CIN Extension at Colposcopy: Relation to Treatment and Blood Parameters.

OBJECTIVE: To determine the colposcopic lesion size that predicts the presence of residual lesion in patients with cervical intraepithelial neoplasia (CIN) 2/3, to aid gynaecologists in selecting conservative management. METHODS: Data from 51 patients with low- and high-grade squamous intraepithelial lesions were evaluated. Colposcopic images were captured and lesion areas were calculated. Polymerase chain reaction (PCR) for human papillomavirus was performed. Laboratory parameters were evaluated. Receiver operating characteristic (ROC) curves were used to obtain cut-off values for lesion area. The performance of PCR in the detection of high-grade CIN was assessed. A flowchart was created to compare the costs of related procedures in the Brazilian health system. RESULTS: For CIN 2/3 treated with excisional surgery, the best cut-off value for lesion area below which no residual lesion was present was 21 019 pixels2 (58.87 mm2). The cut-off value that predicted compromised surgical margins was 155 577.65 pixels2 (435.75 mm2). Among all patients with CIN, lesion area correlated inversely with neutrophil/lymphocyte ratio (NLR; r = -0.446, P = 0.001), platelet/lymphocyte ratio (PLR; r = -0.438, P = 0.001), and absolute number of leukocytes (r = -0.351, P = 0.011). Conservative clinical management with semi-annual clinical follow-up was found to reduce direct costs to the Brazilian Health System by R $909.82 (US $169.42). CONCLUSION: CIN reflects systemic alteration, leading to altered NLRs, PLRs, and absolute numbers of leukocytes. Patients with high-grade CIN and colposcopic lesion areas <21 019 pixels2 could benefit from conservative management, which would result in cost savings for the Brazilian health system.

Qualidade de vida sexual de mulheres no pós-tratamento radioterápico de câncer de colo uterino / Sexual quality of life of women after cervical cancer radiotherapy

A qualidade de vida sexual é frequentemente afetada após tratamento oncológico em ginecologia. Reportamos a qualidade de vida sexual de pacientes em seguimento no serviço de Oncologia Ginecológica da Universidade Federal do Triângulo Mineiro, por meio da aplicação do questionário validado FSFI (Female Sexual Function Index), comparando pacientes diagnosticadas com câncer de colo uterino que receberam tratamento radioterápico com aquelas que foram submetidas a tratamento para câncer de colo uterino no qual não foi necessária a realização de radioterapia. Foi realizada análise estatística utilizando os testes D'Agostino-Pearson e o teste não paramétrico Mann-Whitney. Concluiu-se que a diminuição do desejo e da excitação foi mais frequente nas mulheres tratadas com radioterapia e que não houve diferença significativa entre as pacientes a respeito de lubrificação, orgasmo, satisfação e dispareunia.(AU)

Quality of sexual life is often affected after oncological treatment in gynecology. We report the quality of sexual life of patients in a follow-up at the Gynecological Oncology service of the Federal University of Triângulo Mineiro, through the application of a questionnaire validated in the Portuguese language. The purpose of this study was to compare cervical cancer patients diagnosed who received radiotherapy with those who have been submitted to treatment for cervical cancer in which it was not necessary to perform radiotherapy. Decreased desire and arousal were more frequent in women treated with radiotherapy. Statistical analysis was performed using the D'Agostino-Pearson tests and the non-parametric Mann-Whitney test. It was concluded that decreased desire and arousal were more frequent in women treated with radiotherapy, and that there was no significant difference between patients regarding lubrication, orgasm, satisfaction and dyspareunia.(AU)

Conservative treatment of uterine cervical adenocarcinoma in pregnancy.

