Erythroderma as first manifestation of squamous cell lung cancer: rare case report

Abstract Erythroderma as the first manifestation of a solid organ malignancy is rare. The underlying cancer is a challenging condition to diagnose. There are a few cases of erythroderma in cancer patients reported in the literature. We here describe the case of a 70-year-old man who presented with asthenia, weight loss, dry cough and total body erythema with desquamation over the past month. A chest computed tomography scan showed a nodular lesion, which was finally diagnosed as a squamous cell lung carcinoma. To our knowledge, as an erythroderma presentation, only 13 cases have been reported in the literature. This case report demonstrates the need to search for a neoplasm in patients presenting with erythroderma, particularly in the presence of accompanying debilitating symptoms.

Oral squamous papilloma: a view under clinical, fluorescence and histopathological aspects / Papiloma escamoso oral: uma visão sob aspectos clínicos, de fluorescência e histopatológicos

ABSTRACT Oral squamous papilloma is a benign tumor whose pathogenesis has been associated with human papillomavirus infection. Thus, it is noteworthy that human papillomavirus infection is one of the risk factors associated with the development of cervical, anogenital, pharynx, larynx and oral cavity carcinomas. Oral squamous papilloma can affect any region of the oral cavity, and transmission of human papillomavirus can occur by direct contact, sexual intercourse or from mother to child during delivery. The diagnosis is clinical and histopathological, with surgical removal representing the treatment of choice. Recently, widefield optical fluorescence has been used as a complementary examination to the conventional clinical examination in the screening of oral pathological lesions and for the delimitation of surgical margins. We report a case of oral squamous papilloma with its clinical, histopathological features and, in addition, from the perspective of wide field optical fluorescence.

RESUMO O papiloma escamoso oral é um tumor benigno, cuja patogênese tem sido associada à infecção pelo papilomavírus humano. A infecção pelo papilomavírus humano é um dos fatores de risco associado ao desenvolvimento dos carcinomas cervicais, anogenitais, faríngeos, laríngeos e da cavidade oral. O papiloma escamoso oral pode acometer qualquer região da cavidade oral, e a transmissão do papilomavírus humano ocorre por contato direto, relação sexual ou de mãe para filho durante o parto. O diagnóstico é clínico e histopatológico, e a remoção cirúrgica representa o tratamento de escolha. Recentemente, a fluorescência óptica de campo amplo tem sido empregada como exame complementar ao exame clínico convencional, no rastreio de lesões patológicas orais e para delimitação de margens cirúrgicas. Relatamos um caso de papiloma escamoso oral com suas características clínicas e histopatológicas, sob a perspectiva da fluorescência óptica de campo amplo.

Pilomatrixoma proliferante una rara variante histopatológica simulando un carcinoma de células escamosas / Pilomatrixoma proliferating a rare variant histopathological simulating a cell carcinoma scaly

El Pilomatrixoma es un tumor anexial benigno. Presenta una variante histopatológica infrecuente denominada pilomatrixoma proliferante reportada en 1997 por Kaddu et al. Corresponde a una lesión compuesta predominantemente por una proliferación lobular de células basaloides, con atipia nuclear variable y figuras mitóticas, áreas focales que contienen material cornificado eosinófilo, junto con células sombra. Se propuso al pilomatrixoma proliferante como un subconjunto histopatológico distintivo del pilomatrixoma y se consideró como una variante proliferativa con un perfil histopatológico benigno. La dermatoscopía en este tumor, sobre todo en pacientes de edad avanzada, puede llegar a constituir una trampa dermatoscópica, que es difícil de diferenciar de otras lesiones, como el melanoma o el carcinoma de células basales. Existen múltiples reportes de casos en la literatura donde se informa de pilomatrixomas clásicos o proliferantes simulando otras neoplasias. Presentamos el caso de una paciente de 88 años con pilomatrixoma proliferante facial que simuló clínicamente un carcinoma de células escamosas y llevó a confusión diagnóstica inicial, se destacan las características histopatológicas y clínicas de los pilomatrixomas proliferantes.

Pilomatrixoma is a benign adnexal tumor. It has an infrequent histopathological variant called proliferating pilomatrixoma reported in 1997 by Kaddu et al. It corresponds to a lesion composed predominantly by a lobular proliferation of basaloid cells, with variable nuclear atypia and mitotic figures, focal areas containing eosinophilic cornified material, together with shadow cells. The proliferating pilomatrixoma was proposed as a distinctive histopathological subset of the pilomatrixoma and was considered as a proliferative variant with a benign histopathological profile. Dermatoscopy in this tumor, especially in elderly patients, can result in a dermatoscopic trap, which makes it difficult to differentiate from other lesions, such as melanoma or basal cell carcinoma. There are multiple reports of cases in the literature where classic or proliferating pilomatrixomas were reported simulating other neoplasms. We present the case of an 88-year-old patient with a proliferating facial pilomatrixoma that clinically simulated a squamous cell carcinoma and led to an initial diagnostic confusion, highlighting the histopathological and clinical characteristics of the proliferating pilomatrixoma.

