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PubMed1988

Sensitivity and specificity of endocervical curettage and the endocervical brush for the evaluation of the endocervical canal.

A series of 87 consecutive conization specimens was studied to evaluate the accuracy of endocervical curettage for the detection of dysplasia in the endocervical canal and to investigate the role of the endocervical brush for the outpatient management of patients with atypical Papanicolaou smears. For patients having cervical intraepithelial neoplasia within the endocervical canal in conization specimens, the false-negative rate observed for endocervical curettage was 45% and the false-positive rate for the detection of endocervical involvement was 25%. The false-negative rate for the endocervical brush was only 8.4%, but the false-positive rate for endocervical involvement was 62.5%. The false-negative rate of endocervical curettage could be reduced to 16.7% if an abundant volume of endocervical material (as determined by point counting) was required. The utility of endocervical curettage to detect cervical intraepithelial neoplasia in the endocervical canal appears to be dependent on the adequacy of the specimen. The determination of adequacy is a critical factor for the proper interpretation of specimens obtained by endocervical curettage.

Adult↗
PubMed1997

Management of low-grade squamous intraepithelial lesions during pregnancy.

OBJECTIVE: Our purpose was to determine whether prenatal colposcopy is beneficial in pregnant women with squamous atypia, atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesions on an initial screening Papanicolaou smear. STUDY DESIGN: A retrospective chart review identified a cohort of pregnant patients referred to the colposcopy clinic at Carolinas Medical Center between October 1991 and December 1994 with squamous atypia, atypical squamous cells of undetermined significance, or low-grade squamous intraepithelial lesions. Results of the colposcopic examination, cervical biopsy specimens, postpartum evaluation, and postpartum treatment were recorded. Descriptive statistics were used to tabulate numbers and percentages for all variables with 95% confidence intervals to determine disease progression. RESULTS: Prenatal colposcopy was performed on 253 women during the study period. The colposcopic impression was normal or consistent with low-grade squamous intraepithelial lesions in 235 (93%) of the women. Of the 67 women who had a cervical biopsy, 6 had a histologic diagnosis of high-grade squamous intraepithelial lesions. Postpartum Papanicolaou smears were obtained in 224 patients; 71 (32%) were normal, 145 (65%) were unchanged, and 8 (3%) showed high-grade squamous intraepithelial lesions. Of the 69 patients who had a postpartum cervical biopsy, 4 were found to have high-grade squamous intraepithelial lesions. Eight of the 10 women with biopsy-proved high-grade squamous intraepithelial lesions were compliant with treatment after delivery. Histologic examination of the cervix with tissue obtained by either loop conization or cold knife conization showed no evidence of invasive carcinoma. CONCLUSION: Squamous atypia, atypical squamous, cells of undetermined significance, or low-grade squamous intraepithelial lesions on a Papanicolaou smear in a pregnant patient does not require colposcopic evaluation during pregnancy. Progression of low-grade dysplasia to carcinoma during pregnancy is unusual, and no patient in this study was found to have invasive cancer.

Adolescent↗
PubMed1998

Human papillomavirus 16 and 18 infection of the uterine cervix in women with different grades of cervical intraepithelial neoplasia (CIN).

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.

Adult↗
PubMed1998

Rapid progression to invasive cervix cancer in a woman infected with the human immunodeficiency virus.

BACKGROUND: Previous studies have shown an increased risk of cervical dysplasia in women infected with human immunodeficiency virus (HIV), as well as an increased risk of progression to higher-grade lesions. It is not known whether the rate of progression is accelerated over that in immunocompetent women. CASE: During September 1991, an HIV-positive woman underwent conization of the cervix showing carcinoma in situ. The surgical margins and endocervical curettings were negative for dysplasia. Papanicolaou smears 4 and 7 months after the conization also were negative. She then presented 33 months postconization with a stage Ib2 cervical carcinoma, which proved resistant to chemotherapy and pelvic radiation. CONCLUSION: Immunosuppression caused by HIV infection may cause a more rapid progression of cervical intraepithelial lesions to carcinoma.

Adult↗
PubMedDate not supplied

[Usefulness of the sentinel node in the treatment and staging of initial cervix cancer].