Cancer of the cervix is the most common malignancy diagnosed during pregnancy, with an incidence of 1-10 cases per 10,000 pregnancies. The desire of patients to maintain pregnancy and subsequent fertility is a difficult target to be achieved and should be widely studied, since it depends on the stage of disease, gestational age at diagnosis, and the woman's desire to maintain pregnancy. We describe in this report the case of a pregnant woman with invasive cervical adenocarcinoma in stage IB1 (FIGO) initially treated with neoadjuvant chemotherapy, followed by radical surgery and cesarean section in the same surgical procedure.

Local cytokine profiles of patients with cervical intraepithelial and invasive neoplasia.

Several studies have suggested that patients with cervical intraepithelial and invasive neoplasia have reduced levels of Th1 cytokines, and increased levels of Th2 cytokines. Thus, the aim of this study was to delineate the immunological profile associated with lesion progression. Biopsies were obtained from 28 patients with low grade cervical intraepithelial lesions (LSILs), 53 patients with high grade cervical intraepithelial lesions (HSILs), 25 patients with invasive cancer (CA), and 20 healthy controls. Levels of IFN-γ, TNF-α, IL-2, IL-4, IL-10, IL-12, TGF-ß1 and TGF-ß2 were then assayed by RT-PCR and ELISA for each biopsy sample. For LSILs, higher levels of Th1 cytokines were detected, while HSILs were associated with a Th2 cytokine profile. In contrast, CA tissues were associated with the strongest expression of a Treg cytokine profile. In conclusion the most important contribution of these work is identification of the Treg cytokine profile in HPV progression lesions and in combination, these results suggested that tumor progression is dependent on suppression of cellular immunity.

Atypical squamous cells of undetermined significance: Bethesda classification and association with Human Papillomavirus.

INTRODUCTION: To analyze patients with atypical squamous cells of undetermined significance (ASCUS) through a cytology review and the presence of microbiological agents, with consideration of colposcopy and semiannual tracking. METHODS: 103 women with ASCUS were reviewed and reclassified: normal/inflammatory, ASCUS, low-grade squamous intraepithelial lesion (LSIL), or high-grade squamous intraepithelial lesion (HSIL). If ASCUS confirmed, it was subclassified in reactive or neoplastic ASCUS, ASC-US, or ASC-H; and Regione Emilia Romagna Screening Protocol. Patients underwent a colposcopic examination, and test for Candida sp., bacterial vaginosis, Trichomonas vaginalis, and human papillomavirus (HPV) were performed. RESULTS: Upon review, ASCUS was diagnosis in 70/103 (67.9%), being 38 (54.2%) reactive ASCUS and 32 (45.71%) neoplastic ASCUS; 62 (88.5%) ASC-US and 8 (11.41%) ASC-H. ASCUS (Regione Protocol), respectively 1-5: 15 (21.4%), 19 (27.1%), 3 (27.1%), 16 (22.8%), and 1 (1.4%). A higher number of cases of cervical intraepithelial neoplasia (CIN) II/III in the biopsies of patients with ASC-H compared to ASC-US (P = .0021). High-risk HPV test and presence of CIN II/III are more frequent in ASC-H than ASC-US (P = .031). CONCLUSIONS: ASC-H is associated with clinically significant disease. High-risk HPV-positive status in the triage for colposcopy of patients with ASC-US is associated with increased of CIN.

Utilization of human papillomavirus testing for cervical cancer prevention in a university hospital.

This study aimed to evaluate the performance and cost of using polymerase chain reaction (PCR) and hybrid capture in the detection of cervical intraepithelial neoplasia (CIN) in patients with cytological abnormalities (ASCUS/low-grade squamous intraepithelial lesion--LSIL), and the feasibility of implementing these methods in Brazil's Unified National Health System (SUS). Colposcopy gave a negative predictive value of 92.86% and efficiency of 87.8% for diagnosing CIN. The sensitivity of PCR and hybrid capture for detecting CIN was 83.33% and 66.67%, respectively, and the negative predictive value for diagnosing CIN2/CIN3 was 100% and 94.74%, respectively. The annual cost for 80 patients was lower when all patients with ASCUS/LSIL were referred for colposcopy than when HPV testing was performed and those with positive results were referred for colposcopy. Therefore, at present, it is financially unfeasible for the National Health System to implement HPV testing to screen patients with cytological abnormalities (ASCUS/LSIL). However, considering that large-scale use might make such methods cheaper, PCR should be the chosen method, since it is less expensive, more sensitive, and has a high negative predictive value.