Follow-up of women with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesions (ASC-H) / Acompanhamento de mulheres com celulas escamosas atipicas nao pode excluir lesao intraepitelial de alto grau (ASC-H)

CONTEXT AND OBJECTIVE: The concept that the presence of atypical squamous cells cannot exclude high-grade squamous intraepithelial lesions (ASC-H) was introduced in the 2001 Bethesda System of cervical cytology classification. This nomenclature defines cervical cancer precursor lesions. The objective of this study was to investigate the colpocytological-histological results from a three-year follow-up conducted on a cohort of women with reports of ASC-H who were attended during 2005-2006 at clinics of the Southern Metropolitan Healthcare Service of Santiago, Chile. DESIGN AND SETTING: Prospective cohort study at primary healthcare clinics in Santiago, Chile. METHODS : Colpocytological-histological follow-up was conducted over a three-year period on 92 women with cytological reports of ASC-H who were attended at primary healthcare clinics during 2005-2006. RESULTS : At the end of the follow-up period, high-grade lesions were evaluated and the following outcomes were observed: seven women presented invasive cancer (7.6%), 49 presented high-grade lesions (53.3%), 26 presented low-grade lesions (28.2%) and 10 presented normal results (10.9%). The "Conditional Probabilities Tree Diagram" was used to show the results from tests and the times of lesion detection. It demonstrated that, after a first report of ASC-H, clinical management needed to be interventionist. CONCLUSION: The follow-up on our cohort of women showed that the majority of uncertain ASC-H diagnoses (82.6%) had abnormal colposcopic results and that during the follow-up using ASC-H smears, two out of every three women developed high-grade lesions. .

CONTEXTO E OBJETIVO: O conceito de que à presença de células escamosas atípicas não se pode excluir lesão intraepitelial de alto grau (ASC-H) foi introduzido pelo Sistema de Bethesda 2001, na classificação de citologia cervical. Esta nomenclatura define lesões precursoras do câncer cervical. O objetivo deste estudo foi investigar os resultados colpo-cito-histológicos de três anos de acompanhamento realizado em uma coorte de mulheres com relatórios de ASC-H que receberam atendimento no período 2005-2006 em clínicas do Serviço Metropolitano de Saúde Sul de Santiago, Chile. TIPO DE ESTUDO E LOCAL: Estudo de coorte prospectivo em unidades básicas de saúde de Santiago, Chile. MÉTODOS: Foi conduzido um acompanhamento colpo-cito-histológico por um período de três anos em 92 mulheres com laudos citológicos de ASC-H, que receberam atendimento nas unidades básicas de saúde de 2005-2006. RESULTADOS: No final do período de acompanhamento, as lesões de alto grau foram avaliadas e os resultados foram observados: sete mulheres apresentaram câncer invasivo (7,6%), 49 apresentaram lesões de alto grau (53,3%), 26 apresentaram lesões de baixo grau (28,2%) e 10 apresentaram resultados normais (10,9%). O "Diagrama de Árvore Condicional de Probabilidades" foi utilizado para mostrar os resultados dos testes e o período de detecção das lesões, demonstrando que, depois de um primeiro relatório de ASC-H, o manejo clínico deve ser intervencionista. CONCLUSÃO: O acompanhamento de nossa coorte de mulheres mostra que a maioria dos diagnósticos incertos de ASC-H (82,6%) tiveram resultado colposcópico anormal e, durante o acompanhamento de esses esfregaços ASC-H, duas de cada três mulheres desenvolvem lesões de alto grau. .

The utility of p16 INK4a and Ki-67 to identify high-grade squamous intraepithelial lesion in adolescents and young women.

Background: The repair of the immature squamous epithelium following HPV infection may mimic HSIL in adolescent women. Aim: to study the utility of p16 INK4a and Ki-67 in diagnosis of cervical squamous lesions in adolescents and young adults. Materials and Methods: In a cross-sectional study, the evaluation of p16 INK4a and Ki-67 immunohistochemistry was performed on 72 cervical biopsies of adolescents and young adults women diagnosed as negative for malignancy and intraepithelial lesion (NML) (n = 18) or positive for low grade (LSIL) (n = 31) and high grade (HSIL) (n = 23) squamous intraepithelial lesions in two references services in Fortaleza-Brazil. Data was evaluated using Fisher's test and Kappa index. Results: p16 INK4a was positive in 81% of HSIL, 19% of LSIL and in no NML (P < 0.0001). Ki-67 was positive in 74%, 32% and 5.5% of HSIL, LSIL and NML, respectively. p16 INK4a and Ki-67 in the diagnosis of HSIL showed high sensitivity and negative predictive value. Kappa index was very good for p16 INK4a (k = 0.72). Conclusions: In adolescents and young adults p16 INK4a alone or with Ki-67 represents important tool to reduce mistaken diagnosis of HSIL and to avoid overtreatment.

Infección por virus papiloma humano en pacientes con células escamosas atípicas de un programa de pesquisa de cáncer cervical / Human papilloma virus infection in patients with atypical squamous cells of a screening program for cervical cancer

Evaluar la frecuencia de la infección por virus del papiloma humano en pacientes con células escamosas atípicas de un programa de pesquisa de cáncer de cuello uterino. Laboratorio Asistencial “Lic. Celina Sánchez Rincón y Laboratorio de Biología y Medicina Experimental LABIOMEX. Universidad de Los Andes. Mérida, Estado Mérida. Estudio prospectivo y descriptivo que incluyó las pacientes vistas entre marzo de 2006 y diciembre de 2009. Se tomaron muestras para evaluación citológica y detección del virus papiloma humano, mediante la metodología molecular PCR-RFLP a pacientes de pesquisa de cáncer cervical. Se estudiaron 2 805 pacientes seleccionándose las que presentaron informe citológico de células escamosas con atipias de significado indeterminado y con atipias que no excluyen lesión intraepitelial escamosa de alto grado. Del total de mujeres evaluadas por citología, 121 (4,31 por ciento) tenían informe de anormalidades en células epiteliales. Las células escamosas atípicas se encontraron en 58 (2,06 por ciento) citologías, 52 (1,85 por ciento) eran células escamosas con atipias de significado indeterminado y 6 (0,21 por ciento) eran células escamosas con atipias que no excluyen lesión intraepitelial de alto grado. La prevalencia general de la infección por virus del papiloma humano fue de 32/58 (53,4 por ciento). Los virus del papiloma humano de alto riesgo oncogénico se encontraron en 10/58 (17,2 por ciento) de los casos, la mayoría en el grupo etario de 21-30 años. No se pudo determinar el tipo viral en un 16/58(27,5 por ciento) de las muestras. Se observó una elevada prevalencia de virus del papiloma humano en pacientes con informe citológico de células escamosas atípicas.