OBJECTIVE: The aim of this study was to evaluate the usefulness of intraoperative sentinel node (SN) detection in patients with initial cervix cancer. PATIENTS AND METHODS: Lymphoscintigraphy and intraoperative SN detection was performed in 17 patients with initial cervix cancer who we going to have a radical laparoscopic hysterectomy and pelvic lymphadenectomy. Conization was performed in 4/17. The day before surgery, an injection of 111 MBq 99mtechnetium nanocolloid around the primary tumour and a subsequent lymphoscintigraphy were carried out. Blue dye was injected at the same location intraoperatively. A laparoscopic gamma probe was used to identify SNs. RESULTS: SNs were successfully localized using a combination of radiocolloid and blue dye in 16/17 patients (detection rate 94 %). The detection rate only using blue dye technique decreases to 71 % (12/17) and it reaches an 82 % (14/17) if we avoid the blue dye injection. In 3 cases, there was no migration in lymphoscintigraphy and in one of the three SN could not be detected. Thirty-three SNs were identified (1.9 nodes/patient). The most frequent location was left external iliac nodal group (13 nodes: 39 %). SNs were identified in regions that are not included in usual lymphadenectomy: right parametrium (2 sentinel nodes, one of them in the retrouterine region), and interiliac (2 SNs). In all four patients with previous conization SNs were identified (detection rate 100 %). CONCLUSIONS: The rate of SN detection combining lymphoscintigraphy with gamma probe and blue dye is 82 %. The use of blue dye allows increasing this rate to 94 % in those cases which migration was not seen or when the SN is placed near the injection site. The SN technique offers the possibility to find SNs in regions not included in usual lymphadenectomy.

Adult↗
PubMed2003

Cervical response to vaccination against HPV16 E7 in case of severe dysplasia.

OBJECTIVE: To evaluate the tolerance to vaccination against human papillomavirus (HPV)16 E7 (in SB adjuvant ASO2B) and its histological and immunohistological effects on HPV16 associated high-grade cervical dysplasias associated with HPV16. STUDY DESIGN: Five patients with histologically demonstrated severe cervical dysplasia (CIN3) HPV16 positive were injected three times before conization was performed 2 months after the first injection. We studied cytological, histological, proliferative pattern and immune profile before and after vaccination. The slides were compared with those obtained from non-injected patients. RESULTS: The injections were well tolerated and the specimens displayed a limited regression of the lesions. Nevertheless, massive CD4 and CD8 T cell lymphocytic infiltration was noticed after vaccination. DISCUSSION: We conclude that the vaccination we used provides an obvious immune histological reaction in the HPV infected cervix and that the 2 months delay before the final step (conization) is done is probably too short.

Adolescent↗
PubMed1985

Cervical dysplasia: cytology class III D and CIN I-II.

Some aspects of class III D-smears (suggesting slight to moderate dysplasia) have been investigated. Results of a cytological follow-up in 481 patients and of the histological findings immediately or during the follow-up in 142 patients are presented. In 112 patients a triple cervical smear approach has been used to determine the rate of false negative smears and errors of sampling. This approach includes the preparation of three slides with cellular material obtained separately from the anterior cervical lip, the posterior lip and from the endocervical canal, using three cotton applicators. To compare the results of cytology with the grade of CIN in different areas of the conization specimens triple cervical smears have been taken preoperatively. Finally 28 patients with a conization following a class III D-smear have been investigated for HPV-induced cell changes which were found in six cases.

Adult↗
PubMed2003

Microinvasive squamous cell cervical carcinoma.

Several histologic tumor-related features are the key factors for further treatment planning in microinvasive cervical cancer (MIC) after conization. To better define the indications for conservative treatment of MIC we conducted a literature review for prognostic factors for MIC and we carried out a prospective observational study evaluating most important pathologic factors and the relationships between tumor and edges of the cone and incidence of recurrences. In our experience seven recurrences were observed. Two distinct groups of patients were identified with a clearance lower or higher of 10 and 8 mm for apical and lateral margin respectively. Depth of infiltration and even lymph-vascular involvement have been confirmed as the most important histologic parameters to be evaluated. Apical and lateral clearance of the tumor are significantly correlated with the recurrence rate. If an adequate lateral border of healthy tissue is present on the specimen, conization may be considered as definitive treatment of MIC.

