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PubMed1997

Polyamine measurements in the uterine cervix.

Cervical cancer remains a significant health problem. New strategies based on the molecular aspects of cervical carcinogenesis are needed. Chemoprevention represents a novel strategy for cervical cancer prevention. Our group plans phase I and II trials using alpha-difluoromethylornithine, a suicide inhibitor of ornithine decarboxylase and potent antiproliferative chemopreventive agent. We conducted a study to identify which polyamines in tissue could best serve as surrogate endpoint biomarkers for future trials. Thirty patients with biopsy-proven cervical intraepithelial neoplasia grade 3 underwent colposcopically directed biopsies of normal and abnormal areas of the uterine cervix for analysis of polyamine synthesis biomarkers. Statistically significant differences were found in the ornithine decarboxylase value and the spermidine:spermine ratio between normal and abnormal areas of the cervix. In general, the ranges in measurements varied widely. Differences in polyamine synthesis biomarkers between colposcopically normal and abnormal areas can be demonstrated. However, studies using polyamine synthesis biomarkers in the cervix would require large numbers of patients to achieve significance.

Cervix Uteri↗
PubMed1998

[Re-evaluation of supra-cervical hysterectomy. Incomplete surgery or conservative surgery?].

Up to the middle of this century, most of the hysterectomies executed by benign corporal pathology were subtotal. In the last twenty years this kind of operation is becoming obsolete so that it has been considered a surgical defeat for the gynecologist, who has been judged unable on this occasion, to manage the tenacious uterine adhesions with other organs or pelvic structures. The most important objection, which was made to the supracervical hysterectomy, was that it used to leave in its site a segment of the uterus that more easily than in other cases could lead to canceration. This assertion has never been supported by an adequate cytological, colposcopic preoperatory study of the uterine cervix. Such surveys, nowadays widely spread and trustworthy, would indeed allow to suggest the total hysterectomy for patients affected by intraepithelial and/or invasive lesions. The same surveys would however suggest the conservation of the cervix to those healthy patients willing to a periodical cytological and colposcopic follow-up. Indeed the supracervical hysterectomy is undoubtedly characterized by shorter operation times; it can be easily executed by laparoscopy; it maintains a better pelvic anatomy with poor negative results on the physical, aesthetic and emotional profile.

Decision Making↗
PubMed1998

[The use of electrosurgery in the treatment of extra-cervical genital condylomatosis].

BACKGROUND AND AIMS: The aim of this study was to evaluate the therapeutic efficacy of electrosurgery in the treatment of HPV correlated extra-cervical genital lesions. METHODS: A group of 78 patients with clinical or colposcopic, histologically ascertained vulvar or perineal condylomatosis were enrolled consecutively between March 1994 and July 1995 at the Cervico-Vaginal and Vulvar Pathology Unit of the Obstetrics and Gynecology Clinic at Tor Vergata University, Rome. All patients underwent physical treatment with a radiofrequency electrosurgical knife using exclusively cutting current. In addition to patient compliance, the following parameters were evaluated: length of surgery and recovery times, collateral effects and possible long-term results; a colposcopic and, if necessary, bioptic follow-up was also performed at 3, 6 and 12 months after treatment. RESULTS: Seven out of the group of 68 patients with subclinical condylomatosis presented histologically documented recidivation during the course of follow-up. In the discussion the authors evaluate the positive results obtained using this method and, based on the physical principle underlying electroradiosurgery, they suggest using the term electrosurgical vaporisation for destructive electrotherapy using a cutting current, which is suited to the physical mechanism with which this current acts.

Condylomata Acuminata↗
PubMed1998

An introduction to colposcopy. Concepts, controversies and guidelines for practice.

Colposcopy is a clinical procedure used to investigate the health of the cervix and lower genital tract. This article is limited to an overview of the colposcopic examination. Colposcopy consists of four sequential steps visualization, assessment, sampling, and documentation and correlation. Since most women are dependent on their primary care providers for information and guidance, a post-colposcopic appointment will aid in the discussion of treatment options and help alleviate any fears or unanswered questions. Regardless of the treatment, stress the need for frequent follow-up exams for Pap smears or repeat colposcopy.

