Laparoscopic abdominal cerclage after radical vaginal trachelectomy.

BACKGROUND: The incidence of cervical cancer (CC) in Slovenia in 2011 was 13.2 per 100,000 women. The treatment of early stages of invasive cervical carcinoma involves several surgical techniques. In this article the authors would like to present a new combination of two methods which help to preserve fertility and to improve pregnancy outcome. The first procedure, radical vaginal trachelectomy (RVT), begins with laparoscopic pelvic lymphadenectomy. All suspicious lymph nodes are sent to frozen section. If those lymph nodes are negative, the procedure continues vaginally. Almost the entire cervix is removed with parametria and vaginal cuff. Permanent cerclage stitch is applied and covered with vagina on what is left of uterus. Second procedure, laparoscopic abdominal cerclage (LAC), begins with pneumoperitoneum. Mersilene tape is introduced in the abdominal cavity and placed through the visceral peritoneum at the isthmic part of the uterus with a Berci's needle. It is knotted and remains permanently. MATERIALS AND METHODS: For the first procedure all the patients with confirmed cervical carcinoma (FIGO Stage IA1, IA2, and IB1) and with the desire for fertility were recruited. For the second procedure, all the patients after RVT and after miscarriage after 14th week of gestation were recruited. RESULTS: RVT was performed in 15 patients and laparoscopic abdominal cerclage in three of them (21.5%). All three patients achieved pregnancies and after 36th weeks of gestation delivered by cesarean section (100%). CONCLUSIONS: RVT alone is an indication for LAC. Considering its success, LAC should be performed before any miscarriage.

Clinical audit of patients with cervical cancer in Slovenia. Data analysis from 2003-2006.

PURPOSE OF INVESTIGATION: From 2003 to 2006 the data on Slovenian cervical cancer patients who regularly attended a gynecologist were gathered. Data were analyzed in order to improve the efficiency of the cervical cancer screening program. METHODS: Data on all patients newly diagnosed with cervical cancer were collected at three central clinics in Slovenia. The results are a presentation and comparison of detailed information on some characteristics of cervical cancer patients of the group that regularly visited a gynecologist and of the other group who did not. Data were processed by descriptive epidemiological methods. Mantel-Haenzel chi2 and Fisher's p tests were used to evaluate statistical significance. RESULTS: On average, 55% of patients with cervical cancer underwent a gynecological examination five years before the diagnosis. The patients who regularly attended their gynecologist were, in all age groups, statistically significantly younger, the stage of cervical cancer at diagnosis was statistically significantly lower (p = 0.01) and were, in statistically significantly higher percentage, treated surgically (p < 0.01). From 2003 to 2006, each patient had on average five examinations at her gynecologist within the period of five years to six months before the diagnosis of cervical cancer. The average number of collected smear samples was 3.2. CONCLUSION: From the results of our analysis, it may be concluded that improvements are needed in Slovenia in the field of screening for and early detection of cervical cancer.

Clinical audit of patients with cervical cancer in Slovenia--data analysis for the year 2003.

PURPOSE OF INVESTIGATION: The data gathered in 2003 on the patients with cervical cancer who regularly attended their gynecologist were analyzed with the purpose of clinical audit. METHODS: The data on newly detected patients with cervical cancer in 2003 who regularly attended their gynecologist were gathered simultaneously at three Advisory Boards for Gynecology in Slovenia. RESULTS: Of 149 patients in whom, according to our data, invasive cervical cancer had been diagnosed, 92 (61.7%) patients were examined by a gynecologist in the previous five years. In the majority of these patients, cervical cancer was diagnosed in early, localized disease stage. In the periods of 13-24 and of seven to 12 months before the diagnosis of cervical cancer, almost half the patients had Pap II, and three to six months before diagnosis, 67.6% of patients had Pap II. CONCLUSION: These results encourage us to proceed with clinical audits to analyze individual cervical cancer cases, including another independent reevaluation of cervical smears in the five-year period before diagnosis. A suitable calendar of refresher training courses on colposcopy, which should be obligatory for all performing this examination method, also needs to be set up.

Role of human papillomavirus testing in reducing the number of surgical treatments for precancerous cervical lesions.

