¿Está la virtud en el punto medio? La incertidumbre del CIN2 y el papel del VPH / Is virtue at the midpoint? The uncertainty of CIN2 and the role of HPV

Objetivo: La biopsia guiada por colposcopia (BGC) marca el manejo de la neoplasia intraepitelial cervical. El objetivo de este estudio fue evaluar la concordancia de los resultados entre la BGC y la escisión amplia de la zona de transformación (LLETZ, large loop excision of the transformation zone), y la utilidad del genotipado del virus del papiloma humano (VPH) para seleccionar a las pacientes con riesgo de lesión intraepitelial escamosa de alto grado/neoplasia intraepitelial cervical 3 (HSIL/CIN3). Método: Se compararon los resultados de la BGC y de la LLETZ, siendo esta última el método de referencia. Se evaluó la relación del genotipo del VPH con el diagnóstico final de HSIL/CIN3. Resultados: La precisión de la biopsia comparada con LLETZ fue del 61,4%. La tasa de concordancia fue del 64,4% para CIN1, del 31,4% para CIN2 y del 77,4% para CIN3. La tasa global de sobrediagnóstico fue del 18,68% y la de subdiagnóstico del 19,89%. En mujeres menores de 30 años, la concordancia fue del 62,79% (CIN1 65%, CIN2 39,58% y CIN3 73,08%), la tasa de sobrediagnóstico del 22,67% y la tasa de subdiagnóstico del 15,11%. La infección por VPH16 tuvo una odds ratio de 3,86 para el diagnóstico final de HSIL/CIN3+. Conclusiones: El diagnóstico de CIN2 por BGC parece insuficiente para seleccionar a las pacientes para tratamiento escisional, principalmente en mujeres jóvenes. El hallazgo de VPH16 es un factor de riesgo de HSIL/CIN3+ independientemente del resultado de la biopsia.

Objective: Colposcopy-guided biopsy (CGB) is a basic tool for the management of cervical intraepithelial neoplasia. The aim of this study is to evaluate the concordance of results between CGB and large loop excision of the transformation zone (LLETZ), and the usefulness of human papillomavirus (HPV) genotyping to select patients at risk of H-SIL/CIN3. Method: The results of colposcopy-guided biopsy and LLETZ were compared, with LLETZ being the gold standard. The relationship of HPV genotype to the final diagnosis of CIN3 was assessed. Results: The accuracy of CGB compared to LLETZ was 61.4%. The concordance rate was 64.4% for CIN1, 31.4% for CIN2 and 77.4% for CIN3. The overall overdiagnosis rate was 18.68% and underdiagnosis rate was 19.89%. In women under 30 years of age the concordance rate was 62.79% (CIN1 65%, CIN2 39.58% and CIN3 73.08%), and the rate of overdiagnosis and underdiagnosis was 22.67% and 15.11%, respectively. HPV16 infection had an odds ratio of 3.86 for the final diagnosis of CIN3+ and the result was significant regardless of the biopsy result. Conclusions: The CGB result as CIN2 is inaccurate and seems insufficient to select patients for excisional treatment, mainly in young women. HPV16 infection is a risk factor for CIN3+ regardless of the colposcopy-guided biopsy result.

Conservative Treatment of Stage IA1 Cervical Carcinoma Without Lymphovascular Space Invasion: A 20-year Retrospective Study in Brazil / Tratamento conservador do câncer do colo do útero IA1 sem invasão linfovascular: estudo retrospectivo no Brasil

Abstract Purpose: To evaluate recurrence rates and risk factors among women with stage IA1 cervical cancer without lymph vascular space invasion managed conservatively. Methods: retrospective review of women with stage IA1 squamous cervical cancer who underwent cold knife cone or loop electrosurgical excision procedure, between 1994 and 2015, at a gynecologic oncology center in Southern Brazil. Age at diagnosis, pre-conization findings, conization method, margin status, residual disease, recurrence and survival rates were collected and analyzed. Results: 26 women diagnosed with stage IA1 squamous cervical cancer without lymphovascular space invasion underwent conservative management and had at least 12 months follow-up. The mean follow-up was 44.6 months. The mean age at diagnosis was 40.9 years. Median first intercourse occurred at age 16 years, 11.5% were nulliparous and 30.8% were current or past tobacco smokers. There was one Human immunodeficiency virus positive patient diagnosed with cervical intraepithelial neoplasia grade 2 at 30 months after surgery. However, there were no patients diagnosed with recurrent invasive cervical cancer and there were no deaths due to cervical cancer or other causes in the cohort. Conclusion: Excellent outcomes were noted in women with stage IA1 cervical cancer without lymphovascular space invasion and with negative margins who were managed conservatively, even in a developing country.

Resumo Objetivo: Avaliar recidiva e seus fatores de risco em mulheres com câncer do colo do útero estádio IA1 sem invasão do espaço linfovascular tratadas conservadoramente. Métodos: Estudo de coorte retrospectivo de pacientes com câncer do colo do útero IA1 escamoso submetidas a cone do colo do útero, entre 1994 e 2015, em um centro de ginecologia oncológica do sul do Brasil. Foram revisados e analisados idade no diagnóstico, achados pré-conização, método de conização, margens, doença residual, recorrência e sobrevida. Resultados: 26 mulheres diagnosticadas com câncer do colo do útero estádio escamoso sem invasão do espaço linfovascular foram submetidas a tratamento conservador, com seguimento mínimo de 12 meses. O tempo médio de seguimento foi 44,6 meses. A média de idade no diagnóstico foi 40,9 anos. A primeira relação sexual ocorreu aos 16 anos (mediana), 11,5% eram nulíparas e 30,8% eram tabagistas atuais ou passadas. Houve um caso de recidiva de neoplasia intraepitelial cervical grau 2 aos 30 meses em uma paciente com vírus da imunodeficiência humana. Não houve pacientes diagnosticados com câncer de colo do útero invasor recorrente, e não houve mortes por câncer do colo do útero ou outras causas. Conclusão: Os resultados observados após tratamento conservador em mulheres com câncer cervical escamoso IA1 sem invasão do espaço linfovascular com margens negativas foram excelentes, mesmo em um país em desenvolvimento.

