Hematometra in uterus didelphis: a pitfall in teenagers with lower abdominal mass. Report of two cases.

Müllerian malformations represent a wide spectrum of anomaly of the female reproductive tract, usually detected at birth or at puberty. The presence of uterus didelphys and obstructed hemivagina, associated with ipsilateral renal agenesis, is known as Herlyn-Werner-Wunderlich syndrome, a rare congenital anomaly. Two cases of uterus didelphic and hematometra caused by vaginal septum are reported; the girls had a delayed diagnosis due to absence of a specific clinical feature. Clinicians must be aware of the existence of these malformations. An adequate radiological study is mandatory to assess the anatomic conformation, and to optimize the therapeutic procedures.

Interlaboratory reproducibility of liquid-based equivocal cervical cytology within a randomized controlled trial framework.

Within a multicentre controlled trial framework, an external quality control (EQC) was scheduled to evaluate the interlaboratory reproducibility of liquid-based cytology. In particular, this EQC intended to evaluate the reproducibility of the ASCUS diagnosis.A selected set of 30 slides (4 within normal limit cases, 16 atypical squamous cells of undetermined significance; 4 low-grade squamous intraepithelial lesions and 6 high-grade squamous intraepithelial lesions) circulated among the 13 laboratories involved in the trial.Kappa values were obtained from the comparison between individual laboratory diagnoses and majority diagnoses with target diagnoses. Specific kappa values resulted moderate to high for HSIL and low to moderate for LSIL and WNL. Meanwhile, the specific kappa for ASCUS was below 0.4 in 12 of 13 participating laboratories. The lack of reproducibility for ASCUS was not a result of the introduction of this new technology but rather to the low reproducibility of the ASCUS category itself stemming from intrinsic uncertainties in the reporting criteria.

Genital human papillomavirus types in immunocompetent and immunodepressed women in northeast Italy: prevalence and cytomorphological correlations.

OBJECTIVE: We evaluated the prevalence of genital human papillomavirus (HPV) types in correlation with cytomorphological findings in patients at different risk for cervical intraepithelial neoplasia living in northeast Italy. METHODS: Exfoliated cervicovaginal cells from 943 women, who were divided into three groups, were analyzed by polymerase chain reaction. RESULTS: Overall, HPV prevalence rates were 7%, 38%, and 52%, respectively. The single most frequent type was HPV 16 (18%), followed by types 6, 31, 53, 58, 61, and novel/unidentified (5-7%); other types had a frequency <5%. Infection with multiple types was present in 12%. In HIV-infected women, HPV infection was correlated with lower CD4 level and higher viral load; HGSILs were correlated only with a lower CD4 count, and no correlations were found for LGSILs. CONCLUSIONS: HGSILs were associated with high-risk types, mainly HPV 16 (40%). LGSILs, instead, were associated with a broad spectrum of low-risk and high-risk types.

Vulvar carcinoma in a 12-year-old girl with vertically acquired human immunodeficiency virus infection.

We report the first case of a girl with vertically acquired human immunodeficiency virus (HIV) infection, who developed invasive squamous cell carcinoma of the vulva at 12 years of age. Lesions resembling bowenoid papulosis covered the perianal area as well. She underwent a nonmutilating surgical excision of the infiltrating lesion. More than 3 years later, her clinical condition is excellent, although dysplastic, noninfiltrating multifocal lesions persist. This case highlights the need to perform careful periodic genital examinations in all HIV-infected children and adolescents born to HIV-positive mothers.

Usefulness of human papilloma virus testing in the screening of cervical cancer precursor lesions: a retrospective study in 314 cases.

