December 1993, Volume 43, Issue 12

Original Article

Colposcopy in the Diagnosis of Human Papilloma Virus Infection, Cervical Intraepifhelial Neoplasia and Invasive Carcinoma

Rakhshinda Bajwa  ( Department of Pathology, Postgraduate Medical Institute, Lahore. )
Saeed Akhtar Khan  ( Department of Pathology, Postgraduate Medical Institute, Lahore. )
Ghulam Rasool Qureshi  ( Department of Pathology, Postgraduate Medical Institute, Lahore. )
Naseer Ahmad Chaudhry  ( Department of Pathology, Postgraduate Medical Institute, Lahore. )


Colposcopic diagnosis of 156 different lesions of the cervix was compared with histologic examination of the cervical punch biopsies. Colposcopy showed high degree of sensitivity and specificity (96% and 99.2%) in cases of carcinoma of the cervix. In cervical intraepithelial neopiasia (CIN) It showed a sensitivity of 82.8% and specificity of 49.6%, while in subclinical papliloma virus Infection (SPI), it showed high degree of specificity (93.7%) but poor sensItivity (19.7%) (JPMA 43:257, 1993).


Screening programmes for detection of carcinoma of the cervix in its preclinical stage require consideration of easily identifiable variables like marital status, parity, contraceptive use, symptoms1 and risk factors like sexual habits and number of sexual partners2. In addition to cervical cytelogy, colposcopic examination has become an important part of such a screening programme3. Appropriate biopsies can be obtained through colpo­scope which picks up acetowhite epithelium and abnor­mal vascular patterns4. The present study was aimed to find out the extent to which colposcope helps in diagnosing carcinoma of, the cervix and its precursor lesions.

Patients and Methods

A total of 163 women reporting to out-patient department of Lady Wilingdon Hospital, Lahore were examined colposcopically before and after application of 5% acetic acid. The cervix, squamocolumnar junction and vaginal fomices were examined. Colposcopic diag­nosis of the lesions was made on the criteria already described4-6. Colposcope directed punch biopsies were obtained from the relevant areas. The specimens were fixed in 10% formalin, embedded in paraffin and stained with. H&E and PAS. Human papilloma viral antigens were detected by immuno- histochemical staining using peroxidase-antiperoxidase technique7. After excluding inadequate biopsies (7 cases), the lesions were diag­nosed as normal, chronic cervicites, subclinical papilloma virus infection (SPI), SPI+CIN, CIN and invasive carcinoma.


Table I shows the overall comparison of colpo­scopic and histologic diagnosis which is rather mislead­ing in the case of invasive carcinoma. Twenty-four cases of invasive carcinoma were correctly diagnosed on colposcopic examination. One case diagnosed as car­cinoma on colposcopy turned out to be SPI + CIN. One case diagnosed as CIN on colposcopy turned out to be invasive carcinoma. Diagnostic accuracy of colposcopic examination in three main lesions, that is, SPI, CIN and carcinoma is analysed in Tables II-IV.

The cases ofCIN in Table III .include both the cases of CIN alope and SPI÷CIN.


Recently there has been increased documentation of carcinoma of cervix and its precursor lesions alongwith human papilloma virus (HPV) infection2,6,8-10. Typical exophytic condylomata acuminata account for only a few of the infections of the cervix11. The most common manifestation of HPV Infection of the cervix is a’ macroscopically invisible lesion termed flat condyloma by Meisels and Fortin12 and subclinical papilloma virus infection (SPI) by Reid et al5. Coexisting lesions like SPI + CIN have been reported8,13-15 making the diagnosis further difficult. More or less objective criteria have been defined to diagnose all such lesions on colposcopic examination4,5. However, a number of studies6,10,16 show that colpo­scopic diagnosis is not accurate enough and Kirkup et al concluded that differential diagnosis of subdinical papil­loma virus infection and CIN was not clear cut. In this study we found that colposcopic examination showed a high degree of specificity and sensitivity in the diagnosis of carcinoma of the cervix but not, with premalignant lesions. In cases of cervical intraepithelial neoplasia it showed quite a good sensitivity but was not specific enough to be relied upon. In the diagnosis of subclinical papilloma virus infection it was, highly specific but showed poor sensitivity. It is hoped that with further experience we will be able to improve colposcopic diagnosis in premalignant cervical lesions. Till such time, the ultimate tool to diagnose pre-malignant lesions remains the histological examination of colposcopically directed punch biopsies.


