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PubMed1998

[Electrosurgical loop procedures in ambulatory gynecology].

The article gives a survey of the new electrosurgical excision procedures that are gaining widespread use in office gynaecology in the nineties. A special emphasis is put on the easy learning procedures, relatively low cost of equipment and the results, which seem to match the results of cold-knife- and laser-conization. The advantages and pitfalls of the see-and-treat principle are discussed and the indications, other than cervical intraepithelial neoplasia, are mentioned.

Ambulatory Surgical Procedures↗
PubMed1999

Photodynamic therapy in women with cervical intraepithelial neoplasia using topically applied 5-aminolevulinic acid.

Photodynamic therapy (PDT) is a novel treatment modality that produces local tissue necrosis with laser light after prior administration of a photosensitizing agent. We performed a study of topically applied 5-aminolevulinic acid (5-ALA) in the photodynamic treatment of women with high-grade cervical intraepithelial neoplasia (CIN) using fixed 5-ALA doses and application protocols derived from previous in vitro and in vivo results. Three to 5 hr prior to PDT, 10 ml of a 20% solution of 5-ALA was topically applied using a cervical cap. PDT was performed with irradiation of 100 J/cm2 at an irradiance of 100-150 mW/cm2 with an argon-ion-pumped dye laser at 635 nm. For the endocervix, a specifically designed cylindrical applicator was used. Ten treatment cycles of PDT using 5-ALA were performed in 7 patients with high-grade CIN. Non-thermal laser treatment with 100-150 mW/cm2 was well tolerated. Local toxicity was minor as several patients reported burning sensations and vaginal discharge, but no necrosis, sloughing or scarring occurred. After 3 months, a significant reduction in the size of the ectocervical CIN lesions was noted in only 3 patients, who underwent a second PDT cycle. However, no significant improvement in CIN lesions was noted since cold knife conization revealed persistent CIN in all 7 cases. Therefore, PDT after topical application of 5-ALA using an irradiation of 100 J/cm2 produces only minimal side effects. However, it does not appear to be effective in treating CIN.

Administration, Topical↗
PubMed1997

Microglandular endocervical hyperplasia and tubal metaplasia: pitfalls in the diagnosis of adenocarcinoma on cervical smears.

The detection of atypical glandular cells of undetermined significance (AGUS) has risen recently due to the use of new endocervical canal sampling devices, in particular the cytobrush. From April 1993-June 1994, a diagnosis of AGUS ranging from adenocarcinoma in situ (AIS) to invasive adenocarcinoma was initially made on cervical smears from 6 women for whom histologic follow-up data were available. The purpose of this study was to determine if benign cervical glandular lesions can be reliably distinguished from adenocarcinoma on cytology. Review of the smears and histologic slides from 3 patients showed microglandular endocervical hyperplasia on cervical cone specimens. Cervical smears from 2 of these patients showed clusters of small-to-medium-sized cells with nuclei containing coarse, granular chromatin and prominent nucleoli. Cytoplasmic vacuoles and engulfment of neutrophils were present, findings suggestive of endometrial adenocarcinoma. The third patient's smear showed clusters of large cells with ample, vacuolated cytoplasm and vesicular nuclei containing prominent nucleoli, findings suggestive of endocervical adenocarcinoma. In 3 cases evaluated by cervical conization, histologic slides showed tubal metaplasia. The cervical smears showed clusters and sheets of cells with round-to-oval-shaped nuclei containing evenly distributed, finely granular chromatin and inconspicuous nucleoli. Pseudoglandular formation was present in 2 cases, a finding suggestive of AIS. Since the cytologic features of microglandular endocervical hyperplasia and tubal metaplasia overlap those of adenocarcinoma, a differential diagnosis is prudent on cytologic smears of AGUS.

Adenocarcinoma↗
PubMedDate not supplied

Long-term experience in the surgical management of cancer of the uterine cervix.

Cancer of the uterine cervix is the seventh most common malignancy among women and the fifth most common cause of cancer mortality worldwide. In the United States, the use of the Papanicolaou (Pap) smear for screening has meant a significant decline in the incidence and mortality from cervical cancer over the past five decades. However, there are still approximately 12,800 new cases diagnosed per year in the U.S. and 4,800 deaths are estimated in 1999. Both surgery and radiation therapy have long-established roles in management. Surgery has the advantages of shorter treatment time, removal of the primary tumor, more limited tissue injury, and the potential to preserve ovarian function; radiation therapy has the capacity to treat tumor that involves the bladder and/or rectum while preserving their function. Therefore, the role of surgery is more suited to the management of early-stage disease and centrally located recurrences that occur after radiation therapy. Studies from our institution have played an integral role in the development of the modern surgical approach to cervical cancer. Reviews on early-stage disease helped define the role of conization and simple hysterectomy for microinvasive cervical cancer and identified patients who were at high risk for recurrence after radical hysterectomy. The classic work of Brunschwig has given gynecologic surgeons the ability to offer hope and life to select patients who previously could have expected only pain and death. Future investigation into the techniques of intra-operative radiation therapy may increase the pool of patients for whom surgically based salvage therapy may be offered.