OBJECTIVE: To assess the usefulness of human papilloma virus (HPV) typing for predicting pre-malignant and malignant cervical lesions. STUDY DESIGN: 314 women, who underwent colposcopy, biopsies and high and low-risk HPV typing after a confirmed abnormal routine Pap test were studied. HPV-DNAs were typed by using PCR technique. RESULTS: We found a significant increasing rate of high-risk-HPV by the increasing severity of histology, ranging from 40% in negative cases to 86.9% in those with CIN3 lesions. The positive predictive value of high-risk-HPV ranged from 13.3% in patients with atypical squamous cells of undetermined significance (ASCUS) to 29.4% in those with HSIL. By contrast, negative predictive value was 96% in patients with ASCUS, 97.2% in low-grade squamous intraepithelial lesions (LSIL), and 71.4% in high-grade squamous intraepithelial lesions (HSIL). Sensitivity and specificity for detecting CIN2 or CIN3 was 86.0% and 41.3%, respectively. CONCLUSIONS: The high negative predictive value of high-risk HPV testing suggests that HPV negativity could be used for predicting the absence of important cervical lesions, and therefore avoiding unnecessary colposcopy in ASCUS and LSIL cases.

Colposcopy, cytology and HPV-DNA testing in HIV-positive and HIV-negative women.

In this study we examined the incidence of colposcopic-colpocytologic findings and analyzed Human Papilloma Virus (HPV)-DNA testing by Polymerase Chain Reaction (PCR) in 104 Human Immunodeficiency Virus (HIV) serous positive women (Group 1) and 218 HIV-negative women (control Groups 2 and 3). The aim of the study was to evaluate the most appropriate and efficacious diagnostic methods for screening programs for cervical cancer in HIV-positive women. For Group 1 we also considered the value of CD4+ T-lymphocytes and morphologic and molecular follow-up from 3 to 6 months. The results showed that the abnormal transformation zone (ANTZ) was present in 66.3% of the cases in Group 1 compared with 31.4% in control-Group 2 (p<0.001), and with 58.93% of the cases in control-Group 3 (p=0.257); intraepithelial squamous lesions (SIL) were found in 50% vs 5.66% (p<0.001) and vs 56.25% of the cases (p=0.433), respectively. In 28.85% of the HIV-positive patients the first cytological screening exam was not evaluable due to inflammation but in 56.67% of the cases colposcopy revealed ANTZ. The subsequent colpocytological checkup after therapy showed 10 cases (30%) of low risk squamous intraepithelial lesions (LSIL) and two cases (6.6%) of high risk squamous intraepithelial lesions (HSIL). HPV-DNA testing by PCR was positive in 53.8% of the cases in Group 1, in 6.6% in control-Group 2 and in 42% in control-Group 3. In HIV-positive patients multiple HPV genotypes were simultaneously present in 21.43% of the cases and high risk genotypes were present in 70% of the cases of HSIL. In Group 1, 36.61% of the cases had lesions of the lower genital tract. The value of CD4+ T-lympocytes was <200 cells/ml in 30% of the cases of HSIL. Our data, like those of other Authors, confirm a high incidence of HSIL, abnormal colposcopic findings, and HPV infections in HIV-positive women with respect to control-Group 2, while there was not much difference between Group 1 and control-Group 3. Such frequency again suggests that an integrated morphological diagnostic approach with colposcopy-colpocytology in the screening of immunosuppressed subjects would be worthwhile.

Epidemiological aspects of vaginal intraepithelial neoplasia (VAIN).

In order to evaluate the natural history of Vaginal Intraepithelial Neoplasia (VAIN), its epidemiological characteristics and the risk of its evolving into Invasive Carcinoma, we studied direct vaginal biopsies from 376 outpatients, we ascertained the predominant disease site and investigated whether the lesions (uni or multicentric) were only vaginal, were present at both the cervix and the vagina or were an extension of cervical lesions (DES-like areas). Moreover, in cervical and vaginal biopsies from 265 patients, we compared the severity of intraepithelial neoplasia of the vagina and cervix. In our series, vaginal lesions accounted for over half (52.6%) of the alterations attributable to HPV infection, while VAIN accounted for 46.5%; in 84.8% of cases, VAIN was associated with HPV. In 49.8% of cases, biopsies were from the upper third of the vagina and in 74.8% the pathological areas involved both the cervix and the vagina. The DES-like zone accounted for 7.9% of cases, vaginal wall involvement being limited to the upper third. Finally, the comparison of histological findings, in the 265 patients, confirmed that in 69.8% cases vaginal and cervical lesions were of the same grade; in 18.8% vaginal lesions were more severe than cervical lesions. In our study a higher number of vaginal biopsies were taken than in previous years, and it is difficult to establish whether this depends on improved diagnostic methods or on changes in epithemiological factors, such as the reported increase in the incidence of HPV lesions. A systemic search for lesions and a study on their evolution are therefore required to clarify this aspect.