Colposcopy↗
PubMedDate not supplied

[Radical hysterectomy with pelvic lymphadenectomy in patients with carcinoma of the uterine cervix--3 years' experience].

INTRODUCTION: Almost all patients with invasive cervical carcinoma can be treated with either primary irradiation therapy or primary surgery. Some patients are appropriately treated with the combination of irradiation and surgery. Chemotherapy is not effective as primary treatment of invasive cervical cancer but may be used as additional therapy and when the disease is recurrent or persistent. There are some important advantages of primary extensive surgery over irradiation. The findings at operation and that from the careful pathologic examination of surgical specimens can be very helpful in selection of patients for supplementary postoperation irradiation therapy or chemotherapy, or both [1-6]. AIM OF THE STUDY: The aim of the study was to compare pretreatment clinical evaluations with surgical and postsurgical pathohistological findings. METHODS: Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. The patients were treated at the Department of Obstetrics and Gynaecology of the Clinical Centre of Serbia in Belgrade, between 1993 and 1995. Cervical cancer was detected by clinical examination, colposcopic and cytologic (Pap smear) findings, colposcopically directed biopsy or conisation and pathological findings, sonography, chest radiography, blood and urine analyses. In some cases we had to make other examinations (cystography, cystoscopy, intravenous pyelography, sygmoidoscopy, rectoscopy, CT scanning and magnetic resonance). The surgical treatment of invasive carcinoma of the cervix was limited to those patients in whom the disease was confined to the cervix or vaginal fornix (stage Ia, stage Ib or stage IIa), and who were in high surgical risk. RESULTS: Over a three year period (1993-1995) there were 251 patients with invasive cervical cancer, treated by primary surgery (radical hysterectomy and bilateral pelvic lymphadenectomy sec. Werthein-Meigs), average age 42 years. Most of the patients demonstrated invasive cervical cancer, clinically classified in Ib st. (81.67%). Some characteristics of pathologic findings, such as parametric width, number of removed lymph nodes, percentage of lymph nodes metastases and correlation with clinical stage of invasive cervical cancer, histologic grade of cervical cancer with lymph node metastasis, pathologic findings after surgical treatment, correlation between clinical and surgical staging, were already presented in tables. DISCUSSION: In the last decades the incidence of invasive cervical cancer and death rate have been decreased. Progress in reducing mortality is primarily attributed to the introduction of cervical cancer screening as part of regular gynaecologic examinations. Regular testing with Papanicolaou (Pap) smear and colposcopy have an important role in this problem [1]. Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. We found that the clinical diagnosis of disease extent was correct in 67.7% of patients who underwent extensive surgery for early invasive cervical cancer. Sensitivity of clinical findings was 75.8% and positive predictive value was 86.2%. Lymph node metastasis was detected in 17% patients. Brodman at al. [14] found that clinical examinations, including CT scanning and magnetic resonance, were correct in only 62.5% of cases. It is very difficult to detect parametric involvement and lymph node metastasis by clinical examinations. Irradiation therapy was used in the postoperative period as additional treatment of extensive hysterectomy and bilateral pelvic lymphadenectomy in 89.7% of patients. CONCLUSION: The findings at operation and that from the careful pathologic examination of surgical specimens are absolutely irreplaceable and important in grading invasive cervical cancer and selection of patients for supplementary postoperate irradiation therapy.

Adult↗
PubMed1998

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.

Adolescent↗
PubMed1989

Colposcopy and computer graphics: a new method?

A new method is herein described that uses the most recent computer science techniques to obtain digitalized colposcopic images that may be useful not only as documents, but also as research tools. Because computer graphics is a recent and ever-growing discipline, our method, too, might undergo considerable improvements: some possible improvements are hypothesized in the text. The most striking features of this method are the excellent quality of images, their easy reproducibility, and the reasonable cost.