To evaluate the frequency of human papillomavirus infection in patients with atypical squamous cells of a cervical cancer detection program. Between March 2006 to December 2009, specimens for cervical smears and human papillomavirus molecular detection by PCR-RFLP were taken from the patients attended at the cervical cancer clinic prevention. Facultad de Farmacia y Bioanálisis. Laboratorio Asistencial “Lic. Celina Sánchez Rincón y Facultad de Ciencias, Laboratorio de Biología y Medicina Experimental LABIOMEX. Universidad de Los Andes. Mérida, Estado Mérida, Venezuela. A total of 2 805 patients were evaluated, those with atypical squamous cells of undetermined significance and atypical squamous cells that cannot exclude a high intraepithelial lesion were chosen. Abnormalities in epithelial cells were found in 4,31 percent. Atypical squamous cells were found in 58 (2,06 percent) of the cases, 1,85 percent were atypical squamous cells of undetermined significance and 0,21 percent were atypical squamous cells that cannot exclude a high intraepithelial lesion. The overall prevalence of human papillomavirus infection was 32/58 (53,4 percent). High risk human papillomavirus was found in 10/58 (17,2 percent)of the patients, most of them between 21 and 30 years old. Human papillomavirus could not be determinedin 16/58 (27,5 percent) of the cases. It was observed a high frequency of human papillomavirus in patients with atypical squamous cells in their cervical smears.

Algoritmos de derivación y confirmación diagnóstica de citología cervical atípica: desafíos para la actualización / Derivation algorithms for the clinical management of women with cytologic abnormalities

El Programa Nacional de Pesquisa y Control del Cáncer Cervicouterino de Chile ha contribuido al descenso sostenido de la mortalidad por cáncer de cuello uterino. Para la reducción de esta mortalidad ha sido fundamental la citología exfoliativa del cérvix, la que no está exenta de resultados inciertos. En este sentido, los frotis clasificados como atípicos se consideran ambiguos por la presencia de anomalías celulares de difícil determinación, lo que se traduce en un diagnóstico de probabilidad incierta. En la literatura nacional como internacional, se manifiesta un notorio interés por unificar la nomenclatura citológica cervical y los algoritmos de derivación y confirmación diagnóstica, para el manejo clínico de las mujeres con anomalías citológicas cervicales y lesiones precursoras de cáncer cervicouterino. Por lo anterior, se considera relevante los estudios que proporcionen evidencia clínica epidemiológica actualizada, que permitan optimizar el cumplimiento del Programa Nacional de Cáncer Cervicouterino, conducentes al logro de los Objetivos Sanitarios del período 2011-2020.

The National Research and Control of Cervical Cancer in Chile had contributed to the sustained decline in mortality from cervical cancer. The exfoliative cytology of the cervix has been to reduce this mortality, which is not without uncertain results. The smears classified as atypical are considered ambiguous by the presence of cellular abnormalities difficult to determine, resulting in a diagnosis of uncertain probability. The literature, both nationally and internationally, is widespread interest to unify the nomenclature cervical cytology and the support of the derivation algorithms for the clinical management of women with cytologic abnormalities cervical and cervical cancer precursor lesions. Therefore, it is relevant to perform studies the provide updated epidemiological clinical evidence, to optimize the performance of the National Program for the achievement of health objectives for the period 2011-2020.

Protective association exhibited by the single nucleotide polymorphism (SNP) rs1052133 in the gene human 8-oxoguanine DNA glycosylase (hOGG1) with the risk of squamous cell carcinomas of the head & neck (SCCHN) among north Indians.

Background & objectives: Imbalances in compactly regulated DNA repair pathways in the form of single nucleotide polymorphisms (SNPs) within vital DNA repair genes may result in insufficient DNA repair and increase in DNA breaks thus rendering the human system vulnerable to the debilitatory effects of grave diseases like cancers. The present study involves investigation of association of the non-synonymous SNP rs1052133 (C8069G/Ser326Cys) located in the exonic region of the gene human 8-oxoguanine DNA glycosylase (hOGG1) with the risk of squamous cell carcinomas of the head and neck (SCCHN). Methods: Case-control based genetic association study was performed among 575 (250 SCCHN cases and 325 normal healthy controls) sub-population cluster-matched (Indo-Europeans linguistic subgroup + Caucasoid morphological subtype) samples from the north Indian States of Uttar Pradesh and Uttarakhand using polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) and DNA sequencing analysis. Results: Our results demonstrated statistically significant protective association for the heterozygous CG [Odds Ratio (OR) 0.6587, 95% Confidence Interval (CI) 0.4615 to 0.9402, P=0.0238], homozygous mutant GG (OR 0.2570, 95% CI 0.1070 to 0.6175, P=0.0013) and combined mutant CG + GG (OR 0.6057, 95% CI 0.4272 to 0.8586, P=0.0059) genotypes. Interpretation & conclusions: The results indicate that the polymorphism rs1052133 is strongly associated with SCCHN susceptibility and the mutant (G) allele might be a protective factor for SCCHN among north Indian subpopulations.

