High-grade cervical intraepithelial neoplasia (CIN) in pregnancy: clinicotherapeutic management.

UNLABELLED: An increasing incidence of cervical intraepithelial neoplasia (CIN) among young women has been noticed in recent years. For this reason pregnancy might represent a peculiar opportunity to undergo cytocolposcopic examination for those women who do not take part in a screening program for cervical carcinoma. Diagnosis of CIN during pregnancy poses the question of the management of this disease and particularly of whether it is better to treat the lesion or not during pregnancy. To contribute to the solution of this issue we initiated a study on the management of high-grade CIN in pregnancy. MATERIAL AND METHODS: Five hundred and seventy-one pregnant women underwent cytologic, colposcopic and, when necessary, histologic examination. Those in whom a CIN was discovered in the first four months of gestation underwent laser conization. When the diagnosis of CIN was made after the sixteenth week of gestation, cytocolposcopic monitoring was performed every eighth week during pregnancy and two months after childbirth. Laser conization was performed under colposcopic guidance in the outpatient setting in all cases. All treated patients were submitted to cytologic, colposcopic and, if necessary, histologic examination every third month in the first year after treatment, every sixth month in the second year and yearly from the third year onwards. RESULTS: In 14 (2.4%) of the 571 examined women a CIN III was discovered, 6 of which associated with a human papilloma virus (HPV) infection. Of these, 8 patients, whose diagnosis was made within the sixteenth week of pregnancy, underwent laser conization. In one case a minor hemorrhage occurred during treatment. Two patients reported minor bleeding up to ten days after treatment. No major hemorrhages or cervical stenosis were observed. Histologic examination of the cones confirmed the preoperative diagnosis based on cervical biopsies and the lesion was entirely removed by conization in all cases. Seven of the 8 patients who underwent laser conization during pregnancy had a spontaneous delivery at term. The remaining patient, who had had a previous cesarean section, was again delivered by cesarean section. All treated patients were cured after the first-year follow-up visit. In 6 patients CIN was diagnosed after the sixteenth week of pregnancy. These women underwent cytocolposcopic examination every eighth week during pregnancy and two months after delivery, when the cervical changes associated with gestation had disappeared. Four of these patients showed persistence of CIN at postpartum follow-up and therefore underwent laser conization. In two patients spontaneous regression of the lesion was observed. In no case did progression to invasive carcinoma occur. CONCLUSIONS: Given the increasing incidence of CIN in young women, the beginning of pregnancy may represent a peculiar opportunity for all pregnant women who do not take part in cervical screening programs to undergo a cytocolposcopic examination. In case of a diagnosis of high-grade CIN within the first 16 weeks of pregnancy, a conservative excisional treatment, which does not expose the pregnancy to any risk, should be carried out in order to confirm the intraepithelial localization of the lesion.

Ranitidine bismuth citrate plus clarithromycin 7-day regimen is effective in eradicating Helicobacter pylori in patients with duodenal ulcer.

BACKGROUND: No clinical study has been performed to-date to evaluate the efficacy of the dual therapy of ranitidine bismuth citrate (RBC) plus clarithromycin (C) 500 mg b.d. given for 7 days for the eradication of H. pylori. AIM: To assess the eradication rates achieved by treatment with RBC 400 mg b.d. for 28 days combined with clarithromycin 500 mg b.d. for 7 days in H. pylori-positive duodenal ulcer patients. METHODS: One hundred and twelve H. pylori-positive patients with endoscopically proven active duodenal ulcer were included in a multicentre, open, randomized trial. H. pylori infection was initially detected by CLO-test and histology on antral and corpus biopsies, and by 13C-urea breath test (UBT). Patients were included if at least two of the tests were positive for H. pylori infection. Patients were randomized to receive RBC 400 mg b.d. for 4 weeks combined with clarithromycin 500 mg b.d. for the first 7 days (Group A) or 14 days (Group B). A second endoscopy was performed at least 28 days after the end of therapy for the assessment of ulcer healing and H. pylori infection. Eradication was assumed if all the tests (CLO-test, histology and UBT) were negative for H. pylori. RESULTS: Fifty patients in Group A and 55 in Group B were assessed for H. pylori eradication and ulcer healing. The eradication rates according to intention-to-treat analysis were 75% in Group A and 80% in Group B. Considering only those patients with evaluable data at least 28 days after the end of therapy, H. pylori eradication was achieved in 84% and 82% in Group A and B, respectively. No statistically significant difference in eradication was found between the two groups by Mantel-Haenszel test. Only one patient, in Group A, was withdrawn because of adverse events (epigastric pain and pruritus).

