Diagnosis and therapy of cervical intraepithelial dysplasia in Austria: a survey

PURPOSE: To assess the present state of diagnosis, therapy and follow-up of cervical intraepithelial neoplasia (CIN) in Austria. MATERIAL AND METHODS: 100 questionnaires were sent to all departments of Gynecology and Obstetrics in Austria. The anonymous questionnaire consisted of 22 multiple choice questions. It was possible to choose one or more answers by ticking applicable boxes, with the option in individual cases of giving additional information in the form of free text. RESULTS: 55 (55%) departments returned their answered questionnaires, indicating growing consciousness of quality control in medicine. It was found that in the collection of cytologic specimens 67% of the departments used a wooden spatula and cotton swabs. Management of patients with Pap smears indicating low grade squamous intraepithelial lesion (LSIL) and abnormal colposcopy, in 36 (65%) departments consisted of punch biopsy for histological diagnosis. After 3 recurrent Pap smears indicating LSIL, 76% of the hospitals treated such patients by conization, regardless of the histological grade of the lesion. Following inadequate resection of CIN III by conization, operative management of patients was the most commonly used regimen. CONCLUSION: We regard the results of this survey as a basis for the development of further quality management strategies in the prevention, diagnosis and therapy of cervical intraepithelial neoplasia in Austria.     

Reconstructive surgery in chronic venous disease of the lower limbs

OBJECTIVE: To determine the interpretability and significance of the traditional factors used to predict residual dysplasia in hysterectomy specimens after loop conization. MATERIALS AND METHODS: Loop electrosurgical cervical conization was performed on 372 patients. Ninety three women had a hysterectomy within 6 months of the loop conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. RESULTS: Of the 93 patients having a subsequent hysterectomy, 36 (38.7%) has residual disease in their hysterectomy specimen. The mean age of the patients with residual disease in the post loop conization hysterectomy specimen was 42.22. The mean age of those free of residual disease was 29.42. By multivariate analysis, dysplasia involving the ectocervical margin (p = 0.34) and the endocervical margin (p = 0.35) was not predictive of disease in the hysterectomy specimens. Endocervical curettage (p = 0.005), glandular involvement (p = 0.01), loop conization pathology findings (p < 0.05) and cytological examination (p < 0.001) were predictive of residual dysplasia. CONCLUSIONS: Cytological reports, increasing age, severity of disease, gland involvement and endocervical curettage were the only factors that accurately predicted residual dysplasia. The presence or absence of dysplasia in the loop conization, ectocervical margin and endocervical margin was not predictive of residual dysplasia in post loop conization hysterectomy specimens.     

Adverse effect of electrosurgical loop excision on assignment of FIGO stage in cervical cancer: report of two cases

Electrosurgical loop conization of the cervix is a new procedure that is being rapidly accepted for treatment of cervical intraepithelial neoplasia (CIN). Concerns include fragmentation of the specimen that is frequently mandated by the size of the transformation zone and difficulty in using the largest electrosurgical loops. Two cases are presented that demonstrate the inability to accurately assign depth of invasion in cervical cancer when the focus of invasion is transfected. As a result, the patient and physician were forced to decide on whether a radical hysterectomy and pelvic lymphadenectomy were needed based on incomplete information. It is recommended that electrosurgical loop conization be confined to patients where invasive carcinoma is not expected. The use of this new technique for patients with suspected invasive carcinoma needs further evaluation.     

Hypothalamic-pituitary-adrenal axis in abdominal obesity: effects of dexfenfluramine

BACKGROUND AND OBJECTIVE: Minimal conization with carbon dioxide laser (CO2) for safe diagnosis and treatment of cervical intraepithelial neoplasia (CIN) 1-3 has been utilized for 15 years. To evaluate the results of 15 years' follow-up. STUDY DESIGN/MATERIALS AND METHODS: Clinical prospective study: 2,903 non-pregnant women whose cervicovaginal smear revealed CIN 1-3, confirmed by colposcopy, were referred for minimal conization treatment (LMC). This outpatient free-hand excision is performed under local anesthesia with a 60-W continuous laser beam focused to a 0.1-mm spot size, giving a power density of 165,000 W/cm2. Adjuvant cervical curettage is done routinely. RESULTS: Complications after the procedure were insignificant. Histopathological investigations revealed invasive carcinoma in 1.2% of the minicones. The primary cure rate was 96.1%. In the life table analysis of the patients the cumulative risk of recurrence for all forms of CIN was 0.89% at year 5, 1.36% at year 10, and 3.02% at year 15. There was no sudden onset carcinoma during the follow-up period. CONCLUSION: Minimal conization is a safe, effective treatment for CIN and early forms of microinvasive carcinoma. Invasive carcinoma can be detected early and should be treated without delay. The cumulative risk of developing new CIN is 3.02% at year 15 and there is no risk of sudden-onset invasive carcinoma following this procedure.     

