Histomorfometria, apoptose e proliferação celular em neoplasias intraepiteliais do colo uterino / Histomorphometry, apoptosis and cell proliferation in cervical intraepithelial neoplasia

INTRODUÇÃO: As displasias do colo uterino são precursoras do carcinoma de células escamosas. Mutações induzidas por carcinógenos correlacionam-se com alterações proliferativas. O acúmulo dessas mutações e o descontrole da homeostase genômica permitem mudanças na expressão de determinados genes e geram desequilíbrios na proliferação celular e na apoptose. Marcadores imuno-histoquímicos de proliferação celular, de apoptose e de sobrevivência celular em lesões intraepiteliais cervicais ainda necessitam de estudo morfométricos para definir seus papéis na evolução das displasias ao carcinoma invasivo. OBJETIVOS: Para melhor entender os processos de proliferação celular, apoptose e renovação epitelial nessas lesões, foram realizadas histomorfometria para mitose e apoptose e reações imuno-histoquímicas das proteínas Bax, Bcl-2 e Ki-67 (reatividade, localização e intensidade) em biópsias cervicais. MÉTODOS: As amostras foram divididas em quatro grupos: 1. cervicite (n = 20); 2. displasia leve (n = 20); 3. displasia moderada (n = 20); 4. displasia acentuada (n = 20). RESULTADOS: Foram verificadas intensa proliferação celular e apoptose nas lesões de alto grau e ampla, intensa e difusa imunomarcação para Ki-67 e Bax. Esses achados foram encontrados de maneira discreta ou nula nos grupos cervicite e displasia leve. A marcação para Bcl-2 foi mais intensa nas lesões de alto grau, tendo sido discreta nas demais. A ampla marcação imuno-histoquímica de Ki-67 e Bax é sugestiva de elevado grau de renovação celular, o qual também é sustentado pela histomorfometria. A expressão do Bcl-2 aumenta com a gravidade da displasia. CONCLUSÃO: Esses achados indicam que o processo pré-neoplásico é dinâmico, com apoptose e mitose ocorrendo concomitantemente.

INTRODUCTION: Cervical dysplasias are precursor to squamous cell carcinoma of the uterine cervix. Carcinogen induced mutations correlate with proliferative alterations. Accumulation of such mutations and unbalance of genomic homeostasis induce changes in certain genes as well as affect cell proliferation and apoptosis. Immunohistochemical markers of cellular proliferation, apoptosis and cell survival in cervical intraepithelial lesions still require morphometric studies in order to define their role in the development of dysplasias caused by invasive carcinoma. OBJECTIVES: In order to better understand the processes of cellular proliferation, apoptosis and epithelial turn over in such precursory lesions, histomorphometric evaluation for mitosis and apoptosis as well as immunohistochemical reactions for Bax, Bcl-2 and Ki-67 proteins (reactivity, localization and intensity) were carried out in cervical biopsies. METHODS: Samples were split into four groups: 1. cervicitis (n = 20); 2. light dysplasia (n = 20); 3. moderate dysplasia (n = 20); 4. severe dysplasia (n = 20). RESULTS: Intense proliferation and apoptosis were observed in lesions with high, extensive, intense, and diffuse Ki-67 and Bax immunolabeling. Proliferation and apoptosis were mild or null in groups 1 and 2. Bcl-2 immunolabeling was more intense in high degree lesions and mild in the other groups. Extensive Ki-67 and Bax immunolabeling suggests an increased cellular turn over, which was also corroborated by histomorphometry. The more severe the dysplasia is the higher Bcl-2 expression. CONCLUSION: These data indicate that the pre-neoplastic process is dynamic and is concomitant with apoptosis and mitosis.

Detección de virus papiloma humano (HPV) a partir de muestras celulares de cuello uterino en base líquida: Correlación con la inmunorreactividad de la proteína p16INK4a / Detection of human papilloma virus (HPV) in liquid-based cervical samples: Correlation with protein p16INK4a expression

