Abnormal cervicovaginal cytology, unsatisfactory colposcopy and the use of vaginal estrogen cream: an observational study of clinical outcomes for women in low estrogen states.

AIM: To determine the effectiveness of vaginal estrogen cream to improve the rate of satisfactory colposcopy and subsequent smear result in patients in a hypoestrogenic state and an abnormal Papanicolaou smear. To delineate between abnormal smears secondary to atrophy and inflammation from preneoplastic change and suggest an effective treatment strategy to deal with this challenging situation. METHODS: Patients with abnormal cervicovaginal smears who were in a low estrogen state (postmenopausal or amenorrheic postnatal) undergoing colposcopy were identified. All patients had an unsatisfactory colposcopy and were treated with vaginal estrogen cream twice per week for 6 weeks and underwent repeat colposcopy, smear and targeted biopsy where required. RESULTS: Fifty-four patients had an abnormal smear and were clinically in a low estrogen state, with four having previously had a hysterectomy. After 6 weeks of vaginal estrogen therapy, 32 out of 50 patients' colposcopic examinations were satisfactory. Also, 40 out of 54 patients' smears returned to normal after treatment. Of the 14 patients with persistent smear abnormalities, only three were diagnosed with true high-grade pre-invasive disease. CONCLUSION: The use of vaginal estrogen cream for patients with smear abnormalities and a low estrogen status improves the satisfactory colposcopy rate and improves the accuracy of the prediction of true high-grade pre-invasive disease. This treatment may then reduce the number of patients that require definitive treatment for their screen-detected abnormalities in this patient population.

Fast track surgery: a clinical audit.

BACKGROUND: Fast track surgery is a concept that utilises a variety of techniques to reduce the surgical stress response, allowing a shortened length of stay, improved outcomes and decreased time to full recovery. AIMS: To evaluate a peri-operative Fast Track Surgical Protocol (FTSP) in patients referred for abdominal surgery. METHODS: All patients undergoing a laparotomy over a 12-month period were entered prospectively on a clinical database. Data were retrospectively analysed. RESULTS: Over the study period, 72 patients underwent a laparotomy. Average patient age was 54 years and average weight and BMI were 67.2 kg and 26 respectively. Sixty three (88%) patients had a vertical midline incision (VMI). There were no intraoperative blood transfusions. The median length of stay (LOS) was 3.0 days. Thirty eight patients (53%) were discharged on or before post op day 3, seven (10%) of whom were discharged on postoperative day 2. On stepwise regression analysis, the following were found to be independently associated with reduced LOS: able to tolerate early enteral nutrition, good performance status, use of COX inhibitor and transverse incision. In comparison with colleagues at the SGOG not undertaking FTS for their patients, the authors' LOS was lower and the RANZCOG modified Quality Indicators (QI's) did not demonstrate excess morbidity. CONCLUSIONS: Patients undergoing fast track surgery can be discharged from hospital with a reduced LOS, without an increased readmission rate and with comparative outcomes to non-fast tracked patients.

The role of HPV testing in patients with possible high-grade cervical cytology.

AIM: To assess the role of human papillomavirus (HPV) testing for high-risk types in an Australian population with the equivalent cytological result of atypical squamous cells of undetermined significance - possible high-grade (ASC-H). METHODS: A retrospective review was conducted of all patients referred with a 'possible high-grade squamous abnormality' Pap-smear result who underwent HPV testing for 13 high-risk types, colposcopy and directed biopsy, and any subsequent treatment. RESULTS: The study included 100 patients. Overall, 79% of patients had a positive test for high-risk HPV DNA types. Histopathology was available for 98 patients and demonstrated that 47% of patients had confirmed high-grade dysplasia. HPV testing had a high sensitivity (98%), but low specificity (40%) for the detection of high grade dysplasia, and a negative predictive value of 95%. CONCLUSIONS: The results of this study suggest that among patients with the equivalent of ASC-H cytology, a negative HPV DNA test for high-risk types is a good predictor of the absence of high-grade dysplasia. HPV testing in this patient population therefore has the potential to reduce the number women referred for colposcopy.

p16(INK4a) as a complementary marker of high-grade intraepithelial lesions of the uterine cervix. I: Experience with squamous lesions in 189 consecutive cervical biopsies.