Occurrence of human papillomavirus infection in cervical intraepithelial neoplasia. A retrospective histopathological study of 317 cases treated by laser conization

The aim of the study was to compare the histological outcome of the cone specimens with the diagnoses of the preoperative biopsies, to assess the distribution of histological features consistent with human papillomavirus (HPV) infection and, finally, to analyse the impact of cellular HPV features on classification of cervical intraepithelial neoplasia (CIN). The study comprised a population of 317 women treated for CIN by laser conization during the period 1983-85. A total of 634 cervical specimens (317 preoperative biopsies and their corresponding cones) were studied retrospectively for CIN classification and examined for morphological signs of HPV infection. For presentation of the results, we used a modified terminology for CIN. Low-grade (LG) CIN included borderline lesions and CIN I, while high-grade (HG) CIN included CIN II and CIN III. The blinded histopathological review revealed HG CIN both in the preoperative biopsies and the cones in 71% of the cases. LG CIN or benign lesions were found in the preoperative biopsies and their corresponding cone specimens in 6% of the study population. HPV features were present in 65% of the preoperative biopsies, and were most prevalent in women under 29 years of age (p < 0.001). Thirteen percent of the total biopsy material was downgraded. The downgrading was most prevalent among original CIN II (p = 0.009) and HPV-negative biopsies (p < 0.001). This study demonstrates that CIN lesions are frequently associated with HPV features, which are significantly more prevalent in the youngest women. Concomitant HPV features do not influence the CIN classification.     

Progressive dysregulation of proliferation during cervical carcinogenesis as measured by MPM-2 antibody staining

To better characterize the amount and location of loss of proliferation control during cervical carcinogenesis, 44 cervical cone biopsy specimens containing various grades of premalignant and malignant lesions and 12 normal cervix specimens were immunohistochemically examined using MPM-2. This antibody recognizes a phosphorylated epitope on a group of proteins that are preferentially phosphorylated at mitosis. The spatial organization of mitotic figures was determined using a computer-assisted image analysis system. The mitotic figure frequencies/unit of epithelial area were found to increase as the histological type progressed; the numbers of mitoses/square millimeter was 1.7 +/- 0.5 (mean +/- SE) for control normal epithelium (n = 12), 3.1 +/- 1.7 for normal epithelium adjacent to cervical intraepithelial neoplasia (CIN) and cancer (n = 28), 7.9 +/- 1.3 for CIN1 (n = 24), 75.8 +/- 16.3 for CIN2 (n = 11), 127.2 +/- 9.7 for CIN3 (n = 22), 196.9 +/- 33.2 for carcinoma in situ (n = 9), and 156.2 +/- 31.0 for cervical carcinoma (n = 8). The MPM-2 index was higher in high-risk premalignant lesions (i.e., those adjacent to areas of high-grade CIN and carcinoma) than it was in lower risk premalignant lesions (i.e., those with no adjacent higher grade CIN or cervical cancer), even if they exhibited the same histological grade. Moreover, the mean relative distance of the mitotic cells from the basement membrane (i.e., the distance from the basal layer to the surface) also increased as the histological grade progressed. These results suggest that proliferation becomes sequentially dysregulated both quantitatively and spatially during cervical carcinogenesis and that the MPM-2 antibody might be useful as a proliferation biomarker.     