Lesões escamosas intraepiteliais de baixo grau: conduta em mulheres adultas / Low-grade intraepithelial lesions: management in adult women

O objetivo deste estudo foi rever o acompanhamento adequado das pacientes adultas com diagnóstico citológico de lesão intraepitelial de baixo grau (LSIL). Foi realizada busca eletrônica de publicações no Medline, SciELO e Mesh (por meio do PubMed), LILACS, EBSCO e Google Acadêmico. As diretrizes foram identificadas e sumarizadas. As diretrizes consideradas válidas foram aquelas elaboradas para França, Canadá, Brasil, Europa, Estados Unidos, Nova Zelândia, Hong Kong e Índia. Tais documentos recomendaram três estratégias diferentes: repetição da citopatologia com intervalo de seis meses antes de encaminhar para colposcopia, encaminhamento direto à colposcopia ou realização do teste de DNA do papilomavírus humano (HPV) nas pacientes com diagnóstico de LSIL. As recomendações encontradas variam de acordo com fatores relacionados à paciente e às condições governamentais de cada país. Concluiu-se que a repetição citológica no intervalo de seis meses, conduta preconizada pelo Ministério da Saúde, mostra-se adequada em termos de custo-efetividade para a realidade do Brasil

The purpose of this work was to review the appropriate management of adult patients with low-grade squamous intraepithelial lesions (LSIL) citologic diagnosis. An electronic search of publications in Medline, Scielo and Mesh (through PubMed), LILACS, EBSCO and Academic Google was carried out. The valid guidelines considered were those prepared for France, Canada, Brazil, Europe, United States, New Zealand, Hong Kong and India. Such documents recommend three different strategies: to repeat citopathology at intervals of six months before refer to colposcopy, to refer directly to colposcopy or to carry out the human papiloma virus (HPV) DNA test in patients with LSIL diagnosis. The recommendations found varied according to factors related to the patient and the governmental conditions of each country. It was concluded that repeat citopathology at intervals of six months, management recommended by the Brazilian Ministry of Health, is appropriate in terms of cost-effectiveness for Brazil

Prevalence and pattern of nodal metastasis in pT4 gingivobuccal cancers and its implications for treatment.

Context: The pattern of nodal spread in oral cancers is largely predictable and treatment of neck can be tailored with this knowledge. Most studies available on the pattern are from the western world and for early cancers of the tongue and floor of the mouth. Aims: The present study was aimed to evaluate the prevalence and pattern of nodal metastasis in patients with pathologic T4 (pT4) buccal/alveolar cancers. Settings and Design: Medical records of the patients with pT4 primary buccal and alveolar squamous cell carcinomas treated by single-stage resection of primary tumor and neck dissection at Gujarat Cancer and Research Institute (GCRI), Ahmedabad, a regional cancer center in India, during September 2004 to August 2006, were analyzed for nodal involvement. Materials and Methods: The study included 127 patients with pT4 buccal/alveolar cancer. Data pertaining to clinical nodal status, histologic grade, pT and pN status (TNM classification of malignant tumors, UICC, 6th edition, 2002), total number of nodes removed, and those involved by tumor, and levels of nodal involvement were recorded. Statistical analysis was performed using the Chi-square test. Results: Fifty percent of the patients did not have nodal metastasis on final histopathology. Occult metastasis rate was 23%. All of these occurred in levels I to III. Among those with clinically palpable nodes, level V involvement was seen only in 4% of the patients with pT4 buccal cancer and 3% of the patients with alveolar cancer. Conclusions: Elective treatment of the neck in the form of selective neck dissection of levels I to III is needed for T4 cancers of gingivobuccal complex due to a high rate of occult metastasis. Selected patients with clinically involved nodes could be well served by a selective neck dissection incorporating levels I to III or IV.

Seguimiento de mujeres con anormalidad citológica de cuello uterino, en Colombia / Following-up females having an abnormal Pap smear in Colombia

Objetivo Evaluar el acceso y la oportunidad al diagnóstico y al tratamiento que tienen las pacientes con lesiones cervicales de alto grado o cáncer de acuerdo con el reporte citológico, en Colombia entre junio 2005 a junio del 2006. Metodología Estudio retrospectivo mediante encuestas a una muestra de mujeres con anormalidad citológica residentes de cuatro departamentos de Colombia seleccionados por conveniencia en relación con diferentes tasas de mortalidad. Se realizó análisis descriptivo y se compararon las diferencias entre los departamentos. Resultados El 27 por ciento de las mujeres con lesiones de alto grado o invasoras no tuvieron acceso a alguno de los servicios diagnósticos o terapéuticos por razones de tipo administrativo de los servicios de salud, razones clínicas y culturales de las mujeres. Discusión Un elemento crítico que explica el bajo impacto en la mortalidad por cáncer de cuello uterino en la mayoría de los países de Latino América es la disociación entre actividades de tamización y las de tratamiento.