When is There no Benefit in Performing a Biopsy in the Suspicion of Intraepithelial Lesions of the Cervix? / Quando não há benefício em realizar biópsia na suspeita de lesões intraepiteliais do colo uterino?

Abstract Objective To evaluate whether colposcopy-directed biopsy is necessary to increase the accuracy of diagnosing cervical intraepithelial lesions in relation to colposcopy. Methods We performed a retrospective, observational study by analyzing medical records obtained fromHospital de Clínicas do Paraná fromFebruary 2008 to February 2018. Patients with results of Pap tests, colposcopy, colposcopy-directed biopsy, and surgical procedures (high-frequency surgery or cold conization) were included. Data such as quadrants involved during colposcopy and age differences were also analyzed. Results A total of 299 women were included. Colposcopy was found to have an accuracy rate of 76.25% (95% confidence interval [CI], 71.4-81.1). Among the highest-grade lesions, the accuracy rate was 80.5% (95% CI, 75.7-85.3). The accuracy rates for biopsy were 79.6% (95% CI, 75-84.2) and 84.6% (95% CI, 80-89.1) for the highest-grade lesions. High-grade lesions were accurately confirmed in 76.9% and 85% of patients with 1 and 2 or more affected quadrants, respectively. For women younger than 40 years, the accuracy rates were 77.6% and 80.8% for colposcopy and biopsy, respectively. For women 40 years or older, the accuracy rates were 72.5% and 76.3% for colposcopy and biopsy, respectively. Conclusion There is no difference between the accuracy of colposcopy and that of biopsy in diagnosing cervical intraepithelial lesions in relation with the result of conization. The patients who received the greatest benefit when biopsy was not performed were those with high-grade lesions at colposcopy, a lesion involving 2 or more quadrants, and those younger than 40 years.

Resumo Objetivo Avaliar se a biópsia colpodirigida é necessária para aumentar a acurácia diagnóstica nas lesões intraepiteliais de colo uterino em relaçãoà colposcopia. Métodos Estudo retrospectivo, observacional, incluindo pacientes submetidas a colposcopia, biópsia colpodirigida, e procedimento cirúrgico (cirurgia de alta frequência ou conização a frio), no período de fevereiro de 2008 a fevereiro de 2018, no Hospital de Clínicas da Universidade Federal do Paraná. Dados como número de quadrantes da lesão presentes na colposcopia, número de fragmentos retirados nas biópsias e diferenças por idade também foram analisados. Resultados Um total de 299 mulheres foram incluídas. Foi encontrada uma acurácia de 76,25% (intervalo de confiança [IC] 95% 71,4-81,1) entre a colposcopia e a conização, sendo 80,5% % (IC 95% 75.7-85.3) nas lesões de maior grau. A acurácia da biópsia foi de 79,6% (IC 95% 75-84,2), sendo 84,6% (IC 95% 80-89,1) nas lesões de maior grau. Pacientes com 1 quadrante acometido tiveram confirmação de 76,9% nas lesões de maior grau, enquanto as com 2 quadrantes acometidos apresentaram o mesmo resultado em 85% dos casos. A acurácia com a biópsia de 1 fragmento foi de 78% e com2 ou mais fragmentos 80%. Paramulheres com menos de 40 anos, a acurácia foi de 77,6% e 80,8% para colposcopia e biópsia, respectivamente. Para mulheres com 40 anos ou mais, a acurácia foi de 72,5% e 76,3% para colposcopia e biópsia, respectivamente. Conclusão Não há diferença entre a acurácia da colposcopia e a da biópsia colpodirigida no diagnóstico de lesões intraepiteliais cervicais em relação ao resultado da conização. As pacientes que tiveram o maior benefício quando a biópsia não foi realizada foram as que apresentaram lesão de alto grau na colposcopia e aquelas com menos de 40 anos, não existindo benefício emrealizar biópsia previamente a conização neste grupo de pacientes.

Neoplasia intraepitelial escamosa cervical de alto grau: abordagem ambulatorial / High-grade cervical intraepithelial neoplasia: outpatient approach

As neoplasias intraepiteliais cervicais correspondem a alterações identificadas por rastreamento citológico cervical e estudo histológico, pós-biópsia incisional guiada por colposcopia ou procedimento diagnóstico excisional. Podem ser tratadas com abordagens conservadoras e procedimentos excisionais. A vacinação anti-HPV e o tratamento excisional oportuno constituem, respectivamente, prevenção primária e secundária contra o câncer do colo uterino.(AU)

Cervical intraephitelial neoplasms correspond to changes identified by cervical citological screening and histological study, post-incisional biopsy guided by colposcopy or excisional diagnostic procedure. They can be treated with conservative approaches and excision procedures. Anti-HPV vaccination and timely excional treatment are primary and secondary prevention against cervical cancer, respectively.(AU)

Risk stratified management of cervical adenocarcinoma in situ based on cone margin state / 中华妇产科杂志