Interobserver variation in the reporting of cervical colposcopic biopsy specimens: comparison of grading systems

AIMS: To assess interobserver variation in reporting cervical colposcopic biopsy specimens and to determine whether a modified Bethesda grading system results in better interobserver agreement than the traditional cervical intraepithelial neoplasia (CIN) grading system. METHODS: One hundred and twenty five consecutive cervical colposcopic biopsy specimens were assessed independently by six histopathologists. Specimens were classified using the traditional CIN grading system as normal, koilocytosis, CIN I, CIN II, or CIN III. The specimens were also classified using a modified Bethesda grading system as either normal, low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL). Participants were also asked to categorise biopsy specimens by the CIN system with the addition of the recently proposed category "basal abnormalities of uncertain significance (BAUS)". The degree of agreement between participants was assessed by kappa statistics. RESULTS: Using the CIN system, interobserver agreement was generally poor: unweighted and weighted kappa values between individual pairs of observers ranging from 0.05 to 0.34 (average 0.20) and from 0.20 to 0.54 (average 0.36), respectively. With the modified Bethesda system, interobserver agreement was better but still poor: unweighted and weighted kappa values ranging from 0.15 to 0.58 (average 0.30) and from 0.21 to 0.61 (average 0.36), respectively. There was little or no agreement between observers in the diagnosis of BAUS. CONCLUSIONS: Interobserver agreement in the reporting of cervical colposcopic biopsy specimens using the CIN grading system is poor. Agreement, while still poor, is better when a modified Bethesda grading system is used. There is little or no consensus in the diagnosis of BAUS.     

Conservative management of options for patients with dysplasia involving endocervical margins of cervical cone biopsy specimens

OBJECTIVE: Our purpose was to study the feasibility of conservatively managing selected cases of dysplasia involving endocervical cone margins. STUDY DESIGN: A retrospective review of patients conservatively managed after being found to have squamous cell dysplasia involving the endocervical margins of their cervical cone biopsy specimens. In phase I patients who had cold-knife conization with positive endocervical margins underwent repeat Papanicolaou smears and colposcopy, with biopsies and endocervical curettage as indicated. Those found free of disease were followed up with frequent Papanicolaou smears. In phase II patients with dysplasia to the endocervical resection edges on loop electrical excision procedure biopsy specimens were followed up with frequent cytologic studies. RESULTS: In phase I, 31 patients with positive endocervical margins on cold-knife conization and no evidence of dysplasia on reevaluation were followed up for 1 to 18 years. Dysplasia was detected in one patient during cytologic surveillance. In phase II, 11 patients were followed up for 12 to 31 months; only one patient has dysplasia. CONCLUSION: Selected patients with squamous cell dysplasia at endocervical cone biopsy margins may avoid additional surgery.     

Submandibular gland excision: a five-year review

OBJECTIVE: To evaluate the frequency of human papillomavirus (HPV) 16 and 18 infection in patients with different grades of cervical intraepithelial neoplasia (CIN). METHOD: Five-hundred and five patients with CIN, referred for conization, were included in this study. Before conization, cytological material for in situ hybridization was obtained from the uterine cervix to detect the presence of HPV 16 and 18 infection. RESULT: Among all patients with CIN, 82 (16.2%) were solely HPV 16 and 51 (10.1%) were solely HPV 18 positive. There were 133 patients (26.3%) positive for HPV 16 or HPV 18 and 31 patients (6.1%) were positive for both viral types, giving an overall HPV 16/18 infection rate of 32.4%. There were 15 (55.5%) HPV 16 or HPV 18 positive patients with CIN 1, 45 (33.8%) HPV 16 or HPV 18 positive patients with CIN 2 and 104 (30.2%) HPV 16 or HPV 18 positive patients with CIN 3. CONCLUSION: In patients with CIN 1, HPV 16 and 18 infection was more frequent than in patients with CIN 2, but the difference was not significant. Patients with CIN 2 were infected slightly more frequently, but not significantly, than patients with CIN 3. On the other hand, patients with CIN 1 were significantly more frequently infected than patients with CIN 3.     

Study of organizer nucleolar regions by the argyrophil technique in cervical intraepithelial neoplasias

Thirty three biopsies of the uterine cervix were studied by the AgNOR method, that identifies the nucleolar organizer regions. These comprised 9 cases of cervicitis (with or without squamous metaplasia), 9 cases of cervical intraepithelial neoplasia grade I (CIN I), 8 CIN II and 10 CIN III. A hundred cells were counted and classified according to the number of AgNOR dots. We use a more practical and fast method of AgNOR dots counting in cervical intraepithelial neoplasia, in that we exclude the two basal layers and count only cells with 4 or more dots. Statistically significant differences for AgNOR dots were found between cervicitis or CIN I and CIN II cases (p < 0.02) and between CIN II and CIN III cases (p < 0.001). No statistical difference was found between the cases of cervicitis and CIN I. It was concluded that this method of AgNOR counting can be useful in the identification and classification of individual cases intraepithelial neoplasia and their differentiation from eventual difficult cases of cervicitis.     