Colposcopy, colpocytology and the vaginal ecosystem. Oncological, bacteriological and hormonal evaluation in a series of 400 women.

The Authors retrospectively considered colpocytological and colposcopic findings in a series of 400 women, aged 16 to 83 years, presenting for the first time at the Oncological Gynaecology Unit of the Institute of Gynaecology and Obstetrics of Padua University between 1991 and 1992. In addition to oncological evaluation, the bacteriological profile and hormone status of cytological samples were formulated in all cases. The most common oncological finding was a cell morphology within normal limits (67%), followed by reactive and reparative changes (19%) and low-grade squamous intraepithelial lesions (SIL, 12%). Histological findings correlated well with the cytological diagnosis, though low-grade SIL was over-estimated. As for the bacteriological profile, a mixed flora was most frequent (56.7%) followed, especially in fertile age, by Döderlein's bacillus (20%) and vaginosis (15.5%). Colposcopy most frequently revealed ectopia and/or a normal transformation zone (50.7%) and dystrophic mucosa (21%). An abnormal transformation zone was more common among women with a moderate-to-abundant flora. Fifteen male partners were also checked: cellular changes typical of human papilloma virus infection were found in 40% and colposcopic findings compatible with said virus were observed in 26.6% of cases. These results confirm that colpocytology provides a complete and simultaneous evaluation not only of cell morphology, but also of the bacterial population and hormones in the vaginal ecosystem. It is therefore the method of choice in screening for cervical and vaginal neoplasms and an effective means for simultaneously evaluating vaginal flora and hormone status.

Human papillomavirus infections of the genital region in human immunodeficiency virus seropositive women: integration of type 16 correlates with rapid progression.

The efficacy of treatment of HPV infections was evaluated in 14 HIV-1 seropositive women. Disease evolution was evaluated at follow-up examinations, and findings were compared to those in 14 historic HIV-negative women who had received similar treatment. HPV sequences were demonstrated by Southern blot in 13/14 HIV-positive women and by in situ hybridization in 5/13 HIV-negative women. Types 6/11, 16, and 31/33/35 were equally distributed in both groups; type 18 was never detected. In all but one case, the same viral type was present in different lesions, and in recurrences. Among the HIV-positive women, integration of viral sequences had occurred in the dysplastic lesions in 2 of the 3 HPV-16-positive cases; both cases showed progression to carcinoma in situ within 1 to 2 years. Despite comparable treatment, the HIV-positive women showed lesion persistence or progression, while all HIV-negative women experienced regression.

Endometrial cytology for the prevention and early diagnosis of endometrial neoplasias.