Combined Modality Therapy↗
PubMed1976

Colposcopy.

The main clinical value of colposcopy in modern gynecology is in the clinical diagnosis of patients with abnormal cytology. In colposcopically directed biopsies it is possible for an experienced colposcopist to sample with a high degree of accuracy the most advanced histopathologic changes. This significantly decreases the frequency of diagnostic conization. Colposcopy can efficiently select patients for outpatient treatment of cervical intraepithelial neoplasia, since it precisely defines the size and localization of epithelial changes. A new application of colposcopy is in the evaluation of young girls who have been exposed to stilbestrol in utero. In these patients colposcopy can improve the diagnosis of changes in cervical-vaginal epithelium.

Adenocarcinoma↗
PubMed1976

Cryosurgery. Its use for the abnormal Pap smear.

During a two-and-one-half year period, 317 women were seen in the Colposcopy Clinic for evaluation of an abnormal Pap smear. Seventy-four (23%) desired to maintain their childbearing potential and were treated conservatively. Ten (14%) had inadequate colposcopy and underwent cold knife conization of the cervx. The remaining 64 were treated by adequate colposcopy, combined with cryosurgery; they are discussed in detail. All were managed economically as outpatients without anesthesia and no serious complications occurred. To date, only four have recurrent abnormal cervical cytology and several have delivered children. Adequate colposcopic examination combined with biopsies must proceed all cryosurgical procedures performed for abnormal cervical cytology.

Adolescent↗
PubMed1976

The long-term course of carcinoma in situ of the uterine cervix.

The malignant potential of carcinoma in situ (CIS) of the uterine cervix has been the subject of great controversy. Despite refinements and additions to knowledge in this area, few reports on the long-term course of the disease have appeared in the past decade. Recent developments in diagnostic and therapeutic techniques coupled with changes in the patient population with this disease have prompted renewed interest in conservative management. Results of long-term observation of a group of patients followed initially without ablative therapy are reported. The data indicate that CIS of the uterine cervix is not the inevitably progressive disease that it has been considered to be. Unequivocal invasive cancer develops in only a small percentage of cases and can be controlled, if not cured, by current therapeutic modalities. The intraepithelial lesion, however, tends to persist despite conization, and eventually requires ablative therapy in most cases. Conservative procedures should be regarded as temporizing, at least until their long-term benefits can be recorded.

Adult↗
PubMed1987

Topographic study of cervical condyloma and intraepithelial neoplasia.

In this study of 101 cervical conization specimens, the location and the size of condyloma and intraepithelial neoplasia (dysplasia and carcinoma in situ) were mapped using the last endocervical gland as the marker for the original squamocolumnar junction. Condylomatous changes were identified in 85% of cervices affected by the intraepithelial neoplasia, and were in direct contact with 68% of intraepithelial neoplasms. The proximal location of intraepithelial neoplasia in relation to the condyloma can be explained by the occurrence of neoplasia just proximal to the condyloma and subsequent expansion of neoplasia towards the cervical canal. This study adds topographic evidence linking cervical condyloma to the development of intraepithelial neoplasia.

Carcinoma in Situ↗
PubMed1989

Human papillomaviruses and the pathogenesis of cervical neoplasia. A study by in situ hybridization.

In a previous topographic study of cervical conization specimens, condylomatous changes were commonly present in direct contact with intraepithelial neoplasia and were always located distal (ectocervical side) to the neoplasia. Viral DNA was detected by in situ hybridization using 35S-labeled nick translated DNA probes in 50 of 70 cases (71%) which had adequate lesions: HPV-16 in 30, HPV-18 in ten, HPV-31 in six, and multiple types in four cases. HPV-6/11 was detected only once, in a multiple infection. As a rule, a positive cervix contained a single virus type, and the same virus type was found in condylomatous and neoplastic areas. The results suggest that the neoplastic process is initiated in the area of condyloma toward the endocervix and, once established, extends proximally toward the cervical canal. Capsid antigen was detected in 19 cases, indicating that a proportion of the high-grade lesions is potentially infectious.