Utilization of human papillomavirus testing for cervical cancer prevention in a university hospital

This study aimed to evaluate the performance and cost of using polymerase chain reaction (PCR) and hybrid capture in the detection of cervical intraepithelial neoplasia (CIN) in patients with cytological abnormalities (ASCUS/low-grade squamous intraepithelial lesion - LSIL), and the feasibility of implementing these methods in Brazil's Unified National Health System (SUS). Colposcopy gave a negative predictive value of 92.86 percent and efficiency of 87.8 percent for diagnosing CIN. The sensitivity of PCR and hybrid capture for detecting CIN was 83.33 percent and 66.67 percent, respectively, and the negative predictive value for diagnosing CIN2/CIN3 was 100 percent and 94.74 percent, respectively. The annual cost for 80 patients was lower when all patients with ASCUS/LSIL were referred for colposcopy than when HPV testing was performed and those with positive results were referred for colposcopy. Therefore, at present, it is financially unfeasible for the National Health System to implement HPV testing to screen patients with cytological abnormalities (ASCUS/LSIL). However, considering that large-scale use might make such methods cheaper, PCR should be the chosen method, since it is less expensive, more sensitive, and has a high negative predictive value.

O trabalho objetivou avaliar o desempenho e o custo do PCR e captura híbrida na detecção de neoplasia intra-epitelial cervical (NIC) em pacientes com anormalidades citológicas (ASCUS/lesões de baixo grau - LBG), e a viabilidade da implantação destes métodos no serviço público de saúde. Observou-se valor preditivo negativo de 92,86 por cento e eficiência de 87,8 por cento da colposcopia para diagnóstico de NIC. A sensibilidade do PCR e captura híbrida na detecção de NIC foi de 83,33 por cento e 66,67 por cento, respectivamente. O valor preditivo negativo no diagnóstico de NICII e III do PCR e captura híbrida foi de 100 por cento e 94,74 por cento, respectivamente. O custo anual das oitenta pacientes foi menor encaminhando-se todas as pacientes com ASCUS/ LBG à colposcopia do que se fossem realizados testes biomoleculares e encaminhando-se aquelas com resultados positivos à colposcopia. Portanto, por enquanto, é inviável financeiramente para o Sistema Unico de Saúde a implantação de métodos de biologia molecular para pacientes com ASCUS e LBG à citologia cérvico-vaginal, mas considerando que o uso em grande escala poderia torná-los mais baratos, o PCR deveria ser o método escolhido, por ter menor custo, alto valor preditivo negativo e melhor sensibilidade.

Prevenção do câncer de colo uterino: testes biomoleculares para HPV / Cervical cancer prevention: HPV DNA testing

O câncer de colo uterino é a terceira neoplasia maligna mais comum em mulheres no Brasil. Geralmente, o rastreamento tem sido feito pela citologia cérvico-vaginal, e as pacientes com alterações citológicas são encaminhadas para a colposcopia. A infecção do colo uterino por HPV (papilomavírus humano) de alto risco está associada ao desenvolvimento do câncer de colo uterino e lesões precursoras. Apesar do impacto da citologia oncótica cérvico-vaginal na redução da incidência desse câncer no mundo, esse método possui muitas limitações. Recentemente, o desenvolvimento de testes biomoleculares para a detecção de infecção por HPV do colo uterino tem sido uma alternativa ou um método adjunto à citologia para a detecção de NIC (neoplasia intra-epitelial cervical). Muitos estudos mostram a utilidade clínica dos testes biomoleculares para HPV: no rastreamento primário, como adjunto da citologia de ASCUS (células escamosas atípicas de significado indeterminado) ou LIBG (lesão intra-epitelial de baixo grau) e no seguimento pós-tratamento.