[Cervical intraepithelial neoplasia (CIN) and human papillomavirus (HPV) infection]. / La neoplasia cervicale intraepiteliale (CIN) e l'infezione da human papillomavirus (HPV).

Many studies have shown a strong correlation between CIN and HPV infection. Molecular biology has allowed identification of types of HPV which seem to be connected, more frequently than others, to dysplastic lesions. Physical state of HPV-genome seems to play an important role in the development of cervical cancer. In this study the HPV-genome has been searched in tissue specimens obtained from 34 women affected by CIN II and III. All patients underwent laser conization. Immediately before treatment, colposcopically directed biopsies of the cervical lesion and of the areas with no colposcopically apparent disease were taken and on these samples, HPV-DNA has been searched, isolated and analysed for HPV types and physical state. Histologic examination on cones showed 6 cases of CIN II (3 with HPV), 24 cases of CIN III (14 with HPV), 1 microinvasive carcinoma and 3 with no residual lesion. Southern blot analysis detected HPV-DNA in 4 cases of CIN II (16.7%) and in 20 cases of CIN III (70.6%). In 50% of CIN II and 85% of CIN III HPV 16 DNA has been found and in the remaining 50% of CIN II and 15% of CIN III HPV 31 DNA has been detected. All CIN II and 14 cases of CIN III showed episomal HPV-DNA. Integrated HPV-DNA has been found in 3 cases of CIN III and the other 3 cases of CIN III showed both integrated and episomal HPV-genome. Integrated form has been noticed only for HPV 16 type. In no case of colposcopically normal tissue has HPV-DNA been found. These data seem to confirm the strong correlation between HPV 16 type, which often has integrated form, and CIN III strengthening the hypothesis of its potential oncogenic action.

[Cervical intraepithelial neoplasia and genital condylomatosis in HIV-positive patients. Clinical aspects and management]. / La neoplasia cervicale intraepiteliale e la condilomatosi genitale nelle pazienti HIV-positive. Clinica e terapia.

In this study prevalence of cervical intraepithelial neoplasia (CIN) and genital condylomatosis in HIV-positive women and the possible relation between HIV and HPV infection and CIN have been analyzed. 66 seropositive women underwent cytological, colposcopic and, when necessary, histologic examination and the results have been compared with those obtained from 150 HIV-seronegative controls. HIV-positive patients were divided in two groups, depending on number of CD4+/mm3, < 400 or > = 400, to evaluate the relation between immunity and HPV infection and/or CIN. 35 seropositive and 136 seronegative patients affected by genital condylomatosis and/or CIN I were submitted to laser CO2 vaporization and the results of the treatment have been compared. All cases of CIN II and III underwent laser CO2 conization. Among HIV-seropositive patients the prevalence of genital condylomatosis appeared to be 87.9% and among the seronegative controls 18% (p < 0.001). Multilocated condylomatosis represented 58.7% of genital condylomatosis among seropositive women and 11.1% among the seronegative patients. In HIV-seropositive group the prevalence of genital condylomatosis was of 95.2% among women with CD4+ < 400 and of 75% among those with CD4+ > = 400 (p > 0.01). 13 patients (19.7%) of the 66 seropositive women and 12 of the 150 (8%) seronegative had a cervical intraepithelial neoplasia. A CIN III was diagnosed in 9 seropositive patients (13.6%) and in 5 seronegative (3.3%). Among the HIV-seropositive women who underwent laser vaporization for genital condylomatosis a cure-rate of 34.5% was found; among seronegative women who underwent the same treatment the cure-rate was of 79.4%. Those patients who underwent laser conization resulted all cured at first check. In the group of HIV-seropositive women a higher prevalence (p < 0.001) of genital condylomatosis, particularly multilocated localization, has been found than in HIV-seronegative patients. An increased prevalence of CIN has also been found among HIV-seropositive women. Genital condylomatosis in seropositive patients resulted extremely difficult to treat with laser vaporization in contrast with the 100% success in laser conization for high-grade CIN.

Conizaçäo ambulatorial com laser de dióxido de carbono em pacientes com neoplasia intra-epitelial cervical / Ambulatorial conization with Carbon Dioxide Laser in patients with Intraepithelial Neoplasia

Analisou-se os resultados de conizaçäo ambulatorial com laser em 468 pacientes selecionadas, portadoras de Neoplasia Intra-epitelial Cervical, independente da presença de infecçäo por Papiloma-vírus humano. As indicaçöes constaram em todos os graus II ou III, grau I com colposcopia prejudicada quanto à junçäo escamo-colunar, inexistência de correlaçäo entre citologia, colposcopia e histologia. O achado de 3,4 por cento de carcinoma invasor apoia o tratamento excisional. Conclui-se que o método representa a melhor escolha nesses casos, face à baixa morbidade e elevada eficácia