Carcinoma, Squamous Cell↗
PubMed1998

Evaluation of the cone biopsy excisor compared with the large loop for electrosurgical excision of cervical lesions.

Data incorporated from August 1994 to July 30, 1997.Objective: To compare a newly designed triangular electrode, the Cone Biopsy Excisor to the loop electrode with respect to the margin evaluation, fragmentation, and thermal damage of the conization specimen.Methods: After approval by the Institutional Review Boards of Hartford Hospital, St. Francis Hospital, and New Britain General Hospital/University of Connecticut, patients were randomly assigned to undergo conization with the Cone Biopsy Excisor or with the large loop. Inclusion criteria included biopsy proven CIN II, CIN III, inadequate colposcopy, positive endocervical curettage, or cytohistological discrepancy. Exclusion criteria included pregnancy, undiagnosed uterine bleeding, and invasive carcinoma. The procedures were performed by senior residents on clinic patients at the respective institutions. In addition, after FDA approval November 18, 1996, private OB/GYN practitioners performed cases and added those results to the study. Seventy-eight patients were randomized to the Cone Biopsy Excisor, while 77 patients were randomized to the loop electrosurgical excision procedure (LEEP). To obtain the surgical specimen, Force 2 Valley Lab generators were used with wattage ranging from 35 to 50 according to the size of the instrument chosen, 40/60 blend of coagulation, and cutting current.Pathology reports were reviewed to determine the amount of fragmentation that occurred during the procedure and for tissue diagnosis. Specimens were then evaluated by two gynecologic pathologists blinded to the instrument used. The specimens were analyzed for the ability to evaluate the margins and for degree of thermal damage. A thermal damage score was assigned to each specimen. The scoring system results in 4 levels of thermal damage, from one (minimal thermal damage) to four (heavy thermal damage). Follow-up data was obtained from the patients' medical and pathology records.Results: Seventy-two of 78 (92%) Cone Biopsy Excisor cases vs 10 of 77 (13%) LEEP cases submitted one specimen to pathology, P <.001 based on a chi(2) test. Mean number of specimens submitted to pathology per case in the Cone Biopsy Excisor group was 1.1 +/- 0.5 vs 2.2 +/- 0.8 in the LEEP group, P <.001 based on a t test. Margins were unable to be interpreted because of thermal damage in 2 of 78 (3%) in the Cone Biopsy Excisor group vs 14 of 77 (18%) in the LEEP group, P <.003 based on a chi(2) test.Conclusion: The Cone Biopsy Excisor provided a cervical specimen that had less fragmentation and less thermal damage with margins that were less likely to be indeterminate than those obtained with the large loop electrosurgical procedure.

Journal Article↗
PubMed1994

Micro-invasive squamous cell carcinoma of the cervix: a clinico-pathologic study of 200 cases with long-term follow-up.

The clinico-pathologic details of 200 patients with micro-invasive squamous-cell carcinoma of the cervix have been analyzed. All tumors invaded 5 mm or less below the basement membrane. One hundred and nine were categorized as FIGO stage 1a1 (early stromal invasion) and 91 as FIGO stage 1a2 (micro-carcinoma). The horizontal spread (length) of 12 micro-carcinomas exceeded 7 mm. Twenty-three had stromal invasion 3 mm or more, and 22 had capillary-like space involvement. Fifty-eight patients underwent pelvic lymphadenectomy in addition to hysterectomy and none had positive nodes. Univariate and multivariate analyses of possible prognostic factors including depth, horizontal spread, width, area, volume, grade, growth pattern, capillary-like space involvement, and stromal reaction failed to show any to be significantly associated with recurrence. The median duration of follow-up is now 8 years (0-22 years). Despite complete resection, seven (3.5%) patients developed recurrence of in situ or invasive carcinoma (three after early stromal invasion and four after micro-carcinoma), all of which were located at the vaginal vault. There were two deaths, one due to pulmonary squamous-cell carcinomatosis 21 years after early stromal invasion, the connection being tenuous, and the other due to local recurrence. There have been no recurrences to date in 23 patients treated by conization alone. The uniformly good prognosis of patients in this study is attributed to meticulous sampling of operative specimens resulting in accurate diagnosis and appropriate treatment, which may be conization alone provided the margins are free, there is no capillary-like space involvement, and the depth of penetration is less than 3 mm.

