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PubMed1984

Cervical intraepithelial neoplasia in adolescents.

Three hundred and eleven adolescent patients with abnormal Pap smears were referred for evaluation. Two hundred and ninety-three were evaluated with colposcopy and directed biopsies. Fourteen percent had normal findings, 42% CIN I, 22% CIN II, and 22% CIN III. The distribution of pathologic findings was similar to that in an adult population in the same clinic except that no invasive carcinomas were found in our adolescents. Since there was a predominance of exocervical lesions, only 3% of the patients required diagnostic conization. Ninety-four percent of the adolescents were treated by cryotherapy as compared to 68% of the adults. Since adolescents have significant cervical intraepithelial neoplasia, an abnormal Pap smear should be evaluated and a tissue diagnosis obtained. Outpatient therapy is well suited for the majority of teenagers because the lesions are commonly confined to the exocervix.

Adolescent↗
PubMed1997

Rupture of the membranes and postpartum infection.

The greatest risk of preterm prelabour rupture of membranes (PPROM) is preterm delivery. According to the Perinatal Information System of Slovenia there were 5.92% preterm deliveries in 1994. We studied 809 deliveries of less than 34 weeks of gestation in the Ljubljana Maternity, from 1992 to 1994; 33.7% of these started with PPROM. Risk factors for PPROM were conization, cerclage and use of antibiotics for any reason in current pregnancy. Amnionitis and febrile illness during labour increased with longer duration of PPROM but maternal postpartum infections did not. In neonates, more cases of lower Apgar scores after 1 and 5 min and more cases of suspected sepsis were found with the increased duration of PPROM. In Slovenia, with good facilities for transport in utero and good neonatal care, after PPROM it is best to transport the pregnant women to the third level center and then wait until labour starts or to recur to prompt delivery when maternal or fetal signs so require. From 1987 to 1993 there were 159264 deliveries in gestations equal to or over 34 weeks; 20.8% started with PROM. In our observational study we found the best results when labour was induced. There are, however, many disagreements about the management of (P)PROM.

Bacterial Infections↗
PubMed1999

Villoglandular papillary adenocarcinoma of the uterine cervix.

Villoglandular papillary adenocarcinoma of the uterine cervix was recently (1989) described by three main histological features: exophytic proliferation, papillary architecture and mild to moderate cellular atypicality. The authors report a case of villoglandular papillary adenocarcinoma, clinical stage IB, which was peculiar because of its association with a co-existing and simultaneously discovered invasive squamous cell carcinoma. These two patterns were juxtaposed and not intermingled. The patient was treated with radical hysterectomy followed by vaginal radiation therapy. She remains without evidence of recurrence after 12 months of follow-up. Five main clinicopathological features of the villoglandular papillary adenocarcinoma could be stressed: rare histological variant (72 described cases), young age of patients (25-45 years old), superficial stromal invasion, usual association with other tumoral patterns (in situ or invasive adenocarcinoma as well as in situ or invasive squamous cell carcinoma) and excellent prognosis. For selected cases, a conservative surgical approach (cervical conization) was possible.

Adenocarcinoma, Papillary↗
PubMed1979

Is there a carcinoma in situ of gastric mucosa?

Carcinoma in situ, a precancerous lesion in the strict sense, was first recognized in stratified squamous epithelia. It is characterized by markedly atypical cells replacing the autochthonous epithelial cells without stromal invasion, the basement membrane being well preserved. Notwithstanding gradual transitions between carcinoma in situ on the one hand and dysplasias and invasive cancer on the other hand, its histological separation from the latter is feasible in the uterine portio. Its recognition has decisive therapeutic and prognostic implications, particularly in view of the frequently observed latent period between purely superficial spread and early invasive growth. In contrast difficulties are encountered in applying the concept of Carcinoma in situ to mucosal lesions of the stomach, though an analogous replacement stage has to be postulated, because the gastric and cervical mucous membranes differ fundamentally in their structural characteristics. The epithelial cells of the surface, pits and tubular glands do exhibit progressive atypia during cancerization. However, the single-layered epithelium offers far less distinctive criteria than the stratified squamous epithelium. Newly formed glandular complexes cannot be accepted as evidence for in situ growth. The latent period between purely superficial replacement by atypical cells and invasion appears to be considerably shorter in the stomach than in the portio, probably because the mechanical resistance of the loosely textured gastric lamina propria is small. In addition, stromal invasion may originate from any one epithelial cell in the gastric mucosa, whilst it is just the basal layer from which invasively growing cells may emanate in the uterine portio. The occurrence of dysplasia in the mucosa of the stomach does not justify a gastrectomy, according to our current experience, there being no intervention in gastric surgery equivalent to that of conization.