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)

Atypical squamous cells of undetermined significance: analysis of microbiology, cytological criteria and clinical conduct.

AIMS: To differentiate between two types of atypical squamous cells of undetermined significance (ASCUS): probably neoplastic (PN) or probably reactive (PR), and, in accordance with the recommendations on screening protocols of the Emilia-Romagna Region (PSRER), Italy, to define the best management to follow and the prognosis. Furthermore, the associations between ASCUS and infectious agents and human papillomavirus (HPV) were evaluated. METHODS: Fifty-eight ASCUS smears were reviewed and sorted; if a diagnosis of ASCUS was confirmed, the smear was classified as PR or PN, and the PSRER group was identified. Then, colposcopy was performed with checks for infectious agents (culture evaluation with cytological or clinical criteria) and HPV (hybrid capture). RESULTS: The ASCUS frequency was 3.96%. Of the 58 cases, 33 (56.9%) were diagnosed as ASCUS on review, of which 15 cases were PN and 18 were PR, while 23 (39.7%) smears were normal and 2 (3.4%) showed cervical intraepithelial neoplasia (CIN). There was a higher frequency of bacterial vaginosis (BV) and HPV in ASCUS PR patients compared with normal cytology, and a higher frequency of CIN in ASCUS PN patients compared with normal controls (P < 0.05). By grouping ASCUS 1 and 3, we observed a higher frequency of CIN and of high-grade colposcopy findings compared with ASCUS 2 and 4 (P < 0.05). From the 23 cases not found to be ASCUS, 18 (87.5%) had normal cytology and colposcopy results on the first follow-up. CONCLUSIONS: Classification of ASCUS as either PN or PR helps in clinical conduct and prognosis, because a higher frequency of CIN is found in ASCUS PN. ASCUS subdivisions, based on PSRER and colposcopy, may facilitate the clinical conduct because ASCUS 1 and 3 with high-grade colposcopic findings proved to be related to the presence of CIN. We propose that initial ASCUS cytology be reviewed, and if it is confirmed, colposcopy should be performed. For those cases found to be normal on review of the cytology results, it is suggested that a cytological check-up be carried out every 6 months.

Metastasis of choriocarcinoma to lumbar and sacral column.

We describe the case of a patient who reported a 4-month history of edema in the lower right limb, which was accompanied by pain and paresthesia and which progressed to flaccid paraplegia. Two years earlier she had undergone a uterine curettage for hydatidiform mole. Metastases of a choriocarcinoma to the lumbar and sacral segments of the column were diagnosed.

Abortamento séptico: identificaçäo de fatores de risco para complicaçöes / Septic abortion: identifying risk factors for complications

Objetivo: estudar um grupo de mulheres atendidas com quadro de abortamento séptico, analisando o quadro clínico e terapêutica, identificando um grupo de maior risco para complicaçöes. Métodos: analisaram-se retrospectivamente dados referentes a 224 pacientes com diagnóstico de abortamento séptico. Foram coletados dos prontuários a idade da paciente, paridade, quadro clínico, exames laboratoriais e de imagem, o tratamento e as complicaçöes. A possibilidade de induçäo do abortamento foi baseada nas informaçöes das pacientes e/ou dos parentes e acompanhantes. O diagnóstico de abortamento séptico foi baseado na história clínica, quadro clínico, hemograma, dor à mobilizaçäo do útero e anexos e presença de leucorréia purulenta proveniente do canal cervical. Resultados: a média de idade das pacientes foi de 21,4 ñ 6,2 anos, sendo que 45 tinham menos de 20 anos (20,1 por cento); 66 eram primigestas (29,5 por cento) e 55, secundigestas (24,5 por cento). Em 143 mulheres (63,8 por cento) este abortamento foi o primeiro. As manifestaçöes clínicas mais freqüentes foram a hemorragia presente em 83,9 por cento dos casos e a febre em 61,1 por cento. A induçäo do abortamento foi informada por 37,9 por cento das pacientes, 33,9 por cento informaram que o abortamento havia sido espontâneo e 28,2 näo informaram se foi ou näo espontâneo. Histerectomia foi indicada em 5 casos. Nenhuma histerectomia foi realizada no grupo de pacientes com abortamento espontâneo (2,2 por cento) e o número de complicaçöes neste último grupo foi menor (3,9 por cento versus 1,8 por cento do grupo com abortamento induzido), p<0,05. Conclusäo: a informaçäo da induçäo do abortamento é um dado importante, pois estas pacientes apresentam maior risco para complicaçöes.