Adult↗
PubMed1991

Microinvasive carcinoma of the uterine cervix (International Federation of Gynecology and Obstetrics Stage IA).

In 1985 the International Federation of Gynecology and Obstetrics (FIGO) subdivided Stage IA cervical cancer and specified metric criteria to demarcate Stage IA from Stage IB. Early stromal invasion (Stage IA1) denotes the first invasive protrusions of a carcinoma in situ into the stroma. Microcarcinomas (Stage IA2) are small cancers a number of orders of magnitude larger than Stage IA1 lesions and with a maximum depth of invasion of 5 mm and a maximum horizontal spread of 7 mm; larger lesions are classified as Stage IB. This study reviews 486 patients previously classified as having Stage IA disease. This yielded 344 Stage IA1 and 101 Stage IA2 lesions; 41 cancers were reclassified as Stage IB. Three hundred nine, 89, and 38 patients were followed for greater than or equal to 5 years. One (0.3%) patient with Stage IA1 disease re-presented with Stage IIB disease 12 years after conization. Five (5.6%) patients with Stage IA2 lesions developed invasive recurrences; three died. None of the 38 patients reclassified as having a Stage IB lesion, including 16 who were treated conservatively, developed a recurrence. The FIGO classification is not a guideline for treatment. Stage IA1 lesions can be treated conservatively, but treatment in Stage IA2 must be individualized. Risk factors such as vascular space involvement and confluency are of high sensitivity but low specificity.

Carcinoma↗
PubMed1995

Patterns of care for invasive cervical cancer. Results of a national survey of 1984 and 1990.

BACKGROUND: The American College of Surgeons conducted a national patient care and evaluation study of invasive cervical cancer to measure any changes in patterns of care for the years 1984 and 1990. METHODS: Hospitals with cancer programs were invited to submit data on up to 25 consecutive patients with newly diagnosed invasive cervical cancer for each of the two study years. Data were obtained from 684 hospitals on 5904 patients diagnosed in 1984 and from 700 hospitals on 5817 patients diagnosed in 1990. A long term study of patients diagnosed in 1984 was compared with a short term study of patients diagnosed in 1990. Survival data were described only for patients diagnosed in 1984. RESULTS: Of a total of 11,721 patients, 59.4% were diagnosed and treated at the reporting institution in 1984 and 54.8% in 1990. The remaining patients were referred for treatment after diagnosis elsewhere. The diagnosis was established by cervical biopsy for 69.8% of patients, by conization alone for 9.3%, and by both procedures for 11.8%. The histopathologic diagnoses were squamous cell carcinoma (79.8%), adenocarcinoma (15.8%), and other (4.4%). The stage distributions were as follows: IA, 15.9%; IB, 36.8%; IIA, 8.2%; IIB, 15.5%; IIIA, 2.5%; IIIB, 13.3%; IVA, 2.6%; and IVB, 5.2%. The stage was listed as unknown for 20.3% of patients. Patients were treated with surgery alone (29.2%), radiation alone (40.7%), chemotherapy alone (0.7%), or combination therapy (21.5%), and 7.9% received no treatment at the reporting institution. The overall survival for patients diagnosed in 1984 was 68.3%. Survival by stage in this group was as follows: IA, 93.7%; IB, 80.0%; IIA, 67.2%; IIB, 64.7%; III, 37.9%; and IV, 11.3%. CONCLUSIONS: These data indicate that invasive cervical cancer is highly curable when diagnosed early. During the 5-year period, stage distributions were similar, the use of extended hysterectomy increased, and gynecologic oncologists were more often the primary surgeons. The use of radiation alone decreased.

Adult↗
PubMed2003

Innovations in the treatment of invasive cervical cancer.

Invasive cervical cancer is characterized by basement membrane-invading lesions capable of metastasizing through the lymphatic and vascular systems. Treatment methods were reviewed by panelists at the Second International Conference on Cervical Cancer (Houston, TX, April 11-14, 2002), and new opportunities for translational research were discussed. Reviews encompassed hysterectomy with or without lymph node dissection or cervical conization in cases with microinvasion and radical trachelectomy with or without lymph node dissection as fertility-sparing surgery. Chemoradiation is used to treat advanced cervical malignancies, and the risks and benefits of radiotherapy are significant. Pelvic exenteration is used to treat certain types of recurrences. Use of the Miami pouch for continent urinary diversion was highlighted. Gynecologic oncologists expect novel in vivo imaging techniques currently being developed to help guide therapy choices within the next decade. The most significant research priorities are large group-randomized trials involving fertility-sparing procedures and the management of microinvasive carcinoma (MICA); better identification of candidates for chemoradiation; and the development of innovative approaches to exenteration. Improving diagnostic technologies, refining the criteria by which therapies are chosen, and preserving fertility remain challenges in selecting the most appropriate treatment for invasive cervical cancer. Research advances in both diagnosis and treatment are expected to improve therapy and outcomes.