Carcinoma in Situ↗
PubMed1986

Proliferative activity in dysplasia, carcinoma in situ and microinvasive carcinoma of the uterine cervix.

Proliferative activity of various human uterine cervical lesions obtained by conization was examined by measuring the proportion of mitotic cells including abnormal mitosis and the nuclear DNA content by a microspectrophotometer. Twelve ratios of mitotic cells calculated in the present study showed a step-wise increase from normal squamous cell epithelium through various grades of dysplasia to carcinoma in situ (CIS). The great difference between moderate and severe dysplasia was observed. All ratios in CIS with bulky outgrowth (CIS(b)) were the highest. The nuclear DNA content in various lesions also indicated the great difference between moderate and severe dysplasias in the DNA histograms. Severe dysplasia had a wider distributed DNA histogram without distinct modes similar to those in CIS and the non-invasive areas of the microinvasive carcinoma. These results may suggest that severe dysplasia but not slight or moderate dysplasia is a direct precursor lesion for uterine cervical epidermoid carcinoma.

Carcinoma in Situ↗
PubMed2002

Traditional management of invasive cervical cancer.

Cervical carcinoma is staged clinically by examination and simple radiological procedures. CT and MRI can, however, be used to guide management. Prognosis is best made by tumor size. depth of invasion, parametrial involvement, nodal status, LVSI, and histology. CIN III and CIS can be treated by ablative or excisional procedures. Hysterectomy should not be the primary treatment. Microinvasive (<3 mm) Stage IA cervical carcinoma can be treated conservatively with conization in patients who desire fertility, but the standard of care remains simple hysterectomy. Stages IB and IIA can be treated with either radical hysterectomy or radiation therapy dependent upon the patient's health and preference. Risk factors after radical hysterectomy (eg, bulky tumors, deep invasion, involved nodes or margins. LVSI) might warrant adjuvant radiation therapy. Chemoirradiation is the current standard of care for treatment for Stages IIB, III, and [VA. Some clinicians also use this modality in patients with Stage IB disease who are undergoing radiation as the primary treatment. Locally recurrent disease can be treated with either radiation (after radical hysterectomy) or pelvic exeteration (after primary radiation therapy). Exenteration in appropriately selected patients yields 5-year survival rates up to 82% with low complication rates. Many exenterations are aborted intraoperatively because of distant or unresectable disease, however. The incidence of glandular carcinoma of the cervix is rising, particularly in younger women. Cervical carcinoma detected during pregnancy requires the combined efforts of the gynecologic oncologist and the maternal-fetal medical specialist to determine the timing and method of treatment.

Carcinoma in Situ↗
PubMed1995

Glandular lesions of the cervix: diagnostic and therapeutic dilemmas.

The term 'glandular lesions' applies mainly to the spectrum of intraepithelial neoplasia affecting the glandular epithelium of the cervix, but consideration must also be given to non-neoplastic disorders. Various systems of terminology are used, the most satisfactory being low grade and high grade CIGN. The criteria for histological diagnosis are quite well defined, although the distinctions between low grade and high grade lesions and between intraepithelial and early invasive disease can be problematic. Although many cases are initially diagnosed on smears, the cytological diagnosis can also be difficult, particularly when squamous lesions are also present, as happens in about 50% of cases. Both histologically and cytologically, the differential diagnosis between CIGN and non-neoplastic changes must be made. Treatment for high grade lesions has traditionally been hysterectomy, but there is evidence that conization with careful cytological follow-up may be safe in certain circumstances. Women with low grade lesions are generally managed in the same way; the role of cytological surveillance of women with mild glandular abnormalities in their smear is not clear. Although there is evidence to substantiate the belief that CIGN is a precursor of adenocarcinoma of the cervix, very little is known of the natural history of these lesions, their relations to one another and the significance of the low grade abnormalities. This uncertainty hampers a rational approach to management.

