cases were reported as low grade and one case as invasive cancer on colposcopy. An accurate diagnosis of high grade lesions (CIN II or III) was made in 16 cases. All the three cases of biopsy proven invasive cancers were accurately diagnosed on colposcopy.
The colposcopic impression was in exact agreement (concordance) with the histologic diagnosis in 35 (87.5%) cases.
| Discussion|| |
This study was aimed at evaluating our initial experience with colposcopy. Fifty-nine (65.5%) patients were aged 30-49 years. This age group corresponds to the peak incidence of detection of premalignant and malignant disease of the cervix in most centers in Nigeria.,,
Abnormal Pap smear was the commonest indication for referral constituting 51% of the patients. Most of the patients (44.4%) were referred on account of LSIL because the referral in our center allows for immediate referral of women with low grade abnormalities. This was done in order to improve our detection rate and reduce loss to follow-up. However, in some centers, especially in developed countries, a repeat smear after 3-6 months or HPV testing is advocated when Pap smear shows LSIL (mild dysplasia). This is because some of this abnormality tends to regress spontaneously. In some studies conducted in the UK, women expressed clear preference for immediate colposcopy over continued surveillance, which reduces the anxiety.
Of the 42 specimens sent for histological analysis, 91.7% were adequate and suitable for analysis, exceeding the minimum standard. It is recommended that of all the biopsies taken, more than 90% should be suitable for histological interpretation.
High grade diseases were correctly diagnosed in 16 women (84.2%), thus also achieving the minimum standard of at least 65%. A meta-analysis on the validity of colposcopy in the diagnosis of early cervical neoplasia by Olayinka BO quoted colposcopic accuracy of 89%. The concordance rate of our colposcopic diagnosis was 87.5%, which was higher than 61% reported by Olayinka. Four women (9%) with normal histologic impression were reported as low grade on colposcopy. Difficulty in differentiating between CIN I, cervicitis, and HPV infection may account for this overestimation. Two women (4.5%) with high grade lesions were underestimated as low grade lesion on colposcopy. A high grade lesion may be overlooked when it appears as an inner border of sharp acetowhite demarcation within a less opaque acetowhite area.
| Conclusion|| |
Our initial experience with colposcopy showed good agreement between colposcopic impression and histopathology. This has improved the detection rate of premalignant and malignant disease of the cervix in our center. It is paramount to audit colposcopic services so as to ensure its keeping with the internationally agreed standard.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al
. Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11 [Internet]. GLOBOCAN 2012 v1.0. Available from: http://globocan.iarc.fr
. [Last accessed on 2015 Jun 28].
Ibrahim A, Rasch V, Pukkala E, Aro AR. Predictors of cervical cancer being at an advanced stage at diagnosis in Sudan. Int J Womens Health 2011;3:385-9.
Alliance for Cervical Cancer Prevention. The Case for Investing for Cervical Cancer Prevention. Issue in Depth #3. Seattle: ACCP; 2004. p. 1-2.
Arbyn M, Sankaranarayanan R, Muwange R, Keita N, Dolo A, Mbalawa CG,et al
. Pooled analysis of the accuracy of five cervical cancer screening tests assessed in eleven studies in Africa and India. Int J Cancer 2008;123:153-60.
Afifa W, Sofia I. Abnormal cervical smear, colposcopy and outcome of cervical biopsy. Professional Med J 2012;19:53-8.
Sellas JW, Sankarnarayanan R. Colposcopy and treatment of cervical intraepithelial neoplasia: A Beginner's Manual. International Agency for Research on Cancer. Lyon: IARC Press; 2003. p. 29-30.
Durdi GS, Sherigar BY, Dalal AM, Desai BR, Malur PR. Correlation of colposcopy using Reid colposcopic index with histopathology – A prospective study. J Turk Ger Gynecol Assoc 2009;10:205-7.
Olaniyan OB. Validity of colposcopy in the diagnosis of early cervical neoplasia – A review. Afr J Reprod Health 2002;6:59-69.
Adekunle OO, Samaila MO. Prevalence of cervical intraepithelial neoplasia in Zaria. Ann Afr Med 2010;9:194.
Ezem BU. Awareness and uptake of cervical cancer screening in Owerri, South-Eastern Nigeria. Ann Afr Med 2007;6:94-8.
Adewuyi SA, Shittu SO, Rafindadi AH. Sociodemographic and clinicopathologic characterization of cervical cancers in northern Nigeria. Eur J Gynaecol Oncol 2008;29:61-4.
Jordan J, Arbyn M, Martin-Hirsch P, Schenck U, Baldauf JJ, Da Silva D,et al
. European guideline for quality assurance in cervical cancer screening: Recommendations for clinical management of abnormal cervical cytology, part 1. Cytopathology 2008;19:342-54.
Waller J, McCaffery K, Kitchener H, Nazroo J, Wardle J. Women's experiences of repeated HPV testing in the context of cervical cancer screening: A qualitative study. Psychooncology 2007;16:196-204.
Luesley D, Leeso S. Colposcopy and Programme Management: Guidelines for the NHS Cervical Screening Programme. 2nd
ed. Sheffield: NHSCSP Publication; 2010. p. 27-31.
Usman Aliyu Umar
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Zaria Road, PMB3452, Kano
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]