Cervix Uteri↗
PubMed2003

Long-term follow-up of patients treated with recombinant human interferon gamma for cervical intraepithelial neoplasia.

OBJECTIVES: The immediate results of interferon gamma (IFN-gamma) treatment in the management of cervical intraepithelial neoplasia (CIN) have been described. However, little is known of the long-term results of this conservative treatment and we aimed to assess them. METHODS: We conducted a 5-year follow-up of 13 women with either complete response to intracervical administration of 6,000,000 IU of IFN-gamma (remission from human papilloma virus-induced CIN occurred in nine cases) or partial response (a lower grade of CIN and/or HPV clearance was achieved in four cases). RESULTS: We performed Papanicolaou smears and colposcopic examinations every 3 months for the first 2 years and every 6 months for the next 3 years. We found three cases of relapse of stage 1 CIN (CIN I), for a recurrence rate of 33.3%, and three cases of complete remission in four subjects with initial diagnosis of partial response. This allowed us to assess the overall lesion-free rate at 53% for the entire group of patients who had CIN I and CIN II treated with IFN-gamma. CONCLUSIONS: Immunomodulation therapy with IFN-gamma has a high long-term efficacy; however, it is inferior to that of surgery.

Adult↗
PubMed1995

Modern image capture and data collection technology.

Computer data collection technology is intended to facilitate patient management and clinic administration. The systems should be devised for ease of usage and careful consideration should be given to the core set of data required and the task to be performed by the system. Security of data is important, and it must cover not only the inadvertent access to confidential data, but also must stop corrupt data from entering the system. Audit is becoming increasingly important, and the ability to achieve this should be inbuilt into any data collection system. A staged introduction of these systems is suggested without trying to achieve too much at the initial attempt. Adaptability is important so that as new technologies are introduced, the old systems should not be made redundant. Eventually it should be possible to achieve the goals set, and include fields for image capture of the colposcopic findings, which although not an essential requirement for such systems, is certainly a desirable one.

Colposcopes↗
PubMed1998

Digital imaging colposcopy: corrected area measurements using shape-from-shading.

The quantitative measurement of areas on the cervix is of interest to researchers studying the natural history of human papilloma viral lesions. Measurement of areas from images obtained through a colposcope are, however, inherently in error due to the image being a two-dimensional projection of a three-dimensional object. The ability to correct for these errors through use of digital imaging colposcopy and a practical application of a shape from shading algorithm was developed in this study. The shape from shading technique requires empirical measurement of the relationship between observed light intensity and the viewing angle (referred to as a reflection map). It was found that a population mean reflection map provided a correction that was about as accurate as using an individual's own reflection map (making it unnecessary to measure a map for each exam). Digital red filtering of the images increased accuracy and precision of measurement.

Adolescent↗
PubMed2004

Women with low-grade abnormalities on Pap smear should be referred for colposcopy.

AIM: To assess cytological, colposcopic and histological outcomes in women referred to a teaching hospital dysplasia clinic with low-grade changes on screening Pap smear. METHODS: Analysis of a computerised database. RESULTS: Repeating the Pap test was of little value. Fifteen percent of women with low-grade changes on the referral smear had biopsy proven high-grade change. There was little difference in biopsy proven high-grade change in women referred with an 'abnormal smear of uncertain significance' (23%) or 'an abnormal smear of uncertain significance-possible high-grade change' (24%). CONCLUSIONS: Given these findings and the current medico-legal climate, immediate referral of women with low-grade changes on routine cytology is indicated, and seems a safer option than the more conservative approach of a repeat smear in 6 or 12 months. Further study of the usefulness of separating smears of uncertain significance into high-grade and low-grade categories is warranted. Consumer input into recommendations for management of Pap smear abnormalities is required.

Biopsy↗
PubMed2004

Portable colposcopy in low-resource settings.