Biopsy↗
PubMed2000

The clinical importance of atypical glandular cells of undetermined significance on the cytologic smear.

The objective of the study was to assess the prevalence of underlying cervical and endometrial lesions among patients with atypical glandular cells of undetermined significance (AGCUS) on the cytologic smear. Eighty-six patients with AGCUS, without evidence of squamous intraepithelial lesions, underwent coloposcopy and endocervical curettage (ECC) within 6 months of the initial finding. Endometrial samplings were performed in 25 patients. Coloposcopy, endocervical curettage, and endometrial biopsy results were reviewed. A significant lesion was defined as cervical intraepithelial neoplasia and/or any structural or histologic abnormality of the cervix or uterus (i.e., polyp). Statistical analyses were performed using the t test, chi-square, and Fisher's Exact tests comparing patients with underlying lesions to those without. A significant lesion(s) was identified in 21 (24.4%) patients, with 8 (9.3%) of the lesions being high-grade cervical neoplasias. An additional 14 (16.3%) patients, with negative initial work-ups, had underlying lesions or major cytologic abnormalities diagnosed on subsequent follow-up. All of the endometrial findings were benign. None of the following were statistically significant predictors of underlying pathology: age, gravidy, parity, medications, medical history, tobacco use, history of sexually transmitted diseases including human immunodeficiency virus, previous abnormal cytologic smear, concurrent diagnosis of atypical squamous cells of undetermined significance, or evidence of human papillomavirus. AGCUS is often associated with clinically important underlying lesions. Patients should therefore undergo colposcopy and ECC. Endometrial sampling and possible cervical conization should be performed when coloposcopic evaluation is nondiagnostic.

Journal Article↗
PubMed1998

Hysterosonography as an adjunct to transvaginal sonography in the evaluation of intraluminal lesions of the uterine cavity.

Objective: Hysteroscopy is a simple technique that can be used to outline the contours of the uterine cavity under real-time ultrasound guidance. This study was undertaken to determine whether hysterosonography can be used as an adjunct to transvaginal sonography in predicting either the presence or absence of intraluminal lesions in the uterine cavity and in distinguishing these lesions from subendometrial or myometrial lesions.Methods: In this retrospective analysis, 1,467 transvaginal sonograms performed in the office of a single gynecologic oncology practice from March 1996 through June 1997 were reviewed. Of these, 38 sonograms were considered to have possible intraluminal lesions of the uterine cavity and thus further evaluated by hysterosonography. The principle investigator performed all the hysterosonograms by infusing 15-30 mL of sterile saline directly into the uterine cavity using a Soules 5.3F transcervical catheter. Real-time transvaginal sonography was performed simultaneously, and representative images were compared with the initial transvaginal sonograms.Results: Successful hysterosonograms were obtained in 36 patients (97.3%). One patient had cervical stenosis from a previous conization, precluding access to the uterine cavity. The hysterosonography was tolerated well by the patients with minimal discomfort. There was no incidence of endometritis. The median age was 56.2 years. Postmenopausal bleeding was the most common presenting symptom (30.0%). The indications for hysterosonography were abnormal findings on the initial transvaginal sonograms including lesions suggestive of intraluminal mass (73.0%), thickened endometrial stripe (13.5%), and increased echogenicity (10.8%). Hysterosonography revealed presence of intraluminal masses in only 11 of the 31 cases (35.5%) that had been suggested to contain either a mass or thickened endometrial stripe. Subsequent hysteroscopy, dilatation, and curettage confirmed the presence of endometrial polyp in all 11 cases. The remaining 65.5% contained no intraluminal masses or thickened endometrial stripe.Conclusion: Hysterosonography can be a valuable adjunct to transvaginal sonography and may be used in selected cases to eliminate the need for hysteroscopy, dilatation, and curettage.

Journal Article↗
PubMed2001

Colposcopically directed biopsy findings in the young female.

