Comparative Evaluation of Abnormal Cytology, Colposcopy and Histopathology in Preclinical Cervical Malignancy during Pregnancy

Abstract

The results of a 2.5 year study on cytodetection of preclinical cervical malignancy during pregnancy are presented. Of 3534 pregnant women, 125 (3.5 per cent) had cytologic diagnoses of dysplasia, carcinoma in situ, or microinvasive carcinoma of the uterine cervix. These results are compared with those obtained from colposcopy and from tissue diagnosis following biopsy, cervical conization, and hysterectomy. They are also analyzed in relation to the patients' age, parity, and age at first sexual intercourse. Of the 3534 pregnant women, 3408 (96.5 per cent) had negative results. For 125 patients (3.5 per cent), the cytologic diagnosis was compatible with lesions of preclinical malignancy. Of this latter number, mild and moderate dysplasia was found in 93 patients (2.6 per cent), severe dysplasia and carcinoma in situ in 29 patients (0.82 per cent), and possible microinvasive carcinoma in 3 (0.08 per cent). In those negative smears with infectious processes (1322 cases), the most frequently found of the specific infectious agents were trichomonads (36.5 per cent). The greatest incidence of dysplastic lesions, as well as half the cases of carcinoma in situ, occurred in young patients, those between the ages of 20 and 29. The remaining cases of carcinoma in situ occurred in patients between 30 and 39 years of age. The great majority were multiparous or grandmultiparous, frequently with an early onset of sexual activity (between the ages of 10 and 19). In the 3534 patients, the authors found two cases of invasive carcinoma. Both were grandmultiparous, with an early onset of sexual activity. Of the 125 patients with abnormal smears, colposcopy was performed in 75 cases (60 per cent). For the 93 patients with smears compatible with mild and moderate dysplasia, colposcopic examination was done in 44 cases, just less than half. When evaluating the colposcopic results, we found that abnormal findings occurred in 49 of the 75 cases for which colposcopic examination was carried out, leading to a colposcopic biopsy for histopathologic study. In mild and moderate dysplasia, abnormal colposcopic results were noted in approximately half the total cases; of the 29 patients with a cytodiagnosis compatible with severe dysplasia or carcinoma in situ, abnormal colposcopic findings were noted in almost all cases (93 per cent). In nine of the 49 cases examined, in which colposcopy revealed abnormal findings, with the colposcopic patterns related to the cytologic diagnosis, the colposcopic report mentioned only the presence of a zone of atypical transformation, without specifying the findings. Analysis of the data seems to suggest that white epithelium is the pattern found most commonly in cases of mildly malignant lesions, whereas mosaic and punctation patterns seem to be predominant in more severe malignant lesions. Of 27 cases of severe dysplasia and carcinoma in situ, the colposcopic pattern was mosaicism or punctation in 14 cases, over 50 per cent. The authors found that among the cytologic diagnoses of moderate dysplasia, in only two cases did histologic diagnosis reveal a more serious lesion (one severe dysplasia and one carcinoma in situ). Of 27 cases of severe dysplasia and carcinoma in situ, in only one did histologic diagnosis reveal a more serious lesion (microinvasive carcinoma). There was a good correspondence between the cytologic findings and the final histologic diagnosis (90 per cent of cases); cytology was able to rule out invasion in 19 of the 20 cases considered (95 per cent). The histopathologic diagnoses confirmed the high frequency of severe dysplasia or carcinoma in situ already indicated by cytology. Considering the histologic diagnosis, the incidence of the lesions was 0.74 per cent, i.e. one case of severe dysplasia or carcinoma in situ in every 135 patients. Microinvasion occurred in only one case; the highest incidence of this lesion occurs at an average of 44 years of age, which is, of course, beyond the usual age for pregnancy. For the same 20 cases, the correlation between the initial and final histologic diagnoses was evaluated. The colposcopically directed biopsy diagnosis showed a high level of acceptable agreement with the final histologic diagnoses (17 of 20 cases: 85 per cent). Diagnostic conization was performed during pregnancy in only three cases. In two patients cytology could not rule out invasion, and in one the cytodiagnosis was compatible with carcinoma in situ. A total of 12 patients were ultimately treated by conization. Cesarean hysterectomy was done in seven patients and a radical Wertheim was the treatment for one patient. For 14 patients (41 per cent), the authors were unable to carry out surgical treatment, either because patients refused (a minority of the cases) or because the team was unable to locate them. This calls attention to the difficulties faced when treating patients from poor socioeconomic backgrounds.