Screening for cervical dysplasia is an important public health effort worldwide. In unscreened populations, the incidence of cervical cancer ranges between 2 and 4% of the adult female population, whereas less than 0.1% of the screened population of Caucasian women has cervical cancer in the United States. In developing countries, cervical cytology is difficult to implement successfully because of the cost, cultural constraints, limited access to pathology services, etc. Bypassing cytology and going directly to colposcopy has been successfully implemented as a screening strategy for dysplasia in low resource settings. In this article we describe the development and utilization of a portable binocular colposcope that does not require electricity.

Adult↗
PubMed1990

Microcolpohysteroscopic tailoring of cervical conization.

The ideal cone biopsy should have its apex just above the transformation zone to ensure removal of all abnormal squamous and metaplastic epithelium in the endocervix, with only minimal normal glandular tissue included. The microhysteroscope has been shown to be useful in identifying the upper limit of the transformation zone within the canal, and this distance from the external os can be measured. However, this technique has not been evaluated to determine whether it can tailor cone length to this predetermined measurement. We report an observational analysis of 176 consecutive conizations in patients with colposcopically proved extension of abnormal epithelium high into the cervical canal. In 162 cases, the distance of the transformation zone from the external os could be measured with the microhysteroscope and its endocervicometer, permitting an attempt to tailor the cone length to this measurement plus a safety margin of 5 mm. There was good correlation between the intended cone length and the excised cone length, with 85% of the excised cones falling within 5 mm above or below the intended measurement. In 153 instances (94.4%), the excised cones had clear endocervical margins. Thus, tailoring of the cone length to the hysteroscopically determined measurement is feasible, thereby increasing the chances of complete excision while limiting cone size to the required minimum.

Adult↗
PubMed1985

Use of panendomicroscopy in the detection and evaluation of cervical premalignant and malignant conditions. A preliminary report.

A new diagnostic method, panendomicroscopy, provides an accurate diagnosis and follow-up of normal and abnormal tissues at cellular level. A prospective study of 36 patients presenting with gynaecological symptoms, was undertaken to compare the diagnostic accuracy of cytologic, colposcopic, histologic and panendomicroscopic findings in gynaecology. We have found that panendomicroscopy gave a 95% (19/20) accurate diagnosis of cervical premalignant and malignant conditions, compared to an 80% (16/20) accuracy with traditional Papanicolaou smear and colposcipc screening.

Adult↗
PubMed1979

An inexpensive operating microscope.

A fiberoptic colposcope was converted through minor alterations into an instrument suitable for use in gynecologic microsurgery. Magnification up to 24x may be obtained, and the extreme mobility, price consideration, and reduction in space at the operating table make it an attractive alternative to a bulky, expensive operating microscope.

Colposcopes↗
PubMed2005

Concurrent evaluation of visual, cytological and HPV testing as screening methods for the early detection of cervical neoplasia in Mumbai, India.

OBJECTIVE: Naked eye visual inspection with acetic acid (VIA), magnified VIA (VIAM), visual inspection with Lugol's iodine (VILI), cytology and human papillomavirus (HPV) testing were evaluated as screening methods for the detection of high-grade squamous intraepithelial lesions (HSIL) of the uterine cervix in a cross-sectional study in Mumbai, India. METHODS: Cytology, HPV testing, VIA, VIAM and VILI were carried out concurrently for 4039 women aged 30-65 years. All women were investigated with colposcopy and biopsies were taken from 939 women who had colposcopic abnormalities. The reference standard for final disease status was histology or negative colposcopy. The presence of HSIL was confirmed in 57 women (1.4%). The test characteristics for each method were calculated using standard formulae. RESULTS: The sensitivities of cytology, HPV testing, VIA, VIAM and VILI were 57.4%, 62.0%, 59.7%, 64.9%, and 75.4%, respectively (differences were not statistically significant). The specificities were 98.6%, 93.5%, 88.4%, 86.3%, and 84.3%, respectively. Adding a visual test to cytology or HPV testing in parallel combination resulted in a substantial increase in sensitivity, with a moderate decrease in specificity. The parallel combination of VILI and HPV testing resulted in a sensitivity of 92.0% and a specificity of 79.9%. CONCLUSION: As a single test, cytology had the best balance of sensitivity and specificity. Visual tests are promising in low-resource settings, such as India. The use of both VIA and VILI may be considered where good quality cytology or HPV testing are not feasible. The sensitivity of cytology and HPV testing increased significantly when combined with VIA or VILI.