STUDY OBJECTIVE: To evaluate the colposcopic findings of cervical alterations in the young sexually active female. DESIGN, SETTING, PARTICIPANTS: Colposcopic examination and follow-up of 51 young sexually active females aged 15-20 yr was conducted due to abnormal cytology or a suspicious abnormality of the cervix. The study was conducted at the Colposcopy Units of the 1(st) and 2(nd) Departments of Obstetrics and Gynecology, University of Athens, Greece. ONTERVENTIONS: Colposcopic examination, LEEP, conization. MEAN OUTCOME MEASURES: Biopsy, human papillomavirus (HPV) typing. RESULTS: Colposcopic examinations were within normal limits in 8 of 51 (15.7%) cases. Cervical alterations were related to HPV infection in 14 cases (27.4%), to cervical intraepithelial neoplasia (CIN) I in 15 (29.4%) cases, to CIN II in 13 (25.5%) cases, and to CIN III in 1 (2.0%) case. Of all CIN I cases, 8 of 15 (53.3%) were HPV positive, and HPV type 11, 16, 18, 31, 33, and 11& 16 were found. In CIN II cases, 5 of 13 (38.4%) were HPV positive, and HPV type 11, 16, 18, and 11 & 31 were found. In the CIN III case, only HPV type 16 was found. CONCLUSIONS: Our findings strongly confirm the necessity of obtaining cervicovaginal smears on all sexually active gynecologic and obstetric teenage patients. Colposcopy plays a major role in the evaluation of the cervix and in the treatment that should be given for any individual CIN lesion.

Adolescent↗
PubMed2002

Human papillomavirus DNA testing by PCR-ELISA and hybrid capture II from a single cytological specimen: concordance and correlation with cytological results.

BACKGROUND AND OBJECTIVES: A persistent infection by high-risk HPV is now considered as the major cause of cervical carcinoma. The use of a single cytological specimen for HPV DNA testing by two different molecular methods was analyzed and validated. STUDY DESIGN: HPV DNA testing by PCR-ELISA and hybrid capture II HPV test (HC-II), was investigated on 317 cytological samples obtained from Italian women. Two hundred twenty-seven women were referred to virological lab for HPV DNA testing during cytological routine screening and 90 during a cytological and virological follow-up after a conization or hysterectomy. RESULTS: Overall, the concordance between the two assays was high (K=0.87). Compared with PCR-ELISA, the HC-II showed a sensitivity of 91.7% and a specificity of 95.4%. Although the analytical sensitivity of the PCR-ELISA was higher, the performance of the two tests did not differ in recognizing HPV DNA positive patients with either low or high-grade squamous intraepithelial lesions (LSIL or HSIL). HPV DNA positivity was directly correlated with the severity of cytological diagnosis (P<0.005). CONCLUSIONS: In view of the comparable results obtained with the two assays and of the ease of use, and higher throughput of HC-II, it seems advisable, with a single cytological specimen, to employ the HC-II test as a first-line assay, either for screening or diagnosis, and to perform reflex PCR on positive samples, if typing of prevalent high risk HPVs is needed.

DNA, Viral↗
PubMed2000

Polymorphism at codon 72 of p53 is not associated with cervical cancer risk.

P53 allelic polymorphism at codon 72 has been studied as a possible predisposing factor for cervical carcinogenesis with inconsistent results. Storey and colleagues recently published the interesting finding of a 7-fold increased risk for cervical cancer in women homozygous for the arginine allele at codon 72. This stimulated a number of independent investigations, the majority of which found no association of cervical cancer and arginine homozygosity. With the use of a modified Storey method for determining codon 72 allelotypes, DNA was examined from 431 microdissected, formalin-fixed, archival cervical conization specimens ranging from low-grade squamous lesions to invasive cancer. An alternative independent method using restriction fragment length polymorphism analysis was performed on all arginine homozygotes and all indeterminate cases for confirmation and final allelotype assignment. With the use of Storey's method alone, logistic regression suggested an association (odds ratio, 1.42) between arginine homozygosity and invasive disease. However, with the use of the combined method for accurate allelotyping, this trend disappeared (odds ratio, 1.00), the discordance was clearly resolvable as being due to methodologic variables. With the use of two separate methods for codon 72 allelotyping and accounting for a number of the issues raised in previously published reports, there is no increased risk for invasive cervical cancer associated with arginine homozygosity at codon 72 of p53.