Objective:To investigate the hierarchical management scheme of cervical adenocarcinoma in situ (AIS) based on cervical conization margin state.Methods:All medical records of 249 patients diagnosed as AIS by loop electrosurgical excision procedure (LEEP) conization from Jan. 2010 to Dec. 2015 in Obstetrics and Gynecology Hospital of Fudan University were retrospectively reviewed, to explore the relationship between the status of the resection margin and the residual lesion after LEEP, and the multivariate logistic regression method was used to analyze the related factors that affect the residual lesion after LEEP in cervical AIS patients.Results:(1) The age of 249 cervical AIS patients was (40±8) years old (range: 23-71 years old). Of the 249 patients, 19 (7.6%, 19/249) had residual lesions; 69 cases were pathologically diagnosed as AIS after LEEP, and the residual lesion rate was 13.0% (9/69), which was significantly higher than that of AIS + high-grade squamous intraepithelial lesion [5.6% (10/180); χ2=3.968, P=0.046]; 33 cases were multifocal lesions, the residual rate of lesions was 21.2% (7/33), which was significantly higher than that of single focal lesions patients [5.6% (12/216); χ2=7.858, P=0.005]; 181 patients underwent endocervical curettage (ECC) before surgery, the residual rate of lesions in ECC-positive patients was 14.0% (14/100) , significantly higher than that of ECC-negative patients [4.9% (4/81); χ2=4.103, P=0.043]. (2) Among 249 cases of AIS patients, the positive rate of resection margins after LEEP was 35.3% (88/249); the residual rate of lesions in patients with positive resection margins (14.8%, 13/88) was significantly higher than those with negative margins [3.8%(6/156); χ2=9.355, P=0.002]. The age of patients underwent total hysterectomy after LEEP was (43±7) years old, which was significantly higher than that of patients who did not undergo total hysterectomy [(37±8) years old; t=6.518, P<0.01].Among the patients underwent total hysterectomy after LEEP, 3 cases (2.0%, 3/152) had fertility requirements, while 38 cases (39.2%, 38/97) did not underwent total hysterectomy, the difference between the two groups was statistically significant ( χ2=59.579, P<0.01). Among the 152 patients who underwent total hysterectomy after LEEP, the residual rate of lesions was 11.8% (18/152); the residual rate of lesions in patients with positive resection margins was significantly higher than that of patients with negative resection margins [18.8% (12/64) vs 7.0% (6/86); χ2=4.861, P=0.028]. The median follow-up time of 97 patients who did not undergo total hysterectomy after LEEP was 32 months (range: 4-70 months). During the follow-up period, 3 cases of cervical AIS recurrence (3.1%, 3/97) and were followed by hysterectomy,no invasive adenocarcinoma were seen. (3) Multivariate logistic regression analysis showed that the positive resection margin ( OR=4.098, 95% CI: 1.235-13.595, P=0.021), multifocal lesions ( OR=5.464, 95% CI: 1.494-19.981, P=0.010) were independent risk factors that affected the residual lesions in patients with cervical AIS after LEEP. Conclusions:The cervical AIS patients after LEEP conization suggested be stratified by cone margin state as the first-line stratified index, age and fertility needs as the second-line stratified management index. The individualized management plan should be developed based on comprehensive assessment of high-risk factors of residual lesions.

Células glandulares atípicas: abordagem ginecológica / Atypical glandular cells: gynecological approach

As células glandulares atípicas representam 0,2% a 2,1% dos resultados dos testes de Papanicolaou. Mesmo com essa baixa prevalência, tem um significado importante no diagnóstico do câncer cervical e endometrial, tendo em vista que tais células e subcategorias, associadas à idade da paciente, podem prenunciar um número expressivo de doença intraepitelial, doença invasiva do endocérvix, endométrio e até neoplasias anexiais. E não se pode esquecer do importante número de resultados histológicos benignos, identificados no seguimento dessas pacientes, muitas vezes assintomáticas.(AU)

Atypical glandular cells represent 0,2% to 2,1% of Pap test results even with this low prevalence has an important significance in the diagnosis of cervical and endometrial cancer, considering that such cells and subcategories associated with the patient's age can predict a significant number of intraepithelial disease, invasive disease of the endometrium, endocervix and even adnexial neoplasms; no forgetting the important number of benign histological results, identified in the follow up of these patients, often asymptomatic.(AU)

Analysis of conization results in patients undergoing hysterectomy for uterine adenocarcinoma / Análise dos resultados de conização nos pacientes submetidos a histerectomia por adenocarcinoma uterino

Abstract Objective To observe if the histopathological result of a conization performed after cervical adenocarcinoma in situ diagnosis is compatible with the histopathological analysis of a subsequent hysterectomy. Methods The present descriptive and observational research consisted of the analysis of the medical records of 42 patients who were diagnosed with in situ adenocarcinoma postconization. The analysis consisted of whether there was compatibility between the histopathological reports of conization and hysterectomy and if there was an association between adenocarcinoma in situ and another neoplasia (squamous disease). Interpretation of any immunohistochemistry reports obtained was also performed. In addition, clinical and epidemiological data were also analyzed. Results A total of 42 conizations were performed, 33 (79%) were cold knife conizations and 9 (21%) were loop electrosurgical excision procedures (LEEPs). Of the patients analyzed, 5 (10%) chose not to undergo subsequent hysterectomy to preserve fertility or were < 25 years old. Out of the 37 patients with adenocarcinoma in situ who underwent subsequent hysterectomy, 6 (16%) presented with residual disease. This findingprovedincompatiblewiththe finding of the conizations, which had ruled out invasive cancer. Conclusion The prevalence of adenocarcinoma in situ increased in the past years. There is still a large part of the medical literature that advocates the use of conservative treatment for this disease, even though it is common knowledge that it is a multifocal disease. However, the majority of studies advocate that hysterectomy should remain the preferred treatment for women who have already completed their reproductive purpose.

Resumo Objetivo Observar se o resultado proveniente de uma conização realizada após o diagnóstico de adenocarcinoma cervical in situ é compatível com a análise histopatológica da histerectomia. Métodos A pesquisa foi descritiva e observacional e consistiu na análise de prontuário de 42 pacientes que tiveram o diagnóstico de adenocarcinoma in situ obtidas por conização. Foram analisados se havia compatibilidade entre os laudos de conização e histerectomia, margens do cone, se havia associação com outra patologia (doença escamosa) e interpretação de eventuais laudos histoquímicos obtidos. Além disso, também foram analisados dados clínico-epidemiológicos. Resultados Foram realizadas 42 conizações, sendo 33 (79%) por cone clássico e 9 (21%) por cirurgia de alta frequência. Das pacientes analisadas, 5 (10%) não foram submetidas a histerectomia por desejarem manter a fertilidade ou por terem idade < 25 anos. Das 37 pacientes com adenocarcinoma in situ no exame prévio realizado e que foram submetidas à histerectomia posteriormente, 6 (16%) apresentaram doença residual após o procedimento cirúrgico, apresentando laudos do anatomopatológico pós-histerectomia incompatíveis com o achado na conização que atestava margens livres. Conclusão A prevalência do adenocarcinoma in situ vemaumentando cada vez mais. Ainda há uma grande parte da literatura que defende o uso do tratamento conservador para esta doença, mesmo sabendo que ela é uma doença multifocal e que pode estar presente mesmo em situações nas quais o anatomopatológico evidencie margens livres. Tendo em vista essas características, a maioria preconiza que a histerectomia continua a ser o tratamento preferencial nas mulheres que já completaram o seu intuito reprodutivo.