One hundred and forty women, aged between 46 and 70 years, were submitted to periodic colpocytologic, colposcopic and cytologic endometrial checking. None of the patients had been treated by estrogenic therapy. We evaluated the possible morphologic modifications of the endometrium over time by periodic cytologic checks, personalized on the basis of the anamnestic and actual risks of the patients. From the data it was noted that the endometrium in pre- and in post-menopause may present changes in the absence of substitutive therapies. In fact in women in post-menopause we found 33% of atrophic endometria at first check, going down to 22.3% at the second, while the incidence of hyperplasia increased slightly. At the second check we always diagnosed 2 cases (2.6%) presenting atypia, confirmed by subsequent curettage. At the third check an increase was observed of atrophic endometria (41.8%) and a reduction of focal hyperplasia (4%). Among women in pre-menopause there was a high incidence of endometria with focal hyperplasia, 37.5% at the first check, 40.6% at the second and 39.6% at the third; hyperplasia in 11.5% of cases at first check, 12.5% at the second and 6.3% at the third; presence of atypia in 1.5% of cases at the second check and 3.2% at the third. Curettages subsequently confirmed diagnosis in these last three patients. In the cases where small fragments of endometrial tissue appeared in the cytological sample we found good agreement between histologic and cytologic diagnoses; the latter slightly overestimated focal hyperplasia and diffuse hyperplasia.(ABSTRACT TRUNCATED AT 250 WORDS)

Vulvar invasive and intraepithelial neoplasia. Comparison of some epidemiological and clinical data.

We have compared some of the epidemiological and clinical data of 45 patients affected by Vulvar Intraepithelial Neoplasia (VIN) and of 42 patients affected by Invasive Vulvar Neoplasia who came to our observation between 1986 and 1991. We have evaluated and compared the average age in the two groups of patients, their vulvoscopic pictures and the symptomatology referred at the time of the patients' diagnosis.

Colposcopic pictures of Abnormal Transformation Zone (ANTZ): colpocytological and histological findings.

The Authors have examined the correlation between the colposcopic pictures of the Abnormal Transformation Zone (ANTZ), in its varying degrees, and the colpocytological and histological examinations in order to seek a better definition of the indications of carrying out aimed biopsies. From our results a good agreement has been observed from the colpocytological and histological examination and the colposcopic pictures of the ANTZ. In patients with colposcopic images of ANTZ G2 the colpocytological examination diagnosed a CIN 3 in 80.6% of cases, invasive carcinoma in 6.4%, and in histologic examination CIN 3 in 71% and microinvasive carcinoma in 10.7%. Instead in the ANTZ G1, CIN 3 was revealed colpocytologically in 7.9% of the cases and histologically in 7.3%. Among these last, in half of the cases, the focuses of CIN 3 were present at the level of third inferior of the cervical canal. Finally, in ANTZ G0 there was cytological evidence in 6.6% of cases of CIN 3 with a histological correspondence of 3.9%. In particular the focuses of CIN 3, small and limited, had resulted from biopsies carried out on some glandular openings not clearly attributable to ANTZ G1. With regard to the opportuneness of carrying out aimed biopsies, mandatory in the cases of ANTZ G2, we feel it would be useful to carry them out also for ANTZ G1, above all if alterations are diagnosed at the colpocytologic examinations, and in ANTZ G0 if colpocytological alterations are present. Therefore integrating colposcopic and colpocytologic examinations and aiming the biopsies would seem to lead to good diagnostic reliability and adequate successive personalized treatment.

Vulvar intraepithelial neoplasia. Epidemiological and clinical study of 45 cases.

We observed 45 cases of Vulvar Intraepithelial Neoplasia (VIN) histologically diagnosed which came to our observation between 1986 and 1991. The average age of the patients and the grade of the VIN lesions were evaluated. We also examined the eventual association with Papillomavirus infection, with non-neoplastic epithelial disorders in the adjacent areas and with intraepithelial neoplasias of the cervix and/or the vagina (CIN and/or VAIN). These data were studied in relation to the vulvoscopic pictures and symptomatology presented by the patients at the moment of diagnosis.

Risk of progression in low grade squamous intraepithelial lesions.

In order to evaluate the evolution of the low grade dysplasia using colpocytologic follow-up, 150 women, enrolled in this study, were submitted to yearly colpocytologic control for a period of four years. The rate of progression toward more severe forms was very low; three cases (2.14%) in the first year, one case (0.7%) in the second and two cases (2.32%) in the fourth. Eighty-eight per cent of the patients had cytologic signs of Human Papilloma Virus infection detected in cytologic and histologic examination.

