El método CONO-UC: un protocolo integrado de toma de decisión y manejo de lesiones pre-invasoras del cuello uterino útil para especialistas jóvenes / The CONO-UC method: an integrated protocol for decision-making and management of pre-invasive cervical lesions useful for young specialists

OBJETIVOS: En la actualidad, existe una alta tasa de sobre-tratamiento de lesiones precursoras cervicales, la cual, en su causalidad, depende de la inexperiencia del operador que toma las decisiones. El objetivo del presente trabajo fue desarrollar un método estandarizado de ponderación/juicio de variables diagnósticas y tratamiento útiles de ser usadas por especialistas jóvenes a fin de minimizar el riesgo de manejo inadecuado. MATERIALES Y MÉTODOS: Se incluyeron 471 pacientes referidos por citología anormal y tratados mediante asa de LEEP. Se calcularon la sensibilidad, la especificidad, los valores predictivos y las relaciones de probabilidad para el diagnóstico de NIE2+ para cada uno de los métodos de diagnóstico. A cada residente se le enseñó un protocolo estandarizado de tratamiento mediante asa. Una vez identificados los mejores predictores, se construyó una escala de puntaje que ponderaba las variables y se definió mediante curva ROC el major punto de corte para la predicción de NIE2+. Las diferencias entre los grupos se compararon mediante Chi-cuadrado, ANOVA o t-test. Se construyó curva de fallas mediante el método de 1-Kaplan Meier. RESULTADOS: La prevalencia de NIE2+ en esta cohorte fue 66%. La concordancia entre las pruebas diagnósticas fue baja, teniendo la colposcopia el peor valor predictivo positivo y el mayor riesgo de sobre-tratamiento. Para la escala de puntaje se incluyeron la edad, la citología, la colposcopia (estratificación basada en la extensión de compromiso por cuadrantes), la biopsia por mascada y la concordancia entre pruebas diagnósticas. Un puntaje≥ 9 asociado al uso de un protocolo estandarizado, obtuvo tasas de sobre-tratamiento <15%, de recurrencias de NIE2+ <5% a 5 años y una baja tasa de procedimientos sub-óptimos o con complicaciones (<2 %). CONCLUSIONES: El método CONO-UC al combinar un sistema de puntaje integrado (punto de corte) con un protocolo estandarizado de excisión, permite minimizar el riesgo de sobretratamiento o tratamiento inadecuado, por parte de especialistas jóvenes, de lesiones preinvasoras del cuello uterino, reduciendo además el número de procedimientos indicados innecesariamente y manteniendo una alta tasa de éxito terapéutico.

GOALS: Currently, there is a high rate of over-treatment of precursor cervical lesions, which, in their causality, depends on the inexperience of the decision-making operator. The objective of the present study was to develop a standardized method of weighting / judgment of diagnostic variables and treatment useful to be used by young specialists in order to minimize the risk of improper handling. MATERIAL AND METHODS: We included 471 patients referred by abnormal cytology and treated by LEEP. Sensitivity, specificity, predictive values and likelihood ratios for the diagnosis of CIN2+ were calculated for each of the diagnostic methods. Each resident was taught a standardized protocol to carry out a LEEP procedure. Once the best predictors were identified, a scoring scale was constructed that weighted the variables and the best cut-off point for the prediction of CIN2+ was defined by ROC curve. Differences between groups were compared using Chi-square, ANOVA or t-test. Failure curves were built up using the 1-Kaplan Meier method. RESULTS: The prevalence of CIN2+ in this cohort was 66%. The agreement between the diagnostic tests was low, with colposcopy having the worst positive predictive value and the highest risk of over-treatment. Age, cytology, colposcopy (stratification based on the extent of compromise by quadrants), punch biopsy, and agreement between diagnostic tests were included for building the scoring scale. A score ≥ 9 in association with the use of a standardized protocol obtained rates of over-treatment <15%, recurrences of CIN2+ <5% at 5-year follow-up and a low rate of suboptimal procedures or complications (<2%). CONCLUSIONS: The UC-CONE method, by combining an integrated scoring system with a standardized excision protocol, minimizes the risk of over-treatment or inadequate treatment of pre-invasive cervical lesions by young specialists, reducing the number of procedures indicated unnecessarily and maintaining a high rate of therapeutic success.

Ectopic Prostate in the Uterine Cervix / Female Genital Tract Including Vagina and Vulva: A Review of the Literature.