Análise retrospectiva de 287 casos de abdome agudo em Ginecologia e Obstetrícia / Retrospective analysis of 287 cases of acute abdomen in Gynecology and Obstetrics

OBJETIVO: O abdome agudo em ginecologia e obstetrícia apresenta baixo risco de vida para a paciente, entretanto, o retardo no diagnóstico e tratamento influencia na morbi-mortalidade. O objetivo deste trabalho foi estudar as principais causas de abdome agudo em tocoginecologia. MÉTODOS: Foram revisados 287 casos de abdome agudo em tocoginecologia de janeiro de 1987 a dezembro de 1997 atendidos na Disciplina de Ginecologia e Obstetrícia da Faculdade de Medicina do Triângulo Mineiro. RESULTADOS: Os resultados mostraram que a prenhez ectópica foi a mais freqüente causa de abdome agudo hemorrágico com 98,5 por cento dos casos. Nestes casos, a dor pélvica foi o sintoma mais comum (69,1 por cento). Todas as pacientes foram submetidas à laparotomia e salpingectomia foi realizada em 92,6 por cento dos casos. A causa mais freqüente de abdome agudo inflamatório foi a doença inflamatória pélvica com 94,8 por cento. A dor pélvica aguda estava presente em 91,5 por cento dos casos e a febre em 56,2 por cento casos. A penicilina foi usada com sucesso em 92,1 por cento dos casos. Do total de 201 casos de doença inflamatória pélvica, 13 (6,5 por cento) foram submetidos à laparotomia. CONCLUSÕES: Os autores concluem que o abdome agudo de causa tocoginecológica apresenta quadro clínico variável, portanto, o ginecologista deve estar atento para estabelecer diagnóstico e tratamento precisos.

BACKGROUND: The gynecology or obstetric acute abdomen in woman present a low risk, although the diagnosis and treatment may be a challenge. The aim of this study was to analize the most frequent causes of acute abdomen in gynecology and obstetrics. METHODS: We reviewed 287 cases, from January 1987 to December 1997, attending in Discipline of Gynecology and Obstetrics of the Faculty of Medicine of "Triângulo Mineiro". RESULTS: Ouur results showed that ectopic pregnancy was the most frequent cause of hemorrhagic acute abdomen, with 98.5 percent of the cases. Pelvic pain was the most common symptom (69.1 percent). All patients were submitted to a laparotomy; salpingectomy was performed in 92.6 percent of cases. The most frequent cause of inflammatory acute abdomen was inflammatory pelvic disease, with 92.6 percent. Acute pelvic pain was present in 96,5 percent of the cases and fever in 56.2 percent. Penicillin was successfully used in 92.1 percent. From the 206 cases of IPD, 13(6.5 percent) were submitted to laparotomy. CONCLUSIONS:The authors concluded that acute abdomen for ginecology or obstetrical disorders shows a variability of symptoms that may lead to a wrong diagnostic. Meanwhile, the gynecologist must be aware of these variabilities to perform a correct diagnosis.