Journal Article↗
PubMed1984

Adenocarcinoma in situ of the cervix.

Adenocarcinoma in situ (ACIS) of the cervix is rare and is frequently overlooked. To characterize this disease more fully, 21 cases were studied. All except two patients presented with abnormal smears. The distribution of ACIS was focal in two cases, multicentric in three, and diffuse and continuous in 15 (in one case it was unknown). The depth of crypt involvement varied from 0.5 to 4 mm and the volume was estimated to range from 0.25 to 1,500 mm3. ACIS should and can be distinguished from early ("microinvasive") adenocarcinoma in most cases by its limitation to the glandular field, by the constant admixture of neoplastic and normal glands, and by the lack of stromal response. Invasive adenocarcinoma cannot be excluded by target biopsy, the diagnosis of ACIS requiring conization. If the surgical margins are disease free, conization alone may be adequate therapy.

Adenocarcinoma↗
PubMed2000

Early invasive adenocarcinoma of the uterine cervix.

In an attempt to determine the natural history of early invasive adenocarcinoma of the cervix, defined as depth of invasion of 5 mm or less, an extensive review of the literature was undertaken, together with recent unpublished material of the author. Many of the cases had to be extracted from series dealing with microinvasive squamous cell carcinoma. The pons asinorum for the pathologist is the differentiation between adenocarcinoma in situ and early invasion. The criteria for microinvasion are: 1.) obvious invasion to 5 mm or less; 2.) usually complete obliteration of the normal endocervical crypts; 3.) extension beyond the normal glandular field; and 4.) a stromal response characteristic of invasive carcinoma. Not all of these criteria are present in every case. In all 436 cases were collected. Allowing for vagueness of reports, 126 patients were treated by radical hysterectomy, and none had parametrial involvement. No cases of adnexal tumors were found in the 155 patients in whom one or both ovaries were removed. Of the 219 patients with pelvic lymph node dissection, five (2%) had metastasis. There were 15 recurrences and six tumor-related deaths in the 436 patients. Only 21 patients had conization as the only treatment, and none has suffered a recurrence. It appears that early invasive adenocarcinoma behaves in the same way as its squamous counterpart. Cold knife conization is acceptable treatment only when the cone biopsy has been adequately sampled and the margins are free, especially when preservation of fertility is an issue. Loop excision procedures obscure depth of invasion and margins and are not acceptable either for diagnosis or therapy. Multicentricity does not appear to require cylindrical cones. If hysterectomy is contemplated, removal of the adnexa, per se, is unnecessary.

Adenocarcinoma↗
PubMed2000

Management of stage I cervical cancer in pregnancy.

UNLABELLED: Although cervical carcinoma is the most common gynecologic malignancy associated with pregnancy, its occurrence is rare with an incidence of approximately 1 per 1,200 to 10,000 pregnancies. There are inadequate data addressing both the obstetric implications of the diagnostic evaluation and the impact of intervention on maternal and infant outcomes. Certain conclusions and recommendations, however, can be drawn from the available data. Diagnostic evaluation includes cytological screening, colposcopy and if necessary, biopsy, and selective conization. Staging of the pregnant patient is modified to minimize radiation exposure to the developing fetus. The treatment schema for patients with stage I cervical cancer in pregnancy varies with the stage of disease and gestational age at diagnosis. With close surveillance, deliberate delay of therapy to achieve fetal maturity is a reasonable option for patients with microinvasive and early stage IB cervical cancer. Tumor characteristics and maternal survival are not adversely affected by pregnancy. Conversely, cervical cancer does not seem adversely to affect pregnancy. However, timing and type of therapy may have a significant influence on the fate of the fetus. In counseling patients with cervical cancer during pregnancy, many factors must be considered, including the patient's desire for the pregnancy, stage of disease, and gestational age at diagnosis. Pregnant patients with stage I cervical cancer should be fully informed of all possible treatment options and consequences. The care of these patients should be closely coordinated by experts in perinatology and gynecologic oncology. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to describe the signs and symptoms of cervical cancer during pregnancy and the indications for conization during pregnancy, as well as being able to outline management strategies for the various stages of cervical cancer during pregnancy.