Adenocarcinoma cervical in situ: abordagem na atenção primária e secundária à saúde / Cervical adenocarcinoma in situ: approach in primary and secondary health care

O adenocarcinoma cervical in situ é uma doença rara, totalmente curável, diagnosticada predominantemente por meio de rastreamento cervicouterino seguido de biópsia guiada por colposcopia e/ou conização. O tratamento em pacientes que desejam preservar a fertilidade pode ser realizado num contexto ambulatorial; aquelas com paridade definida deverão ser abordadas em nível terciário.(AU)

Cervical adenocarcinoma in situ is a rare, fully curable disease diagnosed predominantly through cervical-uterine screening followed by colposcopy-guided biopsy and/or conization. Treatment in patients wishing to preserve fertility may be performed in an outpatient setting; those with defined parity should be approached at the tertiary level.(AU)

Efficacy and safety of cryotherapy, cold cone or thermocoagulation compared to LEEP as a therapy for cervical intraepithelial neoplasia: Systematic review / Eficacia y seguridad de crioterapia, cono frio o termo-coagulación en comparación con LEEP como terapia para la neoplasia intraepitelial cervical: Revisión sistemática

ABSTRACT OBJECTIVES To determine the efficacy and safety of the use of cryotherapy, cold knife or thermocoagulation compared to Loop Electrosurgical Excision Procedure (LEEP) for the treatment of cervical intraepithelial neoplasia. METHODS Systematic review with meta-analysis of randomized controlled trials in women with cervical intraepithelial neoplasia undergoing treatment with cryotherapy, cold knife, or thermo-coagulation compared with LEEP, to estimate its efficacy and safety. The search was conducted on MEDLINE/PUBMED, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus, until September 2018. RESULTS The total of 72 studies were identified, of which only 8 studies met the inclusion criteria. The treatment of CIN with cold knife decreases the risk of residual disease compared with LEEP (RR, 0.54, 95%CI, 0.30-0.96, p = 0.04). The management of premalignant lesions with cryotherapy, compared with LEEP, increases the risk of disease recurrence by 86% (RR, 1.86, 95%CI, 1.16-2.97, p = 0.01), increases the risk of infections (RR, 1.17, 95%CI, 1.08-1.28, p < 0.001) and reduces the risk of minor bleeding by 51% (RR, 0.49, 95%CI) %, 0.40-0.59, p ≤ 0.001). CONCLUSIONS The treatment of premalignant lesions of cervical cancer with cold knife reduces the risk of residual disease. Nevertheless, cryotherapy reduces the risk of minor bleeding in the 24 hours after treatment and increases the risk of recurrence of disease and infections.

RESUMEN OBJETIVOS Evaluar la eficacia y seguridad del uso de crioterapia, cono frio o termo-coagulación en comparación con el procedimiento de escisión electroquirúrgica en asa (LEEP) para el manejo de neoplasias intraepiteliales cervicales. MÉTODOS Revisión sistemática de ensayos controlados aleatorizados en mujeres con neoplasia intraepitelial cervical en tratamiento con crioterapia, cono frio, o termo coagulación y LEEP, para estimar su eficacia y seguridad. La búsqueda se realizó en MEDLINE/PUBMED, Registro Cochrane Central de Ensayos Controlados (CENTRAL) y Scopus, hasta setiembre de 2018. RESULTADOS Se identificaron 72 estudios, ocho cumplieron los criterios de inclusión. Cono frio disminuyó el riesgo de enfermedad residual en comparación con LEEP (RR 0,54; IC del 95%, 0,30-0,96, p = 0,04). Crioterapia en comparación con LEEP incrementó el riesgo de recurrencia de enfermedad en un 86,0% (RR 1,86; IC del 95%, 1,16-2,97, p = 0,01) con un tiempo de seguimiento de seis a 24 meses, y de infecciones (RR, 1,17; IC del 95%, 1,08-1,28, p < 0,001); pero redujo el riesgo de sangrado menor en un 51,0% (RR 0,49; IC del 95%, 0,40-0,59, p ≤ 0,001). CONCLUSIONES Cono frio reduce el riesgo de enfermedad residual. Sin embargo, la crioterapia reduce el riesgo de sangrado menor en las 24 horas posteriores al tratamiento e incrementa el riesgo de recurrencia de enfermedad y de infecciones.

Neoplasia cervical intraepitelial tipo III, poshisterectomía supracervical laparoscópica: ventajas e inconvenientes de la conservación del cuello uterino en pacientes histerectomizadas / Cervical intraepithelial neoplasia type III after laparoscopic supracervical hysterectomy. Advantages and disadvantages of cervical conservation in hysterectomized patients

Resumen ANTECEDENTES: Existen múltiples opciones para practicar una histerectomía: por vía vaginal, abdominal laparotómica, laparoscópica o robótica. En pacientes que van a intervenirse por enfermedad benigna puede hacerse mediante la extirpación del cuerpo uterino (histerectomía parcial o supracervical). La preocupación por la posible aparición de una lesión neoplásica en el muñón cervical remanente ha dado lugar a investigaciones acerca de las ventajas de la exéresis del cuello uterino (histerectomía total). CASO CLÍNICO: Paciente de 36 años, intervenida para histerectomía supracervical con salpingectomía bilateral laparoscópica, por útero miomatoso sintomático. Posterior a la cirugía apareció una lesión preneoplásica de alto grado; se le indicó conización cervical. CONCLUSIÓN: Algunos expertos advierten que los riesgos de extirpar el cuello uterino son lo suficientemente notables como para optar por la técnica parcial en pacientes sin antecedentes de patología cervical, sobre todo si tienen cuadros adherenciales o endometriosis del tabique rectovaginal. Por el contrario, otros grupos indican que ante la baja tasa de complicaciones de la histerectomía total y la posibilidad de una patología neoplásica posterior, no está justificada la preservación cervical.