Lack of effect of coumarin on unscheduled DNA synthesis in precision-cut human liver slices

OBJECTIVE: To evaluate the accuracy of cytologic screening in pregnancy through routine colposcopy and to confirm the safety of conservative management of cervical intraepithelial neoplasia (CIN) in pregnancy. STUDY DESIGN: In total, 3,658 pregnant women, screened for cervical cancer with either cytology or colposcopy, were prospectively evaluated. Patients with abnormal findings underwent colposcopically directed biopsy and, in case of CIN, repeat cytology and colposcopy. Biopsy was repeated in case of suspected progression of the lesion. Suspected microinvasion was the only reason for diagnostic conization during pregnancy. After delivery, excisional treatment provided a final specimen from all patients. Diagnostic methods were compared. RESULTS: Comparison between cytology and colposcopy showed 97.1% concordance with a few false positives (2.5%) and false negatives (0.2%). Abnormal cytology and colposcopy, as compared with histology, showed similar concordances, but the risk of underestimation by cytology was significantly higher (P < .05). Initial and final histology of the 63 cases of CIN and microinvasive carcinoma showed 88.9% concordance. Progression of the lesion was not observed. CONCLUSION: These data do not justify combined use of cytology and colposcopy to improve screening for cervical cancer in pregnancy. Delayed treatment of CIN after delivery is safe.     

Crystallization and preliminary X-ray analysis of phenol hydroxylase from Trichosporon cutaneum

OBJECTIVE: To determine the relation between dysplasia at cervical cone margins and the presence or absence of residual dysplasia in post-cone hysterectomy specimens. METHODS: We performed a 6-year retrospective, multicenter study and reviewed 250 cases in which the patient had a cold-knife cervical cone biopsy followed by a hysterectomy within 6 months. Pathology reports from 23 institutions described the margins in conization specimens and the subsequent status of residual dysplasia in the hysterectomy specimens. RESULTS: There was a statistically significant difference in the prevalence of residual dysplasia in hysterectomy specimens between patients with positive margins on cone biopsy (47%) and those with negative margins (23%) (P < .01). The positive predictive value for residual dysplasia given positive cone margins was 47%, and the negative predictive value was 77%. The grade of post-cone residual dysplasia increased commensurately with the grade of dysplasia in the conization specimen. CONCLUSIONS: The presence of dysplasia at the cervical cone margin relates significantly with the presence of residual dysplasia in the post-cone hysterectomy specimen. The grade of residual dysplasia in the post-cone hysterectomy specimen increased as the grade of dysplasia in the conization specimen increased. Free margins on a cone biopsy specimen with dysplasia offer reassurance that invasive cancer is not present in the remaining uterus.     

Cathepsin E expression by normal and premalignant cervical epithelium

We have investigated the expression of the aspartic proteinase cathepsin E and HLA-DR and the presence of HPV16 in normal squamous epithelium (n = 8) and low-grade (n = 21) and high-grade (n = 14) intraepithelial squamous lesions of the uterine cervix. Immunohistochemistry of cervical biopsies revealed that up-regulation of cathepsin E expression was related to increasing severity of the cervical intraepithelial neoplasia (CIN). Up-regulation of protein was associated with increased message as assessed by in situ hybridization. Langerhans cells and the majority of koilocytes did not express detectable cathepsin E levels. Although there was also an up-regulation of HLA-DR expression by cervical keratinocytes in cervical intraepithelial neoplasia lesions, as determined by immunohistochemistry, no significant correlation was found between HLA-DR and cathepsin E expression in these lesions; neither was expression of cathepsin E correlated to the presence of HPV16, detected by polymerase chain reaction. The expression of cathepsin E, an aspartic proteinase that is reported to play a role in antigen processing for presentation by class II major histocompatibility complex molecules, is associated with cellular dedifferentiation in cervical intraepithelial neoplasia.     