Adult↗
PubMed1988

Precision in breast reduction.

Precision in the design and performance of a breast reduction can be enhanced by careful formulation of the criteria. The breast cone should incline about 15 degrees medialward. The intersection of the midshoulder (anterior iliac) spine line with the inframammary fold offers a reference point for horizontal localization of the nipple. The nipple-suprasternal notch length, the diameter of the areola, and the nipple-inframammary fold length are determined by the height of the patient and the size of the brassiere cup. On this basis, a table for breast reduction can be drawn up that gives these dimensions for a given height and size of brassiere cup. Other important factors include the stretch direction of the skin and the course of the nerve to the nipple. A distinction is made between radial segment conization and anterior tangential conization. Criteria and measurements were incorporated into a technique comprising anterior tangential excision of glandular tissue and limited inferior radial segment excision of skin.

Breast↗
PubMed1990

Prevention of post-cone biopsy cervical stenosis using a temporary cervical stent.

Stenosis of the residual cervix is not an infrequent complication of cone biopsy which may result in subfertility, problems with adequate follow-up and dysmenorrhoea. In an attempt to minimize this complication a temporary indwelling cervical support stent has been developed. This is sutured into the exposed cone bed immediately after cutting the cone specimen and removed 2 weeks later. A pilot study using this device in 33 cold knife conizations has been performed. There were no primary or secondary haemorrhages and no post-conization pelvic infections. At follow-up, 6 months after cone biopsy two patients (6%) had clinical cervical stenosis, and one patient (3%) complained of dysmenorrhoea (although the cervix was not stenosed). The cervical transformation zone was fully visible in 21/33 patients (64%) (95% CI 48 to 80) and follow-up smears contained endocervical cells in 20/33 patients (61%) (95% CI 44 to 78). These results compare very favourably with historical controls from the same unit and suggest that cone biopsy support stents should now be assessed in a prospective randomized trial.

Adult↗
PubMed1997

Female genital tract malignancies during puberty. Uterine and cervical malignancies.

Malignancies of the uterine corpus are extremely rare. Diagnostic and therapeutic procedures should be performed according to oncological principles with individually adapted treatment regimes. Clinical cancer of the cervix is rare in adolescence; the treatment is radical surgery. Preclinical stages, that is, CIN III (severe dysplasia, carcinoma in situ) and microinvasive cancer (stages Ia1, Ia2), are important, also because of their frequency. Diagnosis is based on colposcopy, cytology, direct biopsy, histological examination, and conization. In addition, virology (HPV) and DNA cytometry may become prognostic factors. Treatment consists of conization with an exact histological examination in serial sections as a basis for preserving the uterus. The sarcoma botryoides is localized in the cervix in adolescence, whereas it is in the vagina in infants and children.

Adolescent↗
PubMed1969

Positive smear in pregnancy.

Of 8,500 consecutive cervical cytology tests in the antenatal period a positive or suspect result was found in about 1%. For the patients with a positive smear, examination under anaesthesia and small four-quadrant cervical biopsies are proposed as an alternative to antenatal conization, with its risk of subsequent haemorrhage or abortion.A waiting policy is safe and permits normal delivery in hospital. Clinical and cytological follow-up is a vital part of conization-excision therapy. For the suspect smear (dyskaryosis) follow-up tests may revert to normal, but others may become positive and demand biopsy.

Adult↗
PubMed1990

Cytobrush in evaluation of cervical dysplasia. Is cervical curettage necessary?

203 patients suspected of having dysplasia were evaluated by colposcopy, cytologic smear including cytobrush, endocervical curettage, biopsy and conization. The results obtained on the basis of the final cone suggested that directed biopsies and cytological smear by spatula and cytobrush more accurately define the dysplastic lesion than do biopsies and endocervical curettage. Conization seemed necessary for the evaluation of the cervical lesion in patients revealing non-classified dysplasia at successive examinations.

Adult↗