Objective Evaluating the opportunity and access to diagnosis and treatment for females having had an abnormal Pap smear (high-grade epithelial lesion and cervical cancer) in Colombia from June 2005 to June 2006. Materials and Methods This was a retrospective appraisal using a semi-closed survey of females having had an abnormal Pap smear with high squamous intraepithelial lesions or cervical cancer living in four Colombian departments. These areas were conveniently selected according to their different mortality rates. A descriptive analysis was made and the departments differences compared. Results It was found that 27 percent of females having high-grade squamous intraepithelial lesion or cervical cancer had no access to any of the diagnostic or therapeutic services. Health service administration problems and clinical and cultural ones affecting the females in the study could explain such results. Discussion Follow-up care after abnormal cytology was very poor and could explain the lack of cervical cancer screening impact in Colombia and in most Latin-American countries.

Effectiveness of see-and-treat for approaching pre-invasive lesions of uterine cervix / Efetividade da abordagem "ver e tratar" em lesões pré-invasivas no colo uterino / Efectividad del abordaje "ver y tratar" en lesiones pre-invasivas en el colon uterino

OBJECTIVE: To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS: A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS: Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9 percent (95 percent CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4 percent (95 percent CI: 0.04;2.7) and 5. percent (95 percent CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0 percent (95 percent CI: 0.4;3.6). CONCLUSIONS: The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.

OBJETIVO: Comparar a efetividade do método "ver-e-tratar" (V&T) com a abordagem tradicional (biópsia prévia) das lesões escamosas intraepiteliais do colo uterino. MÉTODOS: Trata-se de um estudo transversal realizado na cidade do Rio de Janeiro, RJ, de 1998 a 2004, com 900 pacientes não gestantes que apresentavam citologia sugestiva de lesão intraepitelial escamosa de alto grau. O método V&T inclui a excisão ampla da zona de transformaçao que é indicada quando a citologia é sugestiva de lesão intra-epitelial escamosa de alto grau, a colposcopia é satisfatória e compatível com a alteração citológica e a alteração colposcópica deve estar limitada à ectocérvice e ao primeiro centímetro do canal cervical. Foi analisado o subgrupo de 336 pacientes com colposcopias consideradas satisfatórias, compreendendo dois grupos para comparação: pacientes tratadas sem biópsia prévia (n=288) versus pacientes tratadas após a biópsia mostrando lesão intraepitelial escamosa de alto grau (n=48). Foram consideradas perdas as pacientes não tratadas ou tratadas apenas um ano ou mais após recrutamento pela clínica de colposcopia, no grupo V&T. RESULTADOS: Das pacientes recrutadas durante o período do estudo, 71 não foram tratadas ou foram tratadas apenas um ano mais tarde, fornecendo uma taxa global de abandonos de 7,9 por cento (IC 95 por cento: 6,1;9,7). O tempo médio entre a captação da paciente e o tratamento foi de 17,5 dias no V&T e 102,5 dias no grupo biópsia prévia. As taxas de perdas foram de 1,4 por cento (IC 95 por cento: 0,04;2,7) no grupo V&T e de 5,9 por cento (IC 95 por cento: 0;12,3) no de biópsia prévia (p=0,07). A proporção de tratamentos desnecessários (histologia negativa) no grupo V&T foi 2,0 por cento (IC 95 por cento: 0,4;3,6). CONCLUSÕES: A diferença de tempo médio entre a captação da paciente e o tratamento indicou que o V&T é um método que poupa tempo. A proporção de casos negativos quando o método V&T foi utilizado pode ser considerada baixa.

OBJETIVO: Comparar la efectividad del método "ver-y-tratar" (V&T) con el abordaje tradicional (biopsia previa) de las lesiones escamosas intraepiteliales del colon uterino. MÉTODOS: Estudio transversal realizado en la ciudad de Rio de Janeiro, Sureste de Brasil, de 1998 a 2004, con 900 pacientes no gestantes que presentaban citología sugestiva de lesión intraepitelial escamosa de alto grado. El método V&T incluye la excisión amplia de la zona de transformación que es indicada cuanto la citología es sugestiva de lesión intraepitelial escamosa de alto grado, la colposcopia es satisfactoria y compatible con la alteración citológica y la alteración colposcópica debe estar limita a la ectocervix y la primer centímetro del canal cervical. Fue analizado el subgrupo de 336 pacientes con colposcopias consideradas satisfactorias, comprendiendo dos grupos para comparación: pacientes tratadas sin biopsia previa (n=288) versus pacientes tratadas posterior a la biopsia mostrando lesión intraepitelial escamosa de alto grado (n=48). Fueron consideradas pérdidas las pacientes no tratadas o tratadas sólo un año o más posterior al reclutamiento por la clínica de colposcopia, en el grupo V&T. RESULTADOS: De las pacientes reclutadas durante el período de estudio, 71 no fueron tratadas o fueron tratadas sólo un año más tarde, suministrando una tasa global de abandonos de 7,9 por ciento (IC 95 por ciento: 6,1;9,7). El tiempo promedio entre la captación de la paciente y el tratamiento fue de 17,5 días en el V&T y 102,5 días en el grupo biopsia previa. Las tasas de pérdidas fueron de 1,4 por ciento (IC 95 por ciento: 0,04;2,7) en el grupo V&T y de 5,9 por ciento (IC 95 por ciento: 0;12,3) en el de biopsia previa (p=0,07). La proporción de tratamientos innecesarios (histología negativa) en el grupo V&T fue 2,0 por ciento (IC 95 por ciento:0,4;3,6). CONCLUSIONES: La diferencia de tiempo promedio entre la captación de la paciente y el tratamiento indicó que el V&T ...