La citología del cuello uterino en base líquida mejora la calidad de la muestra y el material residual podría ser utilizado para realizar pruebas complementarias, como la detección del virus papiloma humano (HPV) y estudio inmunocitoquímico de biomarcadores. El propósito de este estudio fue correlacionar la presencia de HPV y la inmunoexpresión de p16INK4a en las muestras citológicas en base líquida para examinar la utilidad de estas nuevas herramientas en la detección de cáncer de cuello uterino. Las pacientes incluidas (n=67) presentaban una citología anormal o patología cervical previa. La detección y genotipificación de HPV se realizó con PCR-SPF10/LiPA (INNOLiPA Extra Amp) y para la inmunodetección de p16INK4a se utilizó el anticuerpo clon E6H4. La citología convencional proporcionó los mismos hallazgos citológicos que la citología en base líquida. La prevalencia general del HPV fue de 43,3% (29/67). El HPV16 fue el tipo viral mas frecuente (31,03%) y el 48,3% de los casos presentó infección múltiple. En el 35,8% de las muestras cervicales se detectó inmunoexpresión de la p16INK4a y ésta fue significativamente (p<0,020) asociada a la presencia de HPV. Estos resultados apoyan la evidencia que la implementación de nuevas tecnologías en la rutina diaria del laboratorio contribuye significativamente en la detección precoz del cáncer de cuello uterino y en el aporte de datos importantes para facilitar en el manejo clínico adecuado de la paciente. La detección de HPV combinada con la p16INK4a podría ser utilizado en la evaluación de pacientes con mayor riesgo a desarrollar lesiones cervicales significativas.

The liquid-based cervical cytology improves the quality of the sample and the residual sample could be used efficiently to carry out complementary tests, such as the detection of HPV DNA and the immunocytochemical biomarkers study. The purpose of this study was to correlate the presence of HPV and immunoexpression of p16INK4a in liquid-based cervical samples to examine the utility of these new tools in the detection of cervical cancer. The included patients (n=67) presented an abnormal cytology or previous cervical pathology. The HPV detection and genotyping were carried out with PCR-SPF10/LiPA (INNOLiPA Extra Amp) and for p16INK4a immunodetection was used antibody clone E6H4. The conventional cytology provided the same cytologic interpretations that those of liquid-based cytology. The overall HPV prevalence was 43.3% (29/67). HPV16 was the most frequent viral type (31.03%) and 48.3% of the cases were infected with multiple HPV types. p16INK4a immunoexpression was observed in 35.8% of liquid-based cytological samples and this was significantly (p < 0.020) associated to the HPV presence. These results support the evidence that the implementation of new technologies in the daily routine of the laboratory, contribute significantly in the early detection of cervical cancer and provide important data to help in the patient’s efficient management. The combined use of HPV detection and p16INK4a expression could be used for evaluation of patients with more risk to develop significant cervical lesions.

Relación colpohistológica en lesiones de cuello de alto grado / Colpohistological relation in high-grade cervical lesions

OBJETIVOS: Analizar la relación entre los resultados citológicos, colposcópicos e histológicos en pacientes conizadas con asa diatérmica por Lesiones de Alto Grado (LAG) de cuello uterino; clasificar la población con lesiones de alto grado en cuello uterino según edad, paridad, antecedentes familiares e inicio de relaciones sexuales; determinar relación entre citología con lesiones de alto grado y la videocolposcopia; identificar proporción de pacientes con diferentes resultados anatomopatológicos en las citologías de LAG; evaluar la utilidad del uso del asa diatérmica en lo referente a los bordes de sección en los conos realizados, así como el resultado de la prueba citológica poscono.MÉTODOS: Se estudiaron 107 pacientes de la consulta de patología de cuello del hospital "Ramón González Coro" en el año 2006, cuyos resultados iniciales de la prueba citológica fue LAG, a dichas pacientes se les realizó conización por asa diatérmica como proceder diagnóstico y terapéutico previa realización de la videocolposcopia.RESULTADOS: Se detectó que el 67 % (72 casos) de las pacientes con resultados citológicos de LAG,presentaron algún hallazgo colposcópico anormal. De las pacientes conizadas el 84,2 % tenían bordes libres de lesión. Detectamos 3 cánceres cérvicouterinos y en el 31,7 % de los casos se demostró la presencia de lesiones de bajo grado (LBG) de cuello uterino. La citología con cepillado de canal a los 6 meses posteriores al proceder quirúrgico, resultó anormal solo en seis de dichas pacientes. Comprobamos relación citohistológica en el 50 % de los casos estudiados.CONCLUSIÓN: La conización con asa diatérmica, según nuestros resultados, es un proceder seguro, eficaz y con mínimas complicaciones, que evita el ingreso hospitalario, así como, los riesgos anestésicos y quirúrgicos de la cirugía convencional