Beta-interferon topical treatment in low and high risk cervical lesions.

In a series of 131 patients we evaluated the effects of medical therapy with beta-Interferon cream in patients with cervical Human Papilloma Virus (HPV) infection, which in some cases, was associated with CIN. Treatment consisted of the direct daily application of 1,000,000 IU beta-Interferon cream to colposcopically positive areas over a period of 15 days. At intervals of 1, 6, 12 and 24 months following treatment, cytohistological tests were carried out to assess the effects of treatment. At the 24-month control, the overall percentage for regression was 79.57% of cases. Regression was observed in 58.33% of patients with cytohistological changes associated with HPV without atypia, and in 69.85% of patients with HPV with atypia (38.9% total regression). The regression pattern for CIN lesions was as follows: in CIN lesions, regression occurred in 85.36%, in CIN II in 84.20%, and 37.5% of CIN III cases showed total regression.

Diathermic loop treatment for CIN and HPV lesions. A follow-up of 130 cases.

In order to evaluate the therapeutic value of Diathermic Loop Excision (DLE), the Authors consider the colpocytohistological follow-up findings (at 3, 6 and 12 months) made in a series of 130 women who underwent DLE for CIN and cervical HPV lesions. The percentages of regression of the lesions, ranging from 84.9% and 93.7% for CIN lesions, and from 62.9% to 71.0% for HPV lesions, confirm that DLE is a rational and effective technique in the treatment of circumscribed cervical intraepithelial neoplasia and HPV lesions.

Cytological patterns of primary malignant uterine fibrous histiocytoma. A case report.

The Authors have reported the cytological patterns of malignant primitive uterine fibrous histiocytoma of a 57 year old woman. The endometrial cytological sampling was performed by an aspiration technique using a feeding-tube; a necrotic-haemorrhagic background filled with hymphocytes and polymorphonuclear leukocytes, and a mixture of highly anaplastic histiocytic and fibroblastic type cells, associated with undifferentiated small round cells, has been described. The result of the histological examination performed on the surgical specimen was the following: polymorphic malignant neoplasia characterized by spindle-like and giant plurinucleated cells, phagocytosis features, endoluminal polypoid growth, wide infiltration of the miometrium two thirds deep, vascular space invasion of the uterine wall and the hilus of the ovaries. The histological features and immunohistochemical analysis were consistent with malignant fibrous histiocytoma in the pleomorphic variety.

The accuracy of colposcopically directed biopsy in the diagnosis of cervical intraepithelial neoplasia.

In order to evaluate the accuracy of colposcopically directed biopsy in the diagnosis of Cervical Intraepithelial Neoplasia (CIN), in a series of 164 patients we compared findings from histological serial section of colposcopically directed biopsy with those from histological serial section of the entire lesion after diathermic loop excision. Colposcopically directed biopsy allowed a correct diagnosis to be made in 73 to 76.3% of cases, depending on the importance of the cervical lesion.

Immunohistochemical reactivity of a monoclonal antibody prepared against human ovarian carcinoma on normal and pathological female genital tissues.

The reactivity profile of the monoclonal antibody (MAb) MOv18, raised against a poorly differentiated ovarian carcinoma specimen, was studied on normal tissues and tumors from the female reproductive system and on the kidney, which like the oviducts, vagina and uterus, also derives from the intermediate mesoderm. The obtained results indicate that MOv18 recognizes an epitope present on the normal epithelium of the oviducts, on 14-week old fetal kidney and, focally, on proximal and distal tubules of normal adult kidney. A strong reactivity was found on ovarian carcinomas, on invasive squamous carcinomas of the cervix and on endometrial carcinomas and hyperplasias. The antigen recognized by MOv18 (CaMOv18) therefore seems to be an epithelial cell marker associated with intermediate mesoderm differentiation, which can be derepressed during the neoplastic transformation of the ovary and the uterus.