Adult↗
PubMedDate not supplied

A cost-benefit analysis of colposcopy for cervical squamous intraepithelial lesions found on Papanicolaou smear.

BACKGROUND: We performed a cost-benefit analysis of a protocol for studying patients with squamous intraepithelial lesions (SIL) on Papanicolaou smears to determine whether it compared favorably with resources spent on other health programs for screening and treatment. METHODS: During a 3-year period, 424 patients with dysplastic Papanicolaou smears were examined, studied by biopsy, and treated. We calculated costs based on a model protocol and derived a cost per year of life saved for preventing death from invasive cervical carcinoma. A sensitivity analysis was performed on selected assumptions of the analysis. RESULTS: The marginal, or incremental, cost of colposcopic evaluation and treatment of Papanicolaou smears with low-grade SIL, high-grade SIL (moderate), and high-grade SIL (severe), depending on assumptions, ranged from $406 to $5746, $160 to $2263, and $85 to $1197 per year of life saved, respectively. Depending on the assumption of the rate of Papanicolaou smears with SIL in the screened population being 1.8%, 5.1%, or 11.5%, the estimated total cost of screening and treating the referral base was $1.3 million, $538,126, and $307,037, respectively. This results in the average cost per year of life saved to screen and treat low-grade SIL, high-grade SIL (moderate), and high-grade SIL (severe) to be $1105 to $68,909, $375 to $21,673, and $177 to $8831, respectively. CONCLUSIONS: Both marginal cost and average screening costs of evaluating and treating abnormal Papanicolaou smears by the protocol described in this article compare favorably with costs per year of life saved for other health care screening and treatment strategies for many assumptions. The marginal cost to perform colposcopy on patients with a Papanicolaou smear with low-grade SIL is so low that it is relatively a very effective strategy.

Adolescent↗
PubMedDate not supplied

Are benign cellular changes on a Papanicolaou smear really benign? A prospective cohort study.

OBJECTIVES: To determine the underlying prevalence of cervical intraepithelial neoplasia (CIN) in women with benign cellular changes on a Papanicolaou smear, and to evaluate follow-up strategies to identify women at high risk for serious underlying pathology. METHODS: Nonpregnant women aged 18 to 75 years with benign cellular changes on a Papanicolaou smear were recruited from primary care clinics of an urban teaching hospital. The subjects (N = 132) were tested at baseline for the presence of human papillomavirus using the polymerase chain reaction technique, and underwent repeated cervicovaginal smears at 3, 6, and 9 months. At 12 months colposcopy was performed. The main study outcome was the proportion of subjects with CIN as determined by colposcopic biopsy specimens. We determined the sensitivity, specificity, and predictive values of historical risk factor information, human papillomavirus testing, and repeated cervicovaginal smears for the detection of CIN. RESULTS: Cervical intraepithelial neoplasia was found in 30 of 132 women, of whom 27 (20%) had low-grade CIN (CIN I) and 3 (2%) had high-grade CIN (CIN II). Underlying CIN was significantly more common in women younger than 35 years or who had a history of Trichomonas infection or venereal warts, a positive human papillomavirus test result, or abnormal follow-up smears. However, no follow-up strategy combined high sensitivity with a low referral rate for colposcopy. CONCLUSIONS: The prevalence of underlying high-grade CIN in women with benign cellular changes is low. However, further prospective studies in other settings are needed before routine follow-up can unequivocally be recommended.

Adult↗