Background: Men are known to have prostate glands but not women. The thought of prostate gland occurring in the female genital tract in women would be petrifying to all clinicians and people who are not aware of its biological behavior. Ectopic prostate in the uterine cervix (EPIUC) and the female genital tract (FGT) is very rare. Aim: To review the literature on EPIUC/FGT and to document its biological behavior. Methods: Information obtained from 17 references, was used for the literature review on EPIUC/FGT. Results: Few cases of EPIUC/FGT have been reported at ages ranging between 21 and 82 years EPIUCs/FGTs may be diagnosed incidentally in biopsies of the cervix/vagina/vulva, or in hysterectomy specimens or they may mimic leiomyomas. Histological examination of cervical biopsies or of the cervix in hysterectomy specimens reveals ducts and acini some papillary or cribriform, with prominent squamous metaplasia EPIUCs/FGTs show positive Immunohisto-chemical staining for prostate specific antigen (PSA), prostatic-specific acid phosphatase (PSAP [PAP]), high molecular weight keratin (for basal cells). EPIUCs reported so far have exhibited benign behavior. Conclusions: Information obtained from the literature would indicate that EPIUCs / FGTs are rare and so far have exhibited benign behavior. Clinicians should report cases of EPIUC/FGT in order to establish whether or not EPIUCs/FGTs may or may not develop into carcinomas in the future.

Procesamiento de las biopsias en cono de cuello uterino en Colombia / Cone biopsy processing in Colombia

Introducción. En Colombia, el cáncer de cuello uterino sigue siendo preponderante, el éxito en el programa de control del mismo, involucra la técnica de extirpación en cono,como medio diagnóstico y terapéutico.Métodos. Se llevó a cabo un estudio prospectivo de tipo ensayo de una prueba diagnóstica, con procesamiento aleatorio de las muestras por dos técnicas diferentes y la lectura histológica ciega por parte de dos patólogos. Se procesaron 20 especímenes de biopsias en cono de cuello uterino con diagnósticode lesión premaligna o maligna, y se evaluaron las técnicas y la concordancia entre observadores.Resultados. De los 20 especímenes consecutivos, la técnica 1 pudo aplicarse solamente a un caso ya que la mayoría de las muestras estaban fragmentadas o ya fijadas. Laconcordancia entre observadores fue de 0,7. Conclusiones. La prueba de referencia de la citología está migrando de la biopsia de cuello uterino al cono. El adecuado manejo de estos especímenes en los servicios depatología es parte esencial en el engranaje del diagnóstico y tratamiento de cáncer de cuello uterino. Se discuten dos diferentes maneras de procesamiento de estosespecímenes...

Introduction. The incidence of cervical cancer remains high in Colombia; control program success is gauged by cone biopsy for diagnosis and therapy. Methods. A prospective trial study on diagnosis with random sampling was perfomed using two different techniques and blind histologicalreading by two pathologists. Twenty (20) cervical cone biopsy specimens with premalignant or malignant lesion diagnosis were processed, andthe techniques and observers concordance were evaluated. Results. Out of the 20 consecutive specimens, technique 1 could only be applied to one case since the majority of samples were either fragmented or already fixed. Concordance between observers was 0.7. Conclusions. Cytology exam gold standard is migrating to cervical cone biopsy. Adequate handling of these specimens by pathologists isessential to the proper diagnosis and treatment of cervical cancer. We discuss two different ways of processing these specimens...

Efficacy of loop conization with right-angled triangular shaped excisor in patients with cervical intraepithelial neoplasia 3 / 부인종양

OBJECTIVE: To evaluate the therapeutic value of conization using right-angled triangular shape loop cone biopsy excisor in patients with CIN 3 who want preserve the uterus. METHODS: A retrospective review of 64 patients was performed who underwent therapeutic conization for CIN 3 by using right-angled triangular shape loop cone biopsy excisor from January 2000 to August 2005. RESULTS: The mean duration of 64 follow-up patients who had conization for therapeutic purpose was 21.5 months (range 10-68). Their mean age was 41.1 years old and mean parity was 1.7. Two of 64 patients had CIN 3 on exocervix margin. During the followed up period, only one person (1/64) had relapse of CIN 3, hence, a simple hysterectomy was done. CONCLUSION: Right-angled triangular shape loop cone biopsy excisor is more effective than U-shaped loop with low rate of margin positive and recurrent rate in conservative treatment in CIN 3 patients who want to preserve uterus or fertility.