Abstract BACKGROUND: There are multiple approaches to perform a hysterectomy; the classic vaginal route, the laparotomic abdominal or the newest endoscopic techniques, such as laparoscopic or robotic. In patients undergoing benign pathology, the technique can only be performed by removing the uterine body (subtotal or supracervical hysterectomy). However, the concern about the possible occurrence of a neoplastic lesion in the remaining cervical stump has led to investigations into the benefits of also performing the cervical exeresis (total hysterectomy). Our goal is to present a review on the current situation of the topic, concluding that there is still no scientific consensus on which technique is the most recommended. CLINICAL CASE: 36-year-old woman who underwent supracervical hysterectomy with laparoscopic bilateral salpinguectomy due to symptomatic myomatous uterus. After surgery, he presented a high-grade preneoplastic lesion, which indicated that cervical conization was indicated. CONCLUSION: Some experts argue that the risks of performing the removal of the cervix are notable enough to indicate subtotal technique in patients without a history of cervical pathology, especially if they have adhesion or endometriosis of the rectovaginal septum. On the contrary, other working groups indicate that cervical preservation is not justified due to the low complication rate of the total hysterectomy technique and the possibility of developing a subsequent neoplastic pathology.

Importancia de los márgenes quirúrgicos afectados en la conización uterina cervical / Importance of surgical margins affected in cervical uterine conization

Resumen: OBJETIVO: Determinar la asociación entre los márgenes afectados con la persistencia-recurrencia de neoplasia intraepitelial cervical, persistencia del virus del papiloma humano y las reintervenciones. MATERIALES Y MÉTODOS: Estudio de casos y controles anidado en una cohorte retrospectiva del Complexo Hospitalario Universitario de Ourense (enero 2010-octubre 2017). Criterio de inclusión: mujeres con al menos una revisión postintervención. Criterios de exclusión: mujeres sin evidencia de displasia de alto grado en la pieza de conización y a las que no se dio seguimiento. Variables de estudio: edad, tabaquismo, preservativo, anticonceptivos orales, vacunación contra VPH, persistencia-recurrencia de NIC y de VPH y reintervención. Se realizaron pruebas paramétricas y no paramétricas entre las variables. RESULTADOS: La cohorte se integró con 248 mujeres, de éstas 81 (32.6%) tuvieron afectación de los márgenes quirúrgicos en la conización. La inmunosupresión, el tabaquismo y la anticoncepción oral fueron las asociaciones más frecuentes en los márgenes afectados. El uso de preservativo y la vacunación contra VPH fueron significativamente más frecuentes en los márgenes libres. Los márgenes afectados reportaron mayor persistencia de VPH (50 vs 23.9%; OR 3.17 (1.90-5.26), p < 0.001), enfermedad persistente-recurrente (47.2 vs 22.5%; OR 3.07 (1.84-5.12), p < 0.001) y reintervenciones (40.2 vs 15.4%; OR 3.679 (2.094-6.463), p < 0.028). El margen más afectado fue, en orden descendente, endocervical (55.6%), exocervical (25%) y ambos (19.4%). CONCLUSIONES: El margen afectado confiere un riesgo importante en la evolución de la infección por VPH y la recurrencia de la enfermedad.

Abstract: OBJECTIVE: To determine the association between affected margins with persistence-recurrence of cervical intraepithelial neoplasia, persistence of human papillomavirus and re-interventions. MATERIALS AND METHODS: Study of cases and controls nested in a retrospective cohort of the Complexo Hospitalario Universitario de Ourense (January 2010-October 2017). Inclusion criteria: women with at least one post-intervention check-up. Exclusion criteria: women without evidence of high-grade dysplasia in the conization piece and who were not followed up. Study variables: age, smoking, condom, oral contraceptives, HPV vaccination, persistence-recurrence of CIN and HPV, and re-operation. Parametric and non-parametric tests were performed among the variables. RESULTS: The cohort consisted of 248 women, 81 of whom (32.6%) had affected surgical margins on conization. Immunosuppression, smoking and oral contraception were the most frequent associations in affected margins. Condom use and HPV vaccination were significantly more frequent in free margins. Affected margins reported greater persistence of HPV (50 vs 23.9%; OR 3.17 (1.90-5.26), p < 0.001), persistent-recurrent disease (47.2 vs 22.5%; OR 3.07 (1.84-5.12), p < 0.001), and reinterventions (40.2 vs 15.4%; OR 3.679 (2.094-6.463), p < 0.028). The most affected margin was, in descending order, endocervical (55.6%), exocervical (25%) and both (19.4%). CONCLUSIONS: The affected margin confers a significant risk in the evolution of HPV infection and disease recurrence.