Prevalence of cervical intraepithelial neoplasia grades II/III and cervical cancer in patients with cytological diagnosis of atypical squamous cells when high-grade intraepithelial lesions (ASC-H) cannot be ruled out / Prevalência de neoplasia intra-epitelial cervical graus II/III e câncer cervical nas pacientes com diagnóstico citológico de células escamosas atípicas, quando não se pode excluir lesão intra-epitelial de alto grau (ASC-H)

Context and objective: The latest update of the Bethesda System divided the category of atypical squamous cells of undetermined significance (ASCUS) into ASC-US (undetermined significance) and ASC-H (high-grade intraepithelial lesion cannot be ruled out). The aims here were to measure the prevalence of pre-invasive lesions (cervical intraepithelial neoplasia, CIN II/III) and cervical cancer among patients referred to Instituto Fernandes Figueira (IFF) with ASC-H cytology, and compare them with ASC-US cases. Design and setting: Cross-sectional study with retrospective data collection, at the IFF Cervical Pathology outpatient clinic. Methods: ASCUS cases referred to IFF from November 1997 to September 2007 were reviewed according to the 2001 Bethesda System to reach cytological consensus. The resulting ASC-H and ASC-US cases, along with new cases, were analyzed relative to the outcome of interest...

Contexto e objetivo: A última atualização do Sistema Bethesda dividiu a categoria de células escamosas atípicas de significado indeterminado (ASCUS) em ASC-US (de significado indeterminado) e ASC-H (quando não se pode excluir lesão intra-epitelial de alto grau). Os objetivos deste estudo foram medir a prevalência da lesão pré-invasiva (Neoplasia Intra-epitelial Cervical, NIC II/III) e câncer cervical, de pacientes que foram encaminhadas ao Instituto Fernandes Figueira (IFF), com citologia ASC-H e compará-la com os casos ASC-US. Tipo de estudo e local: Estudo transversal com coleta de dados retrospectiva, que ocorreu no ambulatório de Patologia Cervical do IFF. Métodos: Casos com diagnóstico de ASCUS recebidos no IFF entre novembro de 1997 a setembro de 2007, foram revisados de acordo com o Sistema Bethesda 2001 até um diagnóstico de consenso. Os casos ASC-H e ASC-US resultantes desta revisão, e os casos novos, foram analisados em relação ao desfecho de interesse...

Evidence for benefits from treating cervical ectopy: literature review / Evidências de benefícios no tratamento de ectopia do colo do útero: revisão de literatura

CONTEXT AND PURPOSE: Uterine cervical ectopy (cervical erosion) is today considered to be a physiological condition, but there still seems to be a strong tendency towards treating it. The purpose of this study was to review the medical literature for evidence regarding benefits from treating cervical ectopy. METHODS: The following databases were reviewed: Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica Database (Embase), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) and Cochrane Library databases. In addition, six medical textbooks were consulted. RESULTS: The review showed that: 1) there is probably an association between ectopy and higher risk of Chlamydia trachomatis, human papillomavirus and human immunodeficiency virus infection; 4) there is probably an association between ectopy and cervical intraepithelial neoplasia; 5) there is an association between ectopy and mucous discharge and nocturia; and 6) there is no evidence of an association between ectopy and cervical cancer, or of protection against cervical cancer associated with ectopy treatment. CONCLUSIONS: 1) No data were found in the medical literature to support routine treatment for ectopy; 2) Treatment could be recommended for symptom relief, but more symptoms are attributed to ectopy than could be demonstrated in a controlled study; 3) Further studies to test the hypothesis of protection against cervical cancer associated with treatment are necessary.

CONTEXTO E OBJETIVO: A ectopia do colo do útero é hoje considerada um fenômeno fisiológico, mas parece ainda haver uma forte tendência no sentido da intervenção (tratamento). Este estudo se propõe a realizar revisão da literatura buscando evidências de benefícios conseqüentes ao tratamento da ectopia. MÉTODOS: Pesquisa nas bases Medical Literature Analysis and Retrieval Sysem Online (Medline), Excerpta Medica Database (Embase), Literatura Latino-Americane e do Caribe em Ciências da Saúde (Lilacs), Biblioteca Cochrane e seis livros especializados. RESULTADOS: A revisão mostrou que: 1) existe provavelmente associação de ectopia com infecção cervical por Chlamydia trachomatis, pelo vírus HPV e maior risco de soroconversão para HIV; 2) existe provavelmente associação entre ectopia e neoplasia intra-epitelial cervical; 3) existe associação com mucorréia e nictúria; 4) não existem evidências sobre associação entre ectopia e câncer de colo do útero nem sobre proteção contra este câncer proporcionada pelo tratamento da ectopia. CONCLUSÕES: 1) Não foram encontrados na literatura dados que justifiquem o tratamento rotineiro da ectopia; 2) O tratamento pode ser utilizado para tratar sintomas associados à ectopia, porém mais sintomas são atribuídos à ectopia do que se pôde confirmar em um estudo controlado; 3) Seriam necessários novos estudos para testar a hipótese de proteção contra o câncer de colo proporcionada pelo tratamento.

How can the overtreatment rate of "see and treat" approach be reduced in women with high-grade squamous intraepithelial lesion on cervical cytology?