Estudio de las pacientes conizadas por patología de cuello / Study of the patients undergoing cone biopsy due to cervix uteri pathology

Se realizó un estudio descriptivo, retrospectivo en el hospital "Ramón González Coro" durante los primeros 8 meses del año 2005, a las pacientes sometidas a conización con asa diatérmica en la consulta de patología de cuello. Con respecto a los 78 casos realizados en el año 2004, se produjo un incremento a 135 mujeres. Se analizó la relación citocolpohistológicas, así como la presencia y significación de algunos de los factores de riesgo para la aparición de neoplasia intraepitelial cervical. Se registró que la paridad no repercutió en los resultados histológicos (p=0,1986) sin embargo se comprobó que el inicio precoz de las relaciones sexuales están asociadas con las lesiones de alto grado de cuello uterino (p=0,038). Se estudiaron los bordes de sección quirúrgico, comprobándose que en más del 85 % de las pacientes se logró resecar completamente la lesión.

A descriptive and retrospective study was conducted at "Ramón Gonzalez Coro" Hospital during the first 8 months of 2005 among the patients undergoing cone biopsy with diathermic loop in the cervix uteri pathology department. As regards the 78 cases performed in 2004, there was an increase of 135 women (57 additional cases). The cytocolpohistological relation, as well as the presence and significance of some of the risk factors for the appearance of cervical intraepithelial neoplasia were analyzed. It was observed that parity did not influence on the histological results (p=0,1986); however, it was proved that the early beginning of sexual relations is associated with high degree cervix uteri lesions (p=0,038). The edges of the surgical section were studied and it was demonstrated that in more than 85 % of the patients it was possible to resect the lesion completely.

Can Ketamine Substitute for Fentanyl in Gynecologic Cone Biopsy Anesthesia? / 대한마취과학회지

BACKGROUND: In a gynecologic cone biopsy, fentanyl is commonly used with propofol for its analgesic effect, but it has many side effects, such as bradycardia, respiratory depression and hypotension. A subanesthetic dose of ketamine has an analgesic effect and minimal cardiovascular effects. We wanted to know whether ketamine can be safely used with propofol in a gynecologic cone biopsy instead of fentanyl. METHODS: Forty woman patients were randomly allocated to two groups. All patients were anesthesized with a propofol infusion. Fentanyl 1mug/kg IV was injected 2 minutes before LMA (laryngeal mask airway) insertion in group I, ketamine 0.25 mg/kg IV was injected also in group II. Blood pressure and heart rate were measured before fentanyl or ketamine injection, 1 minute, 3 minutes and 5 minutes after LMA insertion, and during the operation. A numerical rating scale (NRS) for pain and other side effects were checked for 24 hours after the operation. RESULTS: There were no significant differences between the two groups in blood pressure, heart rate, NRS and side effects, but a more stable systolic blood pressure in the ketamine group occured. CONCLUSIONS: For a gynecologic cone biopsy, propofol anesthesia combined with fentanyl or ketamine was not different for stable cardiovascular results, postoperative pain relief and side effects. Therefore, ketamine as an analgesic combined with propofol could replace fentanyl in gynecologic cone biopsy anesthesia.

Efficacy of Conization in Patients with Cervical Intraepithelial Neoplasia / 대한산부인과학회잡지

OBJECTIVES: The objective of this study is to evaluate the efficacy of conization of the cervix in patients with cervical intraepithelial neoplasia. STUDY DESIGN: Cold-Knife conization was performed in total 436 patients from June 1994 to May 2000. Indications and complications of conization were studied. And the results of cervical cytology, cervical histology, colposcopic findings and pathologic diagnosis of conization specimens were evaluated in comparison with the pathologic diagnosis of hysterectomy specimens and follow-up check of the patients. RESULTS: Followings are results summarized. 1. Patients distribution according to cone biopsy results was 31.0% for CIS, 43.3% for CIN III, 14.7% for CIN II, 7.6% of CIN I, 3.4% for CNI, respectively. 2. The rate of agreement between colposcopy-directed biopsy and conization was 63.1%. 3. The positive rate of resection margin was 15.1%. 4. The recurrence rate in clear resection margin group was 7.0%. But there was no recurrence after hysterectomy in cases with positive resection margin of conization specimen, and the recurrence rate of positive resection margin without hysterectomy group was 10.5%. 5. The incidence of delayed hemorrhage (bleeding after 2 weeks) in hemostatic suture group and electric cauterization only group was 4.7% (13/279) and 15.6% (23/157), respectively. CONCLUSION: We conclude that conization of the cervix as the surgical treatment was effective in CIN patients with careful patient selection.