Pathologic discrepancies between colposcopy-directed biopsy and loop electrosurgical excision procedure of the uterine cervix in women with cytologic high-grade squamous intraepithelial lesions / 부인종양

OBJECTIVE: To investigate pathologic discrepancies between colposcopy-directed biopsy (CDB) of the cervix and loop electrosurgical excision procedure (LEEP) in women with cytologic high-grade squamous intraepithelial lesions (HSILs).METHODS: We retrospectively identified 297 patients who underwent both CDB and LEEP for HSILs in cervical cytology between 2015 and 2018, and compared their pathologic results. Considering the LEEP to be the gold standard, we evaluated the diagnostic performance of CDB for identifying cervical intraepithelial neoplasia (CIN) grades 2 and 3, adenocarcinoma in situ, and cancer (HSIL+). We also performed age subgroup analyses.RESULTS: Among the study population, 90.9% (270/297) had pathologic HSIL+ using the LEEP. The diagnostic performance of CDB for identifying HSIL+ was as follows: sensitivity, 87.8%; specificity, 59.3%; balanced accuracy, 73.6%; positive predictive value, 95.6%; and negative predictive value, 32.7%. Thirty-three false negative cases of CDB included CIN2,3 (n=29) and cervical cancer (n=4). The pathologic HSIL+ rate in patients with HSIL− by CDB was 67.3% (33/49). CDB exhibited a significant difference in the diagnosis of HSIL+ compared to LEEP in all patients (p<0.001). In age subgroup analyses, age groups <35 years and 35–50 years showed good agreement with the entire data set (p=0.496 and p=0.406, respectively), while age group ≥50 years did not (p=0.036).CONCLUSION: A significant pathologic discrepancy was observed between CDB and LEEP results in women with cytologic HSILs. The diagnostic inaccuracy of CDB increased in those ≥50 years of age.

Analysis of the effect of cervical conization through cervical endoscopy in the treatment of High-grade cervical intraepithelial neoplasia / 中国综合临床

Objective@#To investigate the clinical effect of cervical conization under cervical endoscopy in high-grade cervical intraepithelial neoplasia (CIN).@*Methods@#From June 2017 to June 2019, 100 patients with grade II and III CIN admitted to Harbin First Hospital were divided into control group and observation group with 50 cases in each group by random number table method.The control group was treated with traditional cervical cold knife conization, while the observation group was treated with cervical conization under endoscopy.To compare the therapeutic effects of two surgical methods.@*Results@#The incidence of positive margin were significantly lower than that in the control group(8%(4/50) and 18%(9/50)), and the difference was statistically significant (χ2=4.98, P<0.05). The postoperative follow up was proceed one year.The incidence of cure were significantly higher than that in the control group(96%(48/50)vs.84%(40/50)), and the residual rate and recurrence rate were lower than that of the control group(6%(3/50) and 14%(7/50), 2%(1/50)and 8%(4/50)), the difference was statistically significant (χ2=10.56, 3.98, 13.96, all P<0.05). The incidence of postoperative complications in the observation group was significantly lower than that in the control group [6% (3/50) and 18% (9/50)], the difference was statistically significant (χ2=11.25, P<0.05). There was no significant difference in bleeding volume, operation time and wound healing time between the two groups (t value was 1.46, 1.26 and 0.98 respectively, all P>0.05).@*Conclusion@#The cervical conization through cervical canal endoscope can accurately locate the focus of high-grade CIN, with higher rate of lesion clearance, lower rate of lesion recurrence and complications.

Resultados de la conización por radiocirugía en pacientesatendidas en consulta de patología de cuello uterino / Results of Conization by Radiosurgery in patients treated in a Cervical Pathology Clinic

Introducción: La radiocirugía tiene como objetivo proporcionar una herramienta de diagnóstico y tratamiento. Objetivos: Describir los resultados de la conización por radiocirugía en pacientes atendidas en la consulta de patología de cuello uterino de la institución. Métodos: Se realizó una investigación descriptiva de corte transversal en el Hospital General Docente Mártires del 9 de Abril de Sagua la Grande, Villa Clara, Cuba. La población de estudio estuvo conformada por la totalidad de 256 pacientes atendidas en la consulta de patología de cuello uterino que fueron sometidas a conización por radiocirugía, entre enero 2013 y diciembre 2015. Para la recogida de la información se empleó la revisión de documentos y se confeccionó un modelo de recogida de datos. Resultados: El diagnóstico preoperatorio que aportó mayor cantidad de casos fue el NIC III (displasia severa) (78 casos; 30,5 por ciento). Conclusiones: Las lesiones premalignas en el presente estudio comenzaron a aparecer con marcada incidencia a partir de los 20 años y hasta los 49, sobresaliendo el grupo de 30 - 39 años. El aumento en el número de parejas sexuales, así como el comienzo temprano de las relaciones sexuales incrementan el riesgo de padecer lesiones intraepiteliales en el cuello del útero. A partir de los cinco años de iniciada las relaciones sexuales comienzan a aparecer las lesiones intraepiteliales cervicales, el diagnóstico preoperatorio que aportó mayor cantidad de casos fue el NIC III (displasia severa). En los diagnósticos histológicos por sacabocado y cono existió correspondencia en todos los casos(AU)

Introduction: Radiosurgery aims to provide a diagnostic and treatment tool. Objectives: To describe the results of conization by radiosurgery in patients treated in the cervical pathology clinic of the institution. Methods: A descriptive cross-sectional investigation was carried out at Mártires del 9 de abril General Teaching Hospital, in Sagua la Grande, Villa Clara, Cuba. The study population consisted of 256 patients attended in the cervical pathology clinic who underwent conization by radiosurgery, from January 2013 to December 2015. For the collection of the information, the document review was used and a data collection form was made. Results: The preoperative diagnosis that contributed the greatest number of cases was IAS III (severe dysplasia) (78 cases; 30.5 percent). Conclusions: The premalignant lesions in the present study began to appear with a marked incidence from the age of 20 and up to 49, with the group of 30-39 years standing out. The increase in the number of sexual partners, as well as the early sexual intercourse increase the risk of suffering intraepithelial lesions in the cervix. After five years of beginning sexual intercourse, cervical intraepithelial lesions begin to appear, the preoperative diagnosis that contributed the greatest number of cases was IAS III (severe dysplasia). In histological diagnoses by punch and cone correspondence existed in all cases(AU)

Diagnóstico y tratamiento de las lesiones intraepiteliales escamosas de alto grado del cuello uterino / Diagnosis and treatment of high grade squamous intraepithelial lesions of uterine cervix

