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The Accuracy of Colposcopic Grading for Detection of High-Grade Cervical Intraepithelial Neoplasia

Massad, L. Stewart MD1; Jeronimo, Jose MD2; Katki, Hormuzd A. PhD3; Schiffman, Mark MD3National Institutes of Health/American Society for Colposcopy and Cervical Pathology (The NIH/ASCCP) Research Group

Journal of Lower Genital Tract Disease: July 2009 - Volume 13 - Issue 3 - p 137-144
doi: 10.1097/LGT.0b013e31819308d4
Original Articles

Objective. To relate aspects of online colposcopic image assessment to the diagnosis of grades 2 and 3 cervical intraepithelial neoplasia (CIN 2+).

Methods: To simulate colposcopic assessment, we obtained digitized cervical images at enrollment after acetic acid application from 919 women referred for equivocal or minor cytologic abnormalities into the ASCUS-LSIL Triage Study. For each, 2 randomly assigned evaluators from a pool of 20 colposcopists assessed images using a standardized tool online. We calculated the accuracy of these assessments for predicting histologic CIN 2+ over the 2 years of study. For validation, a subset of online results was compared with same-day enrollment colposcopic assessments.

Results. Identifying any acetowhite lesion in images yielded high sensitivity: 93% of women with CIN 2+ had at least 1 acetowhite lesion. However, 74% of women without CIN 2+ also had acetowhitening, regardless of human papillomavirus status. The sensitivity for CIN 2+ of an online colpophotographic assessment of high-grade disease was 39%. The sensitivity for CIN 2+ of a high-grade diagnosis by Reid Index scoring was 30%, and individual Reid Index component scores had similar levels of sensitivity and specificity. The performance of online assessment was not meaningfully different from that of same-day enrollment colposcopy, suggesting that these approaches have similar utility.

Conclusions. Finding acetowhite lesions identifies women with CIN 2+, but using subtler colposcopic characteristics to grade lesions is insensitive. All acetowhite lesions should be assessed with biopsy to maximize sensitivity of colposcopic diagnosis with good specificity.

Detection of any acetowhite lesion yields good sensitivity for high-grade cervical disease, but grading to refine diagnosis is inaccurate, so multiple biopsies are recommended.

1Division of Gynecologic Oncology, Washington University School of Medicine, St. Louis, MO, 2Program for Appropriate Technology in Health, Seattle, WA, and 3Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD

Reprint requests to: L. Stewart Massad, MD, Division of Gynecologic Oncology, Washington University School of Medicine, 4911 Barnes-Jewish Hospital Plaza, St. Louis, MO 63110. E-mail:

©2009The American Society for Colposcopy and Cervical Pathology