1. Parkin, D.M., Flodgson, P. and Clayden, AD. Incidence and prevalence of preclinical carcinoma ofcervixin a British population. BrJ.ObsteL Gynaecol., 1982;89:564-70.
2. Brisson, 3., Roy, M., Fortier, M. et aL Condyloma and intraepithelial neoplasia of the uterine cervir a casecontrol study. Am.J.Epidemiol., 1988;128:337-42.
3. Walker, P. and Singer, A. colposcopy: who, when, where and by whom? Br.J.Obstet.Gynaecol., 1991;98:1011-13.
4. Reid, it, Herschmsn, BR, Cram, CF. et al. Genital warts and cervical cancer V. The tissue basis of colpoacopicchsnge. Am.J.Obstet.Gynaecol., 1984;149:293-303.
5. Reid, It, Stanhope, CR, Henchman, BR. et al. Genital warts and cervical cancer IV. A colposcopic index for differentiating sub-clinical papilloma viral infection from cervical intraepithelial neoplasia. Am.J.Obstet. Gynaecol., 1984;149:815-23.
6. McNicol, P.J., Guijon, F.B., Parsskevss, M. and Brunham, R.C. Comparison of filter in situ deoxyribonudeicacid hybridization with cytologic, colpoacopicand histopathologic examination for detection of human papillosna virus infection in women with cervical intraepithelial neoplasia Am.J.Obstet. Gynaecol., 1989;160:265-70.
7. Kurman, R.J., Shah, KH., Lancaster, W.D. et al. Immunoperoxidase localization of papiiioma virus antigens in cervical dysplasia and vulvar condylomas. Am.J.Obstet. GynaecoL, 1981;140:931-935.
8. Guillet, G., Braun, L, Shah, K. et aL Papilloma virus in cervical condylomas with and withoutassocisted cervical intrdepitheliai neoplasia.J.Invest. DermatoL, 1983;81:S13-16.
9. Carmichael, J.A. and Maskena, P.D. Cervical dyiplasia and human papilloma virus. Am.J.Obstet. Gynaecol., 1989;160:916-18
10. Waeckerlin, LW., Potter, NJ. and Cheatham, G.R. Correlation of cytologic, colpo­scopic and histologic studies with immunohistochemical studies of human papilloms virus structural antigens in an unselected patient population. Am.J.Obstet. Gynaecol., 1981;158:1394-1402.
11. Fletcher, S. Histopathology of pspilloma virus infection of the cervix uteri: the bistoty, taxonomy, nomendature and reporting of koilocytic dysplasias. J.Clin.PsthoL, 1983;36:616-24.
12. Meisels, A., Fortin, R. Condylomstous lesions of the cervix and vagina I: cytologic patterns. Acta. Cytol., 197420:505-9.
13. Meisels, A., Motin, C, Casas-Cordero, M. etal. Human papillomavirus (HPV) venerial infections and gynecologic cancer. Pathol. Annu., 1983;18:277-93.
14. Cram, CF., Egawa, K, Barron, B. et at Human papilloma virus infection (condyloma) of the cervix and cervical intcaepithelial neoplasia. A hiatopathologic and statistical analysis. Gynaecol. Oncol., 1983;15:88-94.
15. McCance, DJ., Campion, M.J., Clarkson, P.K., et al. Prevalence of human papiiioma virus type l6DNAsequencesio cervical intraepithelial neoplasia and invssivecarcinoma ofthecervix. Br.J.Obstet.Gynaecol., 1985;92:1101-5.
16. Purola, RE, Haiila, H., Yesternen, B. Condylomaandcervicalepithelial atypiasinyoung women. Gynsecol. Oncol., 1983;16:34-40.

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