Adenocarcinoma↗
PubMed2001

HPV DNA testing of the residual sample of liquid-based Pap test: utility as a quality assurance monitor.

HPV DNA testing of the residual sample volume of liquid-based Pap tests has been recommended as a way to determine the appropriate follow-up for women who have equivocal results in routine clinical screening. A major aspect of quality assurance in the cytopathology laboratory consists of correlation of smear interpretation with biopsy or conization results as mandated by CLIA '88. However, the use of histology as the gold standard suffers from similar problems of subjectivity and sampling as the Pap smear. In this study we explore the potential use of HPV DNA testing of the residual volume from the ThinPrep Pap Test (Cytyc Corporation, Boxborough, Massachusetts) as a substitute gold standard in quality assurance monitoring of a cervical cytology screening program. The residual samples from 397 ThinPrep Pap cases were retrospectively analyzed for high-risk HPV DNA using the Hybrid Capture II technique. Sensitivity (71.8%), specificity (86.5%), predictive value of positive (77.1%) and negative (82.9%) ThinPrep Pap interpretations were calculated on the basis of HPV DNA results for 266 cases classed as either squamous intraepithelial lesion (SIL) or negative. Overall, there was agreement between the two tests in 80.8% of cases (Cohen's kappa =.59). The percentage of HPV DNA-positive cases interpreted as atypical squamous cells of uncertain significance (ASCUS) was 43.7%, and the percentage of negative cases was 17.1%. We believe that this approach is an objective adjunct to the traditional quality assurance protocol, with the added benefit that it includes cases interpreted as negative, as well as abnormal cases that do not come to biopsy.

Carcinoma in Situ↗
PubMed2002

Situation analysis of atypical squamous cells of undetermined significance smears in Songklanagarind Hospital.

OBJECTIVE: To review the incidence, management, follow-up rate and colposcopic diagnosis of atypical squamous cells of undetermined significance (ASCUS) detected on cervical smears in Songklanagarind Hospital, Thailand. METHODS: A retrospective study of ASCUS smears taken during January 2000 to March 2001 at Songklanagarind Hospital was performed. The type of management was classified and the follow-up rate was detected. Cases with colposcopy, tissue biopsy, endocervical curettage, conization and hysterectomy specimen were reviewed. In the cases without tissue biopsy, the final diagnoses were based on the colposcopic examination. RESULTS: Among the 25068 Pap smears examined, the incidence of ASCUS was 0.62%. Of these, only 56.13% received the further evaluation. The non-compliance rate was 18.71%. The incidences of cervical intraepithelial neoplasia (CIN) and invasive cancer among the cases who received colposcopy were 15.96% and 2.13%, respectively. The incidence of CIN or invasive cancer in ASCUS favor reactive and ASCUS favor neoplasia were not different statistically significant. CONCLUSIONS: Management of ASCUS smears by follow-up may be inappropriate. A practice guideline which consists of active management, intensive follow-up system and well-organized data management should be used to improve the situation.

Adult↗
PubMed1994

Prostaglandin-induced cervical dilatation prior to intracavitary radiotherapy for carcinoma of the cervix: a pilot study.

The efficacy of 1 mg 16,16-dimethyl-trans-Delta2 prostaglandin E1 (Gemeprost) pessaries in achieving cervical dilatation prior to intracavitary brachytherapy was investigated in 16 post-menopausal women with cervical carcinoma. All had received external beam pelvic radiotherapy in the preceding 6 weeks. Four patients were nulliparous and 12 multiparous (mean parity 1.9). FIGO stages were IB (2), IIA (4), IIB (5), IIIA (1), IIIB (3), IVB (1). The cervical os was assessed before pessary insertion and again at the time of intracavitary insertion. The os was closed in 100% (16/16) of patients before and open in 75% (12/16) of patients after pessary insertion. The maximum size of Hegar dilator passed without mechanical dila-tation was recorded. Mean cervical dilatation was 4.25 H (5.5 H in those with a clinical response). The 12 responding patients had rapid and uncomplicated procedures with no need for additional mechanical dilatation. Both patients in whom attempted mechanical dilatation failed had had previous conization of the cervix. The following mild side-effects were reported: abdominal cramps (43.8%), headache (12.5%) and fever (6.3%). These data support the use of Gemeprost pessaries to achieve cervical dilatation in post-menopausal women undergoing intracavitary brachy-therapy following external beam radiotherapy.