OBJECTIVES: To analyze the relationship among the cytologic, colposcopic and histologic results in patients underwent conization with diathermic loop from high grade lesions (HGL) of cervix; to classify the populations with above mentioned high grade lesions according to age, parity, family backgrounds and the onset of sexual intercourses; to determine the relation between cytology with high grade lesions and the video-colposcopy; to identify the patient's ratio presenting with different anatomical-pathological results in HGL cytologies; to assess the profit of diathermic loop use concerning to section edges in the conization carried out, as well as the result of the post-conization first results. METHODS: A total of 107 patients were studied in the cervix pathology consultation of the "Ram¾n Gonzßlez Coro" Gynecology and Obstetrics Hospital in 2006 whose first results of cytology test were HGLs, they underwent conization with diathermic loop as diagnostic and therapeutical procedure before videocolposcopy. RESULTS: The 67 percent (72 cases) of patients with cytologic results of HGLs had some abnormal colposcopic finding. From the conization patients the 84.2 percent had lesion-free edges. There were three cervicouterine cancers and in the 31.7 percent it was demonstrated the presence of cervix low-grade lesions (LGL). The cytology with channel brushing at 6 months after surgical procedure, it was abnormal in six of such patients. Also, there was a cytohistological relationship in the 50 percent of study cases. CONCLUSION: The conization with diathermic loop according to our results is a safe, effective and with minimal complications procedure avoiding the hospital admission, as well as the anesthetic and surgical risks of conventional surgery

Factores de riesgo asociados a alteraciones histológicas del aparato genital en pacientes del primer nivel de atención / Risk factors associated with histological alterations of the female genital tract in patients attending a first-level medical care facility

Objetivo: Determinar los factores de riesgo para las alteraciones histológicas del aparato genital en población abierta. Material y métodos: Estudio de casos y controles anidado en una cohorte. Se incluyeron pacientes de la consulta externa que acudieron de forma espontánea al programa de prevención y control de cáncer cervicouterino. Se estudiaron 1933 pacientes, de las cuales 88 fueron diagnosticadas con alteración celular y fueron pareadas con 88 sin alteraciones. El análisis estadístico se realizó con Anova de una vía para la comparación entre grupos y la asociación de las variables con riesgo relativo para un intervalo de confianza de 95 % y p < 0.05. Resultados: El grupo de pacientes consideradas como casos tuvo edad promedio de 36.1 ± 1.6 y el de controles de 35.8 ± 2.1 años. Los diagnósticos obtenidos en el grupo de casos mostró mayor frecuencia de ectropión, infección por virus del papiloma humano y NIC1. Los factores de riesgo analizados solo demostraron diferencia estadística en el número de gestas mayor a dos (RR = 2.33) y el inicio de vida sexual menor a 19 años (RR = 1.14), para padecer algún problema histológico del aparato genital. Conclusiones: La prevención del cáncer cervicouterino se puede realizar por detección oportuna, orientada a evitar o disminuir factores de riesgo, por lo que utilizar preservativo, posponer el inicio de la vida sexual y limitar el número de parejas, son medidas que debe conocer la población general.

BACKGROUND: We undertook this study to determine risk factors for histological alterations of the female genital tract in an open population who attend a first-level care medical facility. METHODS: We conducted a case/control cohort study that included patients from outpatient consultation who responded to a cervical cancer control and prevention program. We studied 1933 patients; 88 patients (cases) had cellular alterations and were matched with 88 patients without alterations (controls). Statistical analysis was carried out with one-way ANOVA for comparison between groups and association of variables with relative risk for 95% confidence interval; p <0.05. RESULTS: Mean age of the case group was 36.1 +/- 1.6 years and the control group had a mean age of 35.8 +/- 2.1 years. Diagnoses obtained in the case group showed a greater frequency of ectropion, human papilloma virus infection and CIN1. Risks factors analyzed in these patients showed statistical differences in number of gestations >2 (RR = 2.33) and the early initiation of sexual activity (<19 years) (RR = 1.14) for experiencing histological problems of the female genital tract. CONCLUSIONS: Prevention of cervical cancer can be accomplished through timely and opportune detection in order to avoid the disease or to decrease risk factors by using condoms, delaying initiation of sexual activity and limiting the number of sexual partners. These are all strategies that the general population should be aware of.