Objective
The purpose of this study was to evaluate colposcopic sensitivity in the diagnosis of microinvasive squamous carcinoma of the cervix.
Study Design
We conducted a cross-sectional study in 151 patients from 1991-2008. The colposcopic findings of microinvasion suspicion were described by the International Federation for Cervical Pathology and Colposcopy in 2003.
Results
There has been colposcopic suspicion of invasion in 35 patients, which represents a sensitivity of 23%. The major colposcopic findings that were observed in the transformation zone included acetowhite epithelium in 21% (32/151 patients), coarse punctuation in 19% (29/151 patients), coarse mosaic in 17% (26/151 patients), and atypical vessels in 3.9% (6/151 patients). Suspicion of microinvasion was found in 14.5% of unsatisfactory colposcopy and in 8.6% of satisfactory colposcopy.
Conclusion
The sensitivity of colposcopy in the diagnosis of microinvasive carcinoma of the cervix was low. Colposcopy plays an important role in directing the biopsy to the most suspicious area. The definitive diagnosis of microinvasive squamous carcinoma is established only by histologic study.
Microinvasive squamous carcinoma was first described by Mestwerdt in 1947 as being an invasive tumor no >5 mm in depth. In 1994, the International Federation of Gynecology and Obstetrics (FIGO) staging of uterine cancer of the cervix defined stage IA1 tumors as those for which the measured invasion of the stroma is no >3 mm in depth and no >7 mm in diameter and stage IA2 tumors as those for which the measured invasion of the stroma is >3 mm but no >5 mm in depth and no >7 mm in diameter. Lymphovascular space involvement did not change the staging. The staging was revised in 2009, with no changes in this category.
Microinvasive squamous carcinoma stage IA1 represents 4.5-9% of cervical cancer cases, but some studies have shown increased incidence of up to 20% in some studies. Sykes et al reported a drop in the incidence of invasive carcinoma in New Zealand since the introduction of the National Cervical Screening Programme. Despite that, there was an increase in the detection of microinvasive carcinoma. Eighty-two percent of patients with microcarcinoma (confirmed after conization) were referred to the treatment because of abnormal cytologic findings, such as high-grade intraepithelial lesion (HSIL). The suspicion of HSIL on colposcopic examination was more frequent (62%) than invasive suspicion lesion (29%) in these patients.
Despite the diagnosis of microinvasive squamous carcinoma, microinvasion colposcopic features have become a frequent study object. Sugimori et al concluded that there should be suspicion of microinvasive carcinoma when mosaic, acetowhite epithelium, punctuation, and atypical vessels cover the entire length of the transformation zone. Choo et al observed that colposcopic features of microinvasion included ≥3 epithelial changes in the transformation zone. Coppleson defined colposcopic suspicion of incipient invasion to include extensive lesion, several colposcopic aspects within the transformation zone, increased vascularization, and ulceration. Tidbury and Singer demonstrated that lesions where there is invasion are 7 times more extensive than in areas of intraepithelial lesions. Dexeus et al described the main colposcopic signs of microinvasion to include fragility of the lesion, mosaic and coarse punctuation, extensive abnormal transformation zone and atypical vessels of different calibers, bizarre courses, and abrupt changes in direction. Hopman et al demonstrated that atypical vessels have been more related closely to frankly invasive lesions than to microinvasive ones.
The objective of this study was to evaluate colposcopy sensitivity in the diagnosis of microinvasive squamous carcinoma of the cervix stage IA1.
Materials and Methods
Cross-sectional study was carried out from 1991-2008. In this study, 151 of 6823 patients had a histopathologic diagnosis of microinvasive squamous carcinoma in the Cervical Pathology Unit of the Institute of Gynecology of the Federal University of Rio de Janeiro.
The selected patients for colposcopy had an abnormal cytologic condition; atypical squamous cells could not exclude high-grade lesion, HSIL, or suspicion of invasion. The colposcopic examination was performed by conventional technique, by device brand Inami Colposcopy (Tokyo, Japan), with 3 magnifications (×10, ×16, and ×25) with the use of saline solution 0.9%, 5% acetic acid, and Lugol’s solution by 2 experienced colposcopists. The colposcopic criteria of suspicion of invasion were described by the International Terminology of Colposcopy of the International Federation for Cervical Pathology and Colposcopy.
Two types of biopsy procedures were carried out: 54 outpatient operations with loop electrosurgical excisional procedure with local anesthesia and 97 conizations with cold-knife procedure into the operatory block with regional anesthesia. Indications for cold-knife conization were unsatisfactory colposcopy, extensive cervical lesions, or suspicion of microinvasion after previous cervical punch biopsy. Those patients who underwent loop electrosurgical excisional procedures had a rigorous follow-up evaluation in the outpatient unit.
The surgical specimens were analyzed at the Anatomopathology Laboratory of the Institute of Gynecology. The histopathologic study was performed after 60-90 sections and hematoxylin-eosin staining of each specimen. For this study, only those patients with microinvasive squamous carcinoma of the cervix (FIGO stage IA1: ≤3 mm depth and ≤ 7 mm of width) were selected.
This study was approved by the Maternity School of the Federal University of Rio de Janeiro Research Ethics Committee (no. 26/2010).
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