Background: The aim of this study was to determine the incidence and predictors of overtreatment in "see and treat" approach using loop electrosurgical excision procedure (LEEP) in women with high-grade squamous intraepithelial lesion (HSIL) on cervical cytology. The overtreatment was considered when LEEP specimens contained no cervical pathology. Between January 2001 and April 2006, 446 women with HSIL on Pap smear underwent colposcopy followed by LEEP at Chiang Mai University Hospital. Mean age of these patients was 45.6 years with a range of 25-78 years. One hundred and twenty-one (27.1%) women were menopausal. Unsatisfactory colposcopy was observed in 357 (80.0%) women. Of 446 women, histologically-confirmed HSIL, invasive cancer, low-grade squamous intraepithelial lesions, and adenocarcinoma in situ were detected in 330 (74.0%), 76 (17.0%), 9 (2.0%), and 5 (1.1%), respectively. The overtreatment rate on LEEP specimens was noted in 26 women or 5.8% (95% confidence interval [CI] = 3.8 to 8.4) of 446 women. By multivariate analysis, postmenopausal status was the only significant independent predictor of overtreatment with an adjusted odds ratio of 2.89 (95% CI = 1.30 to 6.43, P = 0.009). When postmenopausal women were excluded from analysis, the overtreatment rate was reduced to only 4.0%. In conclusion, "see and treat" approach appears to be an appropriate strategy in managing women with HSIL cytology. The overtreatment rate could be reduced when such policy is limited for premenopausal women.

Significado clínico do achado citológico de células escamosas atípicas de significado indeterminado / Clinical significance of a cervical cytologic diagnosis of atypical squamous cells of undetermined significance

O termo células escamosas atípicas de significado indeterminado (ASCUS) foi introduzido na Classificação Citológica de Bethesda (1988 modificada em 1991) e é utilizado para identificar processos inflamatórios, reativos ou reparativos, atípicos ou mais intensos, que qualitativa e quantitativamente não são suficientes para serem interpretados como neoplasia intra-epitelial cervical (NIC). Desde a subdivisão inicial em provável reativo ou provável neoplásico o sistema de Bethesda descreve diferentes subgrupos para o termo ASCUS e alguns autores sugerem que há valor significante na subclassificação do ASCUS baseada em critérios morfológicos definidos. O uso do termo ASCUS tem ocasionado confusão e controvérsias em relação ao seu significado clínico e uso adequado. O presente estudo tem como objetivo revisar a utilização do termo ASCUS na descrição dos esfregaços cérvico-vaginais e avaliar os recentes avanços descritos na literatura sobre o uso da divisão do termo em critérios morfológicos para definição de melhor conduta e prognóstico, além de associação com agentes microbiológicos causadores de inflamação e Papilomavírus Humano (HPV)

The impact of a community intervention to improve cervical cancer screening uptake in the Amazon region of Brazil

CONTEXT AND OBJECTIVE: In the northern region of Brazil, cervical cancer is the most important cause of cancer-related deaths among women. There is considerable likelihood, however, that official incidence and mortality figures are greatly underestimated. The aim of this study was to estimate the repercussions from improvement in cervical cancer screening programs on the incidence of pre-invasive and invasive cervical lesions in a municipality in this region. DESIGN AND SETTING: This was a quasi-experimental study that assessed process dimensions relevant to the program objectives. The study comprised a sample of 2,226 women seen at primary healthcare units in Cruzeiro do Sul, a small city in the Brazilian Amazon region, from April 2003 to July 2004. METHODS: Women were recruited through local radio advertisements and by oral communication from the investigators. The women answered a structured questionnaire and underwent pelvic examination, which included Papanicolaou (Pap) smears and naked-eye inspection of the cervix after applying diluted acetic acid. Women with positive Pap smears or abnormal gynecological examination were referred for colposcopy and possible biopsy, diathermic large loop excision of the transformation zone or conization. RESULTS: The results obtained were compared with historical official data retrieved from the Brazilian Ministry of Healths database. Intervention resulted in a 40 percent increase in positive Pap smears and detection of cancer was nine times higher than had been observed in routine screening. CONCLUSIONS: Detection of pre-invasive and invasive cervical lesions in the intervention group was remarkably higher than among women seen during routine screening.

CONTEXTO E OBJETIVO: Na Região Norte do Brasil, o câncer do colo do útero é a mais importante causa de morte, por câncer, entre as mulheres. É muito provável, entretanto, que os dados oficiais referentes à incidência e à mortalidade estejam grosseiramente subestimados. O objetivo foi estimar as repercussões que a melhora dos programas de rastreamento possam exercer sobre a incidência de lesões pré-invasoras e invasoras do colo do útero em uma municipalidade da região Amazônica brasileira. TIPO DE ESTUDO E LOCAL: Este estudo "quasi-experimental" avaliou dimensões processuais relevantes para os objetivos do programa de rastreamento. Foi incluída uma amostra de 2.226 mulheres, atendidas em unidades básicas de saúde de Cruzeiro do Sul, uma pequena cidade da Amazônia Brasileira, entre abril de 2003 e julho de 2004. MÉTODOS: As mulheres foram recrutadas através de anúncio pelo rádio e por comunicação oral desempe-nhada pelos próprios pesquisadores. Após assinarem o Termo de Consentimento Informado, responderam a um questionário estruturado e foram submetidas a exame pélvico, o que incluiu coleta e colpocitologia oncológica (CO) e inspeção da cérvice após aplicação de ácido acético diluído. Mulheres com CO positiva ou exame ginecológico anormal foram encaminhadas para colposcopia e eventual biópsia, excisão diatérmica da zona de transformação ou conização. RESULTADOS: Os resultados obtidos foram comparados a dados históricos oficiais referentes à cidade de Cruzeiro do Sul, recuperados do banco de dados do Ministério da Saúde do Brasil. Em comparação aos dados históricos, a intervenção resultou em um aumento de 40 por cento na freqüência de CO positiva, e a detecção de câncer foi nove vezes superior àquela dos dados oficiais. CONCLUSÕES: A detecção de lesões cervicais pré-invasoras e invasoras no grupo que sofreu intervenção foi marcadamente superior à das mulheres atendidas pelo programa oficial de rastreamento.