INTRODUCCIÓN. El cáncer cérvico-uterino tiene una fase precursora de larga duración, pues debe pasar por varios estados previos al cáncer invasivo, denominados lesiones intraepiteliales, de bajo y de alto grado, que pueden transformarse en lesiones malignas. La importancia de un diagnóstico oportuno y certero de las lesiones intraepiteliales escamosas de alto grado radica en que, si son tratadas de manera oportuna, son ciento por ciento curables. OBJETIVO. Proporcionar información actualizada sobre el diagnóstico y tratamiento de las lesiones precursoras de cáncer de cérvix y ayudar a los profesionales en la toma de decisiones médicas. MATERIALES Y MÉTODOS. Estudio de revisión de 45 artículos científicos la gran mayoría de la última década y, unos pocos, con datos históricos vigentes sobre lesiones intraepiteliales escamosas de alto grado del cuello uterino. La búsqueda se realizó en MedLine, PLoS y Scielo utilizando los términos tamizaje, neoplasias uterinas, lesiones intraepiteliales escamosas de cuello uterino y tratamiento. RESULTADOS. Los artículos científicos fueron seleccionados por niveles de evidencia 1 y 2, con recomendaciones A y B. Las recomendaciones de inicio de tamizaje han cambiado y el manejo toma en cuenta el riesgo acumulado por tipo de lesión. El tratamiento, en la mayoría de casos, es la escisión y resulta definitivo. CONCLUSIÓN. El diagnóstico sigue siendo cito-colpo-histológico y el tratamiento depende de la edad de la paciente, pudiendo las posibilidades ir de la observación hasta la escisión quirúrgica y, en casos específicos, la histerectomía.

INTRODUCTION. Cervical-uterine cancer has a long-term precursor phase, as it must go through several states prior to invasive cancer, called intraepithelial lesions, low and high grade, which can become malignant lesions. The importance of a timely and accurate diagnosis of high-grade squamous intraepithelial lesions is that, if treated in a timely manner, they are one hundred percent curable. OBJECTIVE. Provide updated information on the diagnosis and treatment of precursor lesions of cervical cancer and assist professionals in medical decision making. MATERIALS AND METHODS. Review study of 45 scientific articles the vast majority of the last decade and, a few, with current historical data on high-grade squamous intraepithelial lesions of the cervix. The search was conducted in MedLine, PLoS and Scielo using the terms screening, uterine neoplasms, squamous intraepithelial lesions of the cervix and treatment. RESULTS. The scientific articles were selected by levels of evidence 1 and 2, with recommendations A and B. The recommendations for starting screening have changed and management takes into account the accumulated risk by type of injury. The treatment, in most cases, is excision and is definitive. CONCLUSION. The diagnosis is still cyto-histological and the treatment depends on the age of the patient, and the possibilities may range from observation to surgical excision and, in specific cases, hysterectomy.

Artificial Neural Network Analysis of Spontaneous Preterm Labor and Birth and Its Major Determinants

BACKGROUND: Little research based on the artificial neural network (ANN) is done on preterm birth (spontaneous preterm labor and birth) and its major determinants. This study uses an ANN for analyzing preterm birth and its major determinants.

Discussion on the diagnosis and treatment of high-grade squamous intraepithelial lesions in post-menopausal women / 中华妇产科杂志

Objective To analyze the performance of colposcopy and investigate the diagnosis and treatment characteristics of high-grade squamous intraepithelial lesion (HSIL) diagnosed by cervical tissue sampling in post-menopausal women. Methods A retrospective study was performed on 1 449 patients with HSIL diagnosed by cervical tissue sampling under colposcopy and treated by loop electrosurgical excision procedure (LEEP) or extrafascial hysterectomy as the primary therapy at the First Affiliated Hospital of Nanjing Medical University, from November 2015 to October 2017. In order to investigate the diagnosis and treatment of HSIL in post-menopausal women, a case-control study was conducted to compare the difference in performance of colposcopy and treatment modality between 213 post-menopausal patients (14.7%, 213/1 449) and 1 236 pre-menopausal patients (85.3%, 1 236/1 449). Results (1)The proportion of cases pathologically upgraded to cervical cancer was significantly greater in post-menopausal patients (9.4%, 20/213) compared with pre-menopausal patients (3.8%, 47/1 236; P<0.05). (2) The proportion of ≥HSIL diagnosed by colposcopy showed no significant difference between post-menopausal patients (76.1%, 162/213) and pre-menopausal patients (78.2%, 967/1 236; P=0.479). The proportion of typeⅢtransformation zone (TZ) was significantly greater in post-menopausal patients (91.1%, 194/213) compared with pre-menopausal patients (59.1%, 731/1 236; P<0.05). The rate of missed diagnosis of cervical cancer was significantly higher in typeⅢTZ (6.4%, 59/925) compared with typeⅠand(or)ⅡTZ (1.5%, 8/524; P<0.05). The proportion of HSIL detected by endocervical curettage alone was greater in post-menopausal patients (9.9%, 21/213) compared with pre-menopausal patients (2.6%, 32/1 236; P<0.05). (3)Initial treatment with LEEP: the positive rate of endocervical margin was significantly greater in post-menopausal patients (20.5%, 36/176) compared with pre-menopausal patients (10.5%, 130/1 236;P<0.05); in patients who were diagnosed as HSIL after LEEP, the positive rate of endocervical margin and the residual rate were both greater in post-menopausal patients compared with pre-menopausal patients [15.4% (25/162) versus 8.8% (105/1 189), P=0.008; 52.0% (13/25) versus 26.7% (28/105), P=0.014]. (4)Thirty-seven post-menopausal patients were treated by extrafascial hysterectomy as the primary therapy, 5 cases (13.5%, 5/37) were diagnosed as cervical cancer (stage Ⅰa1) after the surgery. Conclusions (1) The lesions of HSIL in post-menopausal patients still have definite features under colposcopy as same as pre-menopausal patients. Endocervical curettage could help detect more HSIL in post-menopausal patients. Compared with pre-menopausal patients, post-menopausal HSIL patients have an increased risk of cervical cancer and are more likely missed by cervical tissue sampling. (2) LEEP has the dual effects of diagnosis and treatment, and is still the recommended treatment for post-menopausal HSIL patients. However, the increase in positive rate of endocervical margin and residual rate requires further active intervention. (3) Considering those post-menopausal HSIL patients who cannot accept conization as the initial treatment, the selection of hysterectomy type requires more thorough study.