Clinical Evaluation of Follow-Up Methods and Results of Atypical Glandular Cells of Undetermined Significance (AGUS) on Cervicovaginal Pap Smears / 대한부인종양콜포스코피학회잡지

OBJECTIVE: To evaluate the efficacy of the follow up methods and results of AGUS detected on cervicovaginal Pap smears. METHODS: From May 1991 to December 1996, we have performed 407,451 cervicovaginal Pap smears, of which 326 patients were identified as AGUS. Out of them, 268 patients were followed by repeated Pap smears, colposcopy, cone biopsy or endometrial curettage. RESULTS: The incidence of AGUS on Pap smears is approximately 0.08%. The mean patient age was 43 years (range 22~79 years). The most common complaint was abnormal vaginal bleeding. The gross findings of the cervix were normal or mild erosion. The past histories of patients that could effect the AGUS results on Pap smears were as follows: 30 had cone biopsy, 21 had Pap smear on pregnancy or within 8 weeks after delivery, 3 had hormone replacement therapy, 2 had intrauterine device for contraception, and 5 were in the process of a follow up after a treatment of cervical cancer. The benign lesions detected during follow up periods were 6 microglandular hyperplasia of the cervix, 5 atypical squamous metaplasia of the cervix, 2 cervical endometriosis, 2 tubal metaplasia, 10 cervical myoma, 11 cervical polyp, 9 endometrial polyp, 3 uterine myoma, 1 pelvic endometriosis, 1 ovarian endometriosis, and 4 uterine adenomyosis. The premalignant or malignant lesions of the cervix were 4 low grade squamous intraepithelial lesion, 24 high grade squamous intraepithelial lesion, 8 glandular atypia/dysplasia, 5 adenocarcinoma in situ, 3 microinvasive denocarcinoma, and 4 invasive adenocarcinoma. The neoplastic lesions of the uterus were 6 endometrial hyperplasia, 11 endometrial adenocarcinoma, 1 malignant mixed M?lerian tumor, and 1 metastatic endometrial adenocarcinoma. Sixty seven (25%) among 268 patients followed up were identified to have clinically significant lesions of the cervix or uterus. The detection rates of abnormal lesions were 3.1% with repeated Pap smears (3/98), 28.4% with colposcopy-directed biopsy (31/109), 63.6% with cone biopsy (35/55), and 29.7% with endometrial curettage (19/64). CONCLUSION: AGUS on Pap smears showed various benign and malignant lesions of the cervix or uterus. The clinicians must communicate with the pathologists regarding the clinical informations of the patient as well as the origin of atypical glandular cells in Pap smears. We recommend that the patients with AGUS on Pap smear should undergo immediate intensive diagnostic studies, including colposcopy with endocervical curettage or cone biopsy in order to detect the lesion of the cervix and endometrial curettage in order to detect the endometrial lesions.

Clinical Study of Cervical Intracpithelial Neoplasm / 대한부인종양콜포스코피학회잡지

Colposcopic examination and biopsy were performed on 197 patients with abnormal cervical cytology. The patients subsequently underwent electrocoagulation, LLETZ, conization and hysterectomy depending on their diagnosis from January, 1989 to December, 1994. The comparison between the diagnosis of cytology and that of colposcopic biopsy showed fair agreement with only 35% of cases(K=20%). The abnormal lesion was underestimated by cytology in 49.7% of cases. Thirty three cases(16.8%) were threated by LLETZ. Histological comparison between the colposcopic biopsies and LLETZ samples showed fair agreement with 39% of cases (K=25%). 5 cases(15%) of the colposcopic biopsy have been underestimated when compared to the LLETZ histology. Sixty two cases were done conization after colposcopic biopsy. Histological comparison between the colposcopic biopsies and conization samples showed fair agreement with 59% of cases(K=38%). The colposcopic biopsies were underestimated in 24.2% of cases compared to the cone biopsy specimen. The correct diagnosis rates of colposcopic biopsy of dysplasia, carcinoma in situ, and microinvasive carcinoma were 70%, 82%, and 20% respectively. (continue)