Intraepithelial lesions of the cervix uteri and human papillomaviruses: comparative study of histological data and in situ hybridization. Apropos of a series of 77 cervical biopsies

Seventy seven biopsy samples of cervical mucosa were tested for the presence of human papillomavirus (HPV) by immunohistochemistry and in situ hybridization. From the 38 samples identified as condyloma or cervical intraepithelial neoplasia (CIN), 31 were positive after in situ hybridization and 14 after immunochemical analysis. HPV 6 was found exclusively in condyloma acuminata (2 samples) whereas the HPV 16 probe essentially hybridized with high grade intraepithelial lesions (CIN II, CIN III). Low grade intraepithelial lesions (flat condyloma, CIN I) demonstrated a larger diversity of HPV types (HPV 16, 18, 31, 33). A close correlation was demonstrated between the histologic features of lesions and their HPV 6 or HPV 31 content but not for other HPV types. HPV 31 containing lesions showed a peculiar architecture with numerous, elongated papillae resulting in a spiked appearance.     

Detection of the Epstein-Barr virus genome in cervical neoplasia is closely related to the degree of infiltrating lymphoid cells: a polymerase chain reaction and in situ hybridization approach

To cast light on the significance of Epstein-Barr virus (EBV) infection in cervical tumorigenesis, 44 cervical intraepithelial neoplasia (CIN) types I/II, and 70 CIN III lesions, 60 invasive squamous cell carcinomas (ISCC), and 20 normal cervical samples were investigated by polymerase chain reaction (PCR) and RNA in situ hybridization (RISH) assays. The EBV genome was detected by PCR using primers targeting the IR region in three (6.8%) of the CIN I/II, 15 (21.4%) of the CIN III and 13 (21.7%) of the ISCC lesions, while using an EBER oligonucleotide probe RISH revealed positive signals in infiltrating lymphocytes located in the cervical stroma, but not in dysplastic or tumor cells. There was a significant correlation between the presence of EBV DNA and the degree of lymphoid cell infiltration (P = 0.0223). In contrast, none of the normal cervical samples that were without inflammation demonstrated any EBV infection. Thus, the results indicated that a positive result for EBV on PCR may be simply dependent on the amount of lymphocytes in cervical stroma, suggesting that this virus does not play a major role in the etiology of cervical neoplasia.     

Cervical intraepithelial neoplasia 3, coinfected with HPV-16 and -18--case report

Recently, detection of human papillomavirus (HPV)mRNA expression was made possible by in situ hybridization. We described a patient with cervical intraepithelial neoplasia (CIN) 3, showing a distinctive and rare form of co-infection with HPV type 16 and 18. HPV-16 was detected in high grade squamous intraepithelial neoplastic lesion (CIN 3) and HPV-18 was in low grade lesion just adjacent to the HPV-16 infected area. This case suggests that HPV infection may be one of the most responsible causative agents producing malignant transformation and two distinctive HPV types can also simultaneously infect the squamous epithelium of the uterine cervix.     

Loop excision of the transformation zone (LETZ) as an outpatient method of management for women with cervical intraepithelial neoplasia: our experience

Between March 1996 and July 1998, 90 patients were treated with diathermy loop excision (LETZ) for cytologically, colposcopically and histologically verified cervical intraepithelial neoplasias (CIN), at the outpatient clinic. In average, the patients were 30.22 years of age, and 61.1% of them were nulliparas. In 80 surgical samples (88.9%), the exocervical and endocervical margins were histologically free of disease. From the total of 65 patients with CIN III diagnosis, 58 (89.2%) had free margins samples. In the post-operative period the patients had a changed vaginal discharge for 16 days. A slight feeling of pain in the abdomen lasted for 2.5 days on the average, and most patients did not take analgetics. Moderate postoperative hemorrhage from the excision site occurred in 5 (5.5%) patients, and was outpatiently treated with electrocoagulation, with no need for blood replacement. In 65 patients (90.3%), the cytological control results were normal. During the follow-up period, 9 patients became pregnant, which resulted in 6 terminal deliveries so far; 2 pregnant women are about to deliver, and one is in the first trimester of pregnancy. Cerclage cervicis has not been performed on any of the patients. LETZ is a safe and simple procedure which can be done at outpatient clinics, it is relatively easily mastered, it is short, quite bearable for patients if done only under local analgesia, the equipment costs are acceptable, and the treatment can be used both diagnostically and therapeutically, since an adequate surgical sample is obtained for histological assessment. Cytological and colposcopical check ups are imperative in the postoperative period.     