Hemoperitoneum: a complication of loop electrosurgical excision procedure

Loop electrosurgical excision procedure (LEEP) is commonly performed for the management of cervical intraepithelial neoplasia. Although LEEP is considered to be a relatively simple procedure, several unexpected complications have been reported in the literature. Herein, we report a case of hemoperitoneum caused by uterine perforation following LEEP. Blood collection in pelvic cavity and two small defects of the uterus were confirmed by diagnostic laparoscopy. The defects were sutured and the patient recovered well after the operation.

Leep in the treatment of cin and its impact on the reduction of mortality of cervical cancer / A cirurgia de alta frequência no tratamento da neoplasia intraepitelial cervical e seu impacto na redução da mortalidade por câncer cervical

Introduction: The adequate treatment of cervical intraepithelial neoplasia (CIN) is an important component of cervical cancer prevention programs and its inadequate management may increase the future risk of neoplasia. Objective: To evaluate the role of loop electrosurgical excision procedure (LEEP) conization in the treatment of CIN, in an important state capital in southern Brazil, and to determine the impact on reducing cervical cancer mortality in the next 20 years. Methods: A retrospective cohort study was conducted in patients who underwent CIN treatment from January 1999 to December 2007 at Erasto Gaertner Hospital, analyzing the treatment morbidity and recurrence rate of the disease, using the χ2 test for statistical analysis and p≤0.05. Results: A total of 1,550 women, between 14 and 93 years of age (35±11.42) were evaluated. Recurrence rate was 6.8%. The postoperative complications were 5.8% bleeding, 2% cervical stenosis and 2% infection. The cervical cancer mortality rate decreased from 12 to 3.8/100,000 women and there was an increase in the incidence of the lesion in situ as opposed to the reduction of other clinical stages. Conclusion: LEEP conization was proven to be a highly effective tool in CIN treatment, substantially contributing to the reduction of mortality from cervical cancer, justifying its use in a systematic way in prevention programs.

Introdução: O adequado tratamento da neoplasia intraepitelial cervical é um importante componente dos programas de prevenção do câncer cervical, e seu manejo inadequado pode aumentar o risco futuro de progressão para neoplasia. Objetivo: Avaliar os resultados da cirurgia de alta frequência no tratamento da neoplasia intraepitelial cervical em uma importante capital do Sul do país e o impacto na redução da mortalidade por câncer cervical nos 20 anos subsequentes. Métodos: Estudo tipo coorte retrospectivo de pacientes submetidas a tratamento da neoplasia intraepitelial cervical, no período de janeiro de 1999 a dezembro de 2007, no Serviço de Patologia Cervical do Hospital Erasto Gaertner, Curitiba, Brasil, analisando a morbidade do tratamento e o risco de recorrência da doença utilizando o teste das proporções (χ2 ) e valor p≤0,05, relacionando esses dados às taxas de mortalidade no período dos últimos 20 anos. Resultados: O número de 1.550 pacientes, com idade entre 14 e 93 anos (35,3±11,42). A taxa de recidiva foi 6,8%. As complicações pós-operatórias foram 5,8% de sangramento, 2% de estenose de colo e 2% de infecção. A taxa de mortalidade para câncer de colo na cidade de Curitiba caiu de 12 para 3,8 casos/100mil mulheres, ocorrendo o aumento da incidência da lesão in situ em contraposição à redução dos demais estadios clínicos. Conclusão: a cirurgia de alta frequência mostrou-se um instrumento relevante e de alta eficácia no tratamento da neoplasia intraepitelial cervical, contribuindo de forma efetiva para a redução da mortalidade por câncer de colo uterino, justificando seu uso de maneira sistemática dentro dos programas de prevenção.

IA1 microinvasive cervical adenocarcinoma in a young woman: conservative procedure and reproductive outcome / Adenocarcinoma microinvasor IA1 do colo do útero em mulher jovem: conduta conservadora e resultado reprodutivo

Introduction: The expansion of cytological screening programs for cervical cancer leads to an increase in the proportion of both adenocarcinomas and diagnoses in young women with reproductive intention. Conservative treatment is not fully established. Objective: to report the conservative management and follow-up difficulties of a real case of microinvasive cervical adenocarcinoma in a young woman. Case report: This is a case report of a 23-yearold patient with stage IA1 microinvasive cervical adenocarcinoma related to HPV18. The patient was vaccinated against HPV 16/18 at 16 years of age and conservatively treated. She became pregnant during follow-up with a favorable outcome. Conclusion: We discuss the difficulties and uncertainties regarding follow-up and opportunity for hysterectomy, emphasizing the need for a multidisciplinary approach to make a balanced decision between conservative treatment and oncological safety, as well as mitigate follow-up difficulties in real life.

Introdução: A ampliação dos programas de rastreamento citológico de câncer do colo uterino resulta em aumento na proporção de adenocarcinomas e de diagnósticos em jovens ainda com desejo reprodutivo. O tratamento conservador não está totalmente estabelecido. Objetivo: descrever a condução conservadora e as dificuldades de seguimento em caso real de adenocarcinoma microinvasor do colo em uma jovem. Relato de caso: É relatado o caso de uma paciente de 23 anos com adenocarcinoma microinvasor IA1 do colo uterino relacionado ao HPV 18, mesmo vacinada contra HPV 16/18 aos 16 anos. Foi tratada conservadoramente, com gestação e desfecho favorável. Conclusão: São discutidas as dificuldades e incertezas em relação ao seguimento e à oportunidade para histerectomia, ressaltando a necessidade de abordagem multidisciplinar para decisões equilibradas entre tratamento conservador, segurança oncológica e, ainda, amenizar as dificuldades de seguimento na vida real.