Análise comparativa entre a ressecção óssea marginal e segmentar da mandíbula no tratamento dos carcinomas epidermóides avançados de loja amigdalina e região retromolar / Comparative analysis between marginal and segmental mandibular resection in the treatment of tonsil and retromolar trigone advanced epidermoid carcinoma

INTRODUÇÃO: A ressecção do ramo ascendente da mandíbula foi, durante várias décadas, considerada o tratamento de eleição para os tumores da loja amigdalina e região retromolar, independente do grau de acometimento do osso mandibular, ocasionando um déficit funcional e estético considerável, muitas vezes, com prejuízos irreparáveis à qualidade de vida, às vezes desnecessário. Assim, a ressecção marginal do osso mandibular surgiu como uma alternativa de tratamento viável, uma vez que a manutenção de um segmento do ramo mandibular, em lesões sem comprometimento ósseo, não aumenta os índices de recidiva, tampouco compromete os princípios de radicalidade oncológica. OBJETIVO E MÉTODOS: Por meio de estudo retrospectivo de Outubro de 1994 a Dezembro de 2001, foram comparados 42 pacientes portadores de tumores avançados de região retromolar e loja amigdalina, sendo 20 deles submetidos a ressecção marginal do osso mandibular e 22 submetidos a ressecção do ramo ascendente da mandíbula, em relação a complicações, seqüela de procedimentos, recidiva locorregional e sobrevida. RESULTADOS: Dos 20 pacientes tratados com mandibulectomia marginal, avaliados por um período de 9 a 60 meses, sete (35%) pacientes morreram com doença, com sobrevida mínima de 09 meses, 3 por recidiva local, 3 por recidiva regional e 1 por recidiva locorregional. Um paciente morreu no pós-operatório imediato. Na avaliação da peça cirúrgica encontramos todas as margens livres, considerada exígua em profundidade em dois pacientes, um deles falecido por recidiva local. Houve disseminação linfonodal em 15 pacientes sendo com ruptura extracapsular em 4, encontrada em 2 pacientes com recidiva regional. O controle locorregional foi obtido em 63% dos pacientes. Dos 22 pacientes tratados com ressecção segmentar do osso mandibular, com intervalo de seguimento de 14 a 60 meses, 8 (36,4%) morreram pela doença, com sobrevida mínima de 9 meses, 5 por recidiva local e 3 por recidiva à distância...

INTRODUCTION: For several decades, resection of the ascending ramus of the mandible was considered to be mandatory for the treatment of tonsil and retromolar trigone tumours, independent from the damage degree of the mandibular bone, causing considerable functional and aesthetic deficit, many times with irreparable quality of life loss, sometimes unnecessary. Thus, marginal resection of the mandibular bone appeared as a feasible alternative treatment, since maintaining a segment of the mandibular ramus in lesions without bone involvement did not increase the recurrence indexes or compromise the principles of oncological radicalness. OBJECTIVES AND METHODS: Through a retrospective study from October 1994 to December 2001, 42 patients with advanced retromolar and tonsil tumors were compared, 20 undergoing marginal resection of the mandibular bone and 22 undergoing segmental resection of the ascending ramus of the mandible, with regard complications, injury originated from the procedure, locoregional recurrence and survival. RESULTS: From the 20 patients undergoing to marginal mandibulectomy, assessed for a period of 09 to 60 months, seven (35%) patients died of the disease, with a minimal survival of 9 months: 3 due to local recurrence, 3 due to regional recurrence and 1 due to local and regional recurrence. One patient died in the immediate postoperative period. When assessing the surgical part, all the margins were found to be free and in two patients, were considered to be of little depth, one of them being found in one of the patients that died from local recurrence. There was lymph nodal dissemination in 15 patients, with capsular rupture in 4, of which two presented regional recurrence. The locoregional control was obtained in 63% of the patients. From the 22 patients undergoing to segmental resection of the mandibular bone, with a follow-up varying from 14 to 60 months, 8 (36.4%) died of the disease, with a minimum survival of 9 months, 5 due...

High-grade squamous intraepithelial lesion with endocervical cone margin involvement after cervical loop electrosurgical excision: what should a clinician do?

This study was undertaken to evaluate the incidence and severity of residual lesions in women featuring high-grade squamous intraepithelial lesion (HSIL) histology with endocervical cone margin involvement after the loop electrosurgical excision procedure (LEEP). The medical records of women undergoing LEEP at Chiang Mai University Hospital between October 2004 and February 2006 were retrospectively reviewed and 74 cases were identified. Nineteen women were excluded because of loss to follow-up. The remaining 4 were referred to other hospitals and 2 declined re-excision, leaving a study population of 55 women for analysis. Mean age+/-SD of the patients was 48.5+/-8.9 years. Residual lesions were noted in 26 (47.3%, 95%CI=33.7 to 61.2). Four (7.3%) had unrecognized invasive cervical carcinoma in subsequent specimens. In conclusion, approximately half of women with positive endocervical cone margins after LEEP for HSIL histology have residual disease. Repeat diagnostic excision is recommended for evaluation of lesions and severity.