Journal Article↗
PubMed1995

The role of the loop electrosurgical excision procedure in the diagnosis and management of early invasive cervical cancer.

The management of cervical intra-epithelial neoplasia (CIN) has evolved so that excisional techniques are now preferred over ablative procedures. This is in part due to a 1-3% rate of discovering unsuspected early invasive carcinomas that would not have been detected by ablative management of CIN. A review of our initial experience over 20 months with the loop electrosurgical excision procedure (LEEP) in treating CIN found seven out of 237 patients (3%) to have otherwise unsuspected invasive lesions. The management of three additional patients with suspected early invasive lesions has been facilitated by LEEP. The procedure has been found to produce excellent pathologic specimens and has virtually replaced traditional operative cervical conization in the management of both CIN and early invasive cervical cancer.

Journal Article↗
PubMedDate not supplied

A comparison of the therapeutic efficacies of large loop excision of the transformation zone and hysterectomy for the treatment of cervical intraepithelial neoplasia III.

The technique of large loop excision of the transformation zone (LLETZ) came into vogue in the 1990s, and has been widely used in place of cold knife conization for diagnosis and treatment. Although its therapeutic efficacy for cervical intraepithelial neoplasia (CIN) has been confirmed and accepted in many countries, no direct comparison is available of the efficacies of LLETZ and hysterectomy for the treatment of CIN III, and unfortunately, hysterectomy is still widely used in many other countries. The aim of this analysis was to confirm the efficacy of LLETZ for the treatment of CIN III and to compare its results with those of hysterectomy. Between Jan. 1993 and Dec. 1997, 380 patients with CIN III were treated in the Seoul National University Hospital. We defined group I (n = 101) as those patients who underwent therapeutic LLETZ and follow-up only and group II (n = 279) as those patients who underwent hysterectomy following LLETZ. Three patients in groups I (3.0%) and II (1.1%) developed persistent/recurrent CIN or vaginal intraepithelial neoplasia (VAIN). This result was not statistically significant. Group II contained more patients with positive resection margins and glandular extensions than group I (P < 0.05), and these factors might have been confounding variables. However, when parameters influencing the rate of treatment failure were compared, no significant differences were found by logistic regression analysis (P > 0.05). The results obtained show that the LLETZ is almost identical in terms of its therapeutic efficacy to hysterectomy and that it should be accepted as a standard treatment for CIN III.

Adult↗
PubMedDate not supplied

Nonradical treatment is as effective as radical surgery in the management of cervical cancer stage IA1.

This study was designed to evaluate a series of patients who underwent surgical management due to cervical cancer stage IA1 fitting the 1995 FIGO definition. A total of 149 patients were followed from 3 years to 11.7 years with a median follow-up interval of 5 years. The cases with invasions of < or = 1 mm and > 1 mm but < or = 3 mm were noted in 89 (59.7%) and 60 (41.3%) patients, respectively. Lymphvascular space invasion was identified in five patients. In 49 patients, conization or nonradical hysterectomy was performed without pelvic lymph node dissection (PLND) and pelvic recurrence developed in one patient who had an extended hysterectomy. PLND was performed in 100 patients and the average number of lymph nodes examined per case was 26.5 +/- 10.1. None of the 100 patients had metastasis to the pelvic lymph node and recurrence. None of the 149 patients has died from recurrent disease. In conclusion, this study suggests that patients with cervical cancer stage IA1 have an extremely low risk of pelvic lymph node metastasis, very rarely recur, and present an excellent prognosis, so nonradical management that excludes PLND could be as effective as radical surgery in these patients.

Adenocarcinoma↗