AIM: To test the usefulness of p16(INK4a) immunostaining for improving the diagnostic accuracy of cervical punch biopsies referred to a routine laboratory setting during the investigation of women with abnormal Papanicolaou smears. METHODS: A total of 188 consecutive and unselected colposcopically directed cervical biopsies and a single contemporaneous cervical polyp were accessioned prospectively over a 3-month period, step-serially sectioned and examined by H&E and immunostained for p16(INK4a). The clinical context, results of concurrent Papanicolaou smears/ThinPrep slides and Digene hybrid capture tests for high-risk human papillomavirus (HPV) subtypes, as well as follow-up cervical smears/ThinPrep, biopsies and loop excisions of transformation zones or cone biopsies were all correlated with the morphological and immunohistochemical findings. RESULTS: Seventy-seven biopsies (40.7%) displayed a high-grade squamous intraepithelial lesion (HGSIL; cervical intraepithelial neoplasia [CIN] 2-3), 27 (14.3%) showed a low grade squamous intraepithelial lesion (HPV +/- CIN1) and 85 (45%) showed a range of non-dysplastic (inflammatory or reactive) changes. Diffuse strong parabasal immunostaining for p16(INK4a), suggestive of integrated high-risk HPV DNA into the host genome, was observed in 81 biopsies (42.9%, including the cervical polyp) and correlated (>90%) with HGSIL in the H&E sections. Only one case revealed irreconcilable discordance between the histological features and this strong parabasal immunostaining pattern. Focal and weaker midzonal or superficial p16(INK4a) immunostaining, suggestive of episomal HPV infection, was noted in 19 biopsies (10%) and these biopsies exhibited a range of histological changes but predominantly low grade squamous intraepithelial lesion (LGSIL). No staining of the squamous epithelium was seen in 89 biopsies (47.1%). Again, only one case revealed irreconcilable discordance between the histological features and this negative immunostaining pattern. On review of all cases where discordant results were noted between the H&E appearances and expected p16(INK4a) immunostaining, we found 26 cases (13.7%) in which this discordance prompted justifiable modification of the original diagnosis. CONCLUSIONS: Thus, within a routine diagnostic laboratory, p16(INK4a) immunostaining appears to be a very useful adjunctive test in the examination of colposcopically directed cervical biopsies, in the diagnostic cascade of women investigated for abnormal Papanicolaou smears. It is possible, as further data accumulate concerning the importance of integration of high-risk HPV DNA into the host cell genome and the reliability with which this can be identified by p16(INK4a) immunostaining, that this will become the diagnostic 'lesion of interest', replacing the subjective histological grading of cervical dysplasia, in the management of such patients; i.e., the discriminatory watershed between continued surveillance and active intervention.

Epithelioid trophoblastic tumour: report of a case in the fallopian tube.

A case of epithelioid trophoblastic tumour (ETT), occurring in a fallopian tube of a 39-year-old woman, is reported. The patient presented with a positive pregnancy test, but continued to have 'periods'. A palpable right adnexal mass was noted that was confirmed on ultrasound. The mass was removed together with the uterus, omentum and associated ovary. Careful examination of the uterus revealed no evidence of either an antecedent tumour or intra-uterine pregnancy. Histologically, the tubal mass displayed sheets and islands of large, relatively uniform, mitotically active polyhedral cells, with surrounding necrosis. The immunoprofile of the tumour was atypical in that alpha-inhibin and epidermal growth factor were weakly positive, but other results were consistent with the diagnosis of ETT. The patient received a foreshortened course of standard EMACO (etoposide, actinomycin-D, methotrexate, vincristine, and cyclophosphamide) combination chemotherapy for high-risk gestational trophoblastic disease. Serum beta-hCG fell from a pre-operative level of 52 000 U/mL to non-pregnant levels within two courses and she remains well and disease-free 12 months post-diagnosis.