…all of your cervical biopsies correlate with the cervical cytology findings and colposcopic impression. Yet how often does this happen in your practice? The most optimistic of forecasts regarding the sensitivity of colposcopy say that the procedure can determine the location and extent of 90% of cervical intraepithelial neoplastic (CIN) lesions Morrow CP, 1981), while other, perhaps more realistic estimates put the figure at around 70% (Cantor SB, 2008). To get an accurate picture of the patient’s ‘biology’ one might imagine that improved colposcopic skills may help. This is of course subject to many limitations, not least of which is experience; a trait literally impossible to attain overnight! Additionally, this too has a ‘ceiling’ in that even the most experienced colposcopist, regardless of skill, may not be able to appreciate subtle, thin lesions of the cervix with the tools at their disposal. An alternative is to consider additional biopsies. A recent study (Pretorius RG, 2011) compared the sensitivity of colposcopy directed biopsy among physicians and investigated the increase in yield (if any) of CIN 3 or cancer (CIN 3+) per colposcopy associated with additional, ‘random’ biopsies and/or endocervical curettage (ECC). The results showed marked variability in the sensitivity of colposcopy among clinicians. Amongst 7 physicians, who performed a total of 1,383 colposcopic examinations on women with abnormal cervical cytology, sensitivity for CIN 3+ with colposcopy ranged from 28.6% to 92.9% with a mean of 68%. As for whether additional biopsies improve sensitivity; for 6 of the 7 colposcopists the yield of CIN 3+ per colposcopy increased with the addition of an ECC and up to 4 ‘random’ cervical biopsies in quadrants of the cervix that did not show a visible lesion. Overall, the yield of CIN 3+ increased from 10.2% to 16.1% per colposcopy, a statistically significant finding. Additional biopsies may take the form of ‘random’ quadrant sampling, as used in this study. However, a disadvantage to increasing the number of biopsies is the possibility of increased trauma and discomfort to the patient. Although not described as used within this study, the new fabric based exo- and endocervical biopsy tools (see next page) are described as being significantly less traumatic than conventional biopsies (Winter M, 2012), increasing the willingness to perform multiple biopsies and therefore increase disease detection. by PathAdvantage pathologist Richard Hopley, MD