Reflex human papillomavirus deoxyribonucleic acid testing in women with abnormal Papanicolaou smears

OBJECTIVE: The study examined interrelationships between sensitivity and specificity of "reflex human papillomavirus deoxyribonucleic acid testing" from liquid-based cervical cytologic specimens by means of receiver operator characteristics curves. STUDY DESIGN: A cohort study was performed on 265 women evaluated by colposcopy because of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion found on Papanicolaou smear. RESULTS: At a positive threshold of 0.2 pg/ml (1000 copies of human papillomavirus per test), human papillomavirus deoxyribonucleic acid testing detected 86% of women with cervical intraepithelial neoplasia and 93% of women with high-grade cervical intraepithelial neoplasia with a specificity of 30%. Decreasing the sensitivity of the human papillomavirus test to 1 pg/ml (5000 copies of human papillomavirus per test) improved the specificity of a positive result to 44% but decreased the clinical sensitivity to 78% for cervical intraepithelial neoplasia grade 2 or 3. Relationships between sensitivity and specificity were influenced by patient age and referral diagnosis. For example, limiting the analysis to only women with a referral for atypical squamous cells of undetermined significance found on Papanicolaou smear and a positive human papillomavirus test threshold of 0.5 pg/ml produced a sensitivity of 90% for cervical intraepithelial neoplasia grade 2 or 3 and a test specificity of 55%. CONCLUSION: Human papillomavirus deoxyribonucleic acid testing of residual cellular material from liquid cytologic specimens appears to be more appropriate for older women (>30 years old) and women with atypical squamous cells of undetermined significance, as opposed to low-grade squamous intraepithelial lesion, on their Papanicolaou smears.     

Virological and biological characteristics of cervical intraepithelial neoplasia grade I with marked koilocytotic atypia

The aim of this study was to evaluate virologic and biological significance of marked koilocytotic atypia observed in some cases of grade I cervical intraepithelial neoplasia (CIN I). Thirty-one CIN I cervical biopsy specimens with marked koilocytotic atypia, defined by the presence of meganuclei in the superficial epithelial layers, were compared to 37 CIN I biopsy specimens with usual koilocytes for (1) the human papillomavirus (HPV) type and signal pattern as detected by nonisotopic in situ hybridization (ISH); (2) the proliferation index assessed by Ki 67 immunostaining and (3) the p53 labeling pattern. Interobserver agreement for meganuclei was excellent (k = 0.9). Twenty-five out of 68 biopsies (37%) were positive by ISH for the 6 of 11 HPV probe, 30 (44%) for the 16-18 probe, and 7 (10%) for the 31/33 HPV probe, 6 (9%) were negative for ISH. The presence of meganuclei was strongly related to high and intermediate risk HPV type (P = 0.0001). The sensitivity and specificity of meganuclei for the detection of high or intermediate risk HPV in CINI were 73 and 87%, respectively. Loss of p53 immunostaining in the lower third of the epithelium was also related to the presence of meganuclei (P < .05), but the MIB-1 index and ISH labeling pattern were not. In conclusion, marked koilocytotic atypia in CIN I is a reliable and sensitive marker for infection by high or intermediate-risk HPV, and might be a guide to therapy.     

Cervical intraepithelial neoplasia in HIV seropositive patients

In order to assess the frequency of cervical intraepithelial neoplasia (CIN) in a high risk population, 32 women infected with human immunodeficiency virus (HIV), with no AIDS-related symptoms, underwent colposcopic, cytologic and histologic examinations of the uterine cervix. In seven cases (21.9%) cervical smears showed dysplasia and in nine cases (28.1%) histologic evaluation indicated CIN. No invasive carcinomas were observed. In seven of the nine women CIN was associated with lesions due to human papillomavirus infection (HPV). These data confirm that HIV-positive women are at increased risk for developing neoplasias in the lower genital tract and are in need of regular and careful cytologic and, in particular, colposcopic and histologic examinations.