Combined Modality Therapy↗
PubMed2004

Prognosis and recurrence risk for patients with cervical squamous intraepithelial lesions diagnosed during pregnancy.

BACKGROUND: In the current study, the authors sought to examine the prognosis and recurrence risk for patients with cervical squamous intraepithelial lesions (SILs) diagnosed during pregnancy. METHODS: A retrospective review of all women who gave birth at Walter Reed Army Medical Center (Washington, DC) or the National Naval Medical Center (Bethesda, MD) between 1986 and 1997 was performed. One hundred fifty-seven patients with SILs who underwent antepartum and postpartum evaluation were identified from a total of 6248 records of birth at these two institutions. Patient demographics and cervical cytology and histology were reviewed. RESULTS: One-hundred twenty-nine patients were diagnosed with low-grade squamous intraepithelial lesions (LSILs) antepartum. Of these patients, 49 (38%) had a previous history of abnormal cervical cytology (30 LSILs and 19 high-grade squamous intraepithelial lesions [HSILs]). Twenty-eight patients were diagnosed with HSIL antepartum. Of these patients, 24 (86%) had a history of abnormal cervical cytology. Sixty-two percent of patients with antepartum LSILs had disease regression postpartum, 32% had persistent LSILs postpartum, and 6% experienced progression of an LSIL to an HSIL. All cases of HSIL that were diagnosed antepartum persisted on postpartum cytologic examination. Three patients were found to have microinvasive squamous cell carcinoma after postpartum conization. Five years of follow-up data were available for 98 patients (60%), 78 of whom had antepartum LSILs and 20 of whom had antepartum HSILs. Sixty percent of patients with antepartum LSILs detected on Pap smear developed recurrent LSILs within 5 years, and all 20 patients with antepartum HSILs developed recurrent HSILs within 5 years. CONCLUSIONS: Most cases of LSIL regressed or remained stable during pregnancy. All cases of HSIL diagnosed antepartum persisted in the postpartum period, and 11% of patients with antepartum HSILs were found to have invasive carcinoma postpartum. High rates of recurrence for both LSIL and HSIL were noted 2-5 years after the diagnosis of SIL in the antepartum.

Carcinoma, Squamous Cell↗
PubMed2005

Atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion: the practice experience of a hospital-based reference laboratory with this new Bethesda system diagnostic category.

The 2001 Bethesda System diagnostic category of atypical squamous cells cannot exclude a high grade squamous intraepithelial lesion (ASC-H) was developed and implemented after many studies that proved its clinical relevance. In this study, we describe the practice experience of a hospital-based reference laboratory with this new diagnostic category. The anatomic pathology computer database was searched, and 414 Papanicolaou (Pap) smears signed out as ASC-H were discovered among 60,390 Pap smear accessions over a 17-month period of time. One hundred four cases had corresponding tissue specimens. Slides from all Pap smears and tissue specimens were reviewed, and five Pap smears were reclassified, leaving 99 study cases. In our laboratory, 88.9% of the study cases had either low or high grade dysplasia diagnosed on subsequent tissue specimens. The positive predictive value of ASC-H for histologically proven high-grade squamous intraepithelial lesions (HSIL's) was 40.4%. Of those having human papillomavirus (HPV) hybrid capture II testing, high-risk HPV types were detected in 73.9% of cases. The majority of study cases had less than 25 atypical cells. In two hysterectomy cases and three loop electrosurgical excession procedure (LEEP) conization cases, high-grade dysplasia was present as a single microscopic focus, suggesting that the paucity of atypical cells in ASC-H Pap smears may be secondary to small lesion sampling. Thirteen study patients were postmenopausal and 30.8% had low-grade dysplasia, and of these, 46.2% had high-grade dysplasia on subsequent tissue specimens. In conclusion, our practice experience with ASC-H is similar to that reported in the literature before the 2001 Bethesda System.

DNA Probes, HPV↗
PubMed1994

Cytologic atypia associated with microglandular hyperplasia.

Although it has long been known that microglandular hyperplasia (MGH) may be associated with cytologic atypia in cervical smears, the cytomorphology of MGH has not been described in great detail. To clarify its cytomorphology, Pap smears obtained from biopsy proven cases of MGH over a 3-yr period were reviewed. Of 122 smears containing endocervical cells, 34 (28%) showed striking glandular abnormalities. In two cases, adenocarcinoma and adenocarcinoma in situ were falsely suggested and a high grade squamous intraepithelial lesion (HGSIL-CIN III) was not confirmed in a conization specimen which showed only low grade SIL and MGH. Review of six cytologic diagnoses of HGSIL (CIN III) unconfirmed on biopsy suggested overcalls related to MGH related atypia in five. Cytologic features of MGH, therefore, may occasionally result in erroneous interpretations of HGSIL as well as glandular neoplasia. Although these changes may be striking, comparison with glandular atypia not associated with MGH shows that they are not entirely specific.

Adolescent↗
PubMed1978

Carcinoma in situ cervicis uteri: diagnosis, treatment and prognosis.

A total of 252 patients with carcinoma in situ colli uteri were treated at the Women's Clinic at Turku University between 1964 and 1971. Seventy-seven percent of the patients came to the clinic for treatment after they had participated in a mass screening program (cytodiagnosis, colposcopy). Extrafascial hysterectomy was performed most often on women in the older age groups, while most of the younger patients were treated by conization. Patients were followed up for a minimum of 5 years. There was a 1.0% recurrence of invasive carcinoma and a 4.0% recurrence of noninvasive carcinoma. All invasive recurrences occurred after hysterectomy. None of the patients died from complications of carcinoma.

Adult↗
PubMed2004

Time-dependent hexaminolaevulinate induced protoporphyrin IX distribution after topical application in patients with cervical intraepithelial neoplasia: A fluorescence microscopy study.

BACKGROUND AND OBJECTIVES: Compared to the conventional management of cervical intraepithelial neoplasia (CIN) the potential advantage of photodynamic therapy (PDT) for the treatment of cervical human papilloma virus (HPV)-related disease encompasses a minimal invasive procedure with reduced risk of profuse bleeding as a consequence of conization, and possibly more favorable long-term results avoiding cervical stenosis. At present little is known about the precise time-dependent distribution and histological localization of hexaminolaevulinate (HAL) induced protoporphyrin IX (PPIX) fluorescence in healthy tissue and in CIN. The aim of this study was to use ex vivo fluorescence microscopy to determine whether PPIX is selectively induced by neoplastic cells of the cervical epithelium at various times after topical application. STUDY DESIGN/MATERIALS AND METHODS: Cold cream containing 0.5% HAL was applied by means of cervical cap over various periods of time. We analyzed 52 healthy cervical mucosa and 84 CINs. RESULTS: At time delay 100 (+/-10) minutes, high epithelial fluorescence and a significant selectivity between epithelium and underlying lamina propria was found. By contrast, no significant difference between healthy and neoplastic tissues, or between low and high-grade epithelial dysplasia (P > or = 0.05), was observed at any time point. CONCLUSIONS: Application of HAL 0.5% cream to the cervix induced selective fluorescence in epithelial cells. The optimal ratio with a homogeneous PPIX distribution was obtained after 100 ( +/- 10) minutes cream application, which should be evaluated further for PDT.

Administration, Topical↗
PubMed2003

Does cervical length at 13-15 weeks' gestation predict preterm delivery in an unselected population?

OBJECTIVE: To assess the role of early mid-trimester cervical length measurement as a predictor of spontaneous preterm birth in an unselected population. METHODS: In this prospective study, unselected, asymptomatic, Caucasian women with singleton pregnancies underwent standardized transvaginal ultrasonographic (TVS) cervical length measurement at 13-15 weeks' gestation as a screening test for preterm delivery (PTD). Women with multiple gestations, iatrogenic PTD, and previous cervical conization were excluded. The primary outcome measures were spontaneous PTD at < 37 and < 34 weeks. The correlation between cervical length and previous obstetric history was evaluated. RESULTS: A total of 2469 patients met the inclusion criteria. The mean gestational age at cervical assessment was 14 + 2 weeks. The mean gestational age at delivery was 40 + 0 weeks. The rate of spontaneous deliveries before 37 weeks' gestation was 1.7%. In 0.2% the delivery occurred before 34 weeks' gestation. The mean +/- standard deviation cervical length for the entire population was 44.2 +/- 5.4 mm. No difference was observed between cervical length in women that delivered at term and those that delivered either before 37 or before 34 weeks' gestation. Previous obstetric history (prior preterm birth, previous miscarriages and terminations, and parity) did not affect cervical length at 14 weeks of gestation. CONCLUSIONS: Performed at 14 weeks' gestation, TVS measurement of the cervical canal length to predict spontaneous PTD is not a reliable screening procedure.

Adolescent↗