PURPOSE OF INVESTIGATION: To determine whether the addition of the Hybrid Capture II (HC II) test (Digene Corp., Gaithersburg, MD, USA) to cytological, colposcopical and histological results could reduce the number of surgical treatment procedures for precancerous cervical lesions. METHODS: Surgical treatment of precancerous cervical lesions was performed in 181 women. Priorly, the women were tested for high-risk human papillomavirus (HPV). Sensitivity, specificity, positive and negative predictive value were calculated to assess the performance characteristics of HC II in the detection of cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) and grade 3 or worse (CIN 3+). RESULTS: Eighty (44.2%) women had a histological result < CIN 2; 117 (64.6%) women had < CIN 3. Fifty-three (29.3%) women with < CIN 2 tested HPV negative; 69 (38.1%) women with < CIN 3 tested HPV negative (p < 0.05). The sensitivity of HC II for detecting CIN 2+ and CIN 3+ was 76.2% and 87.5%, respectively. CONCLUSION: A high proportion of women were overtreated probably due to cytological and histological overestimations. HPV testing would reduce the number of unnecessary surgical treatments and should be used as an additional screening tool.

Human papillomavirus infection in relation to mild dyskaryosis in conventional cervical cytology.

PURPOSE OF INVESTIGATION: To establish the prevalence and distribution of high-risk human papillomavirus (HPV) genotypes in Slovene women with repeat mild dyskaryosis, and to evaluate three molecular methods for the detection of HPV that could be used as a complementary method to cervical cytology. METHODS: In this prospective study 148 women with three subsequent cervical cytologic tests within two years showing mild dyskaryosis were enrolled. HPV infection was determined using three molecular tests: Hybrid Capture II and two variants of polymerase chain reaction (PCR-PGMY11/PGMY09 and PCR-CPI/CPIIG). RESULTS: HPV was detected in 17 of the 45 women aged < or =30 years and in 21 of the 103 women aged >30 years (37.8% vs 20.4%, p = 0.04). The most common genotype was HPV 16 detected in eight (21.1%) women, the next were HPV 53 and HPV 51, each detected in five (13.2 %) women. The three molecular methods matched in 92.9%. CONCLUSION: Low prevalence of HPV infections indicates that cervical screening programmes in Slovenia are overburdened with mild dyskaryosis. Repeat cytology is not reliable; HPV testing might be useful as a complementary method.

Factors predicting disease outcome in early stage adenocarcinoma of the uterine cervix.

CONTEXT: Adenocarcinoma (AC) and adenosquamous carcinoma (ASC) comprise the second principal histological types of cervical carcinoma. As compared with the squamous cell cancer (SCC), these lesions are far less frequent, and their epidemiology, natural history and prognostic determinants are less well understood. OBJECTIVE: Patients with an early stage AC of the uterine cervix diagnosed in our clinic were subjected to detailed analysis for the prognostic determinants. STUDY SUBJECTS: A series of 94 women with early stage (adenocarcinoma in situ (AIS) to IIB) cervical ACs or ASCs diagnosed and treated in our department during 1995-1999 and subsequently followed-up for a mean of 43.1 +/- 16.2 (S.D.) months. MAIN OUTCOME MEASURES: Patients were examined by colposcopy, Papanicolaou (PAP) smear and biopsy. The stage of the disease (FIGO) and tumour histology in operative specimens were recorded, and univariate (Kaplan-Meier) and multivariate survival analysis (Cox) were run to explore the factors predicting disease outcome. RESULTS: Mean age of the women was 44.2 +/- 2.5 (S.D.) years (range 24-81 years), which is significantly (P=0.000) lower than that (49.9 +/- 14.2) of 464 SCC patients in our material. Minority of the women (38.2%) reported any clinical symptoms, but these correlated with the stage (P=0.041). Screening history was acceptable (i.e. screening interval 3 to 4 years) in 56 women, whereas 28 (29.8%) had no previous PAP smear taken. Interpretation errors were established in 17 (23.6%) and sampling errors in 6 (8.3%) of the 72 smears available for re-screening. No colposcopic lesions were found in 29 (30.9%) women. Follow-up data were available from 72 patients, of whom the disease progressed in four (one died), whereas 68 patients are alive and well at the moment. Patient's age (P=0.000), screening history (P=0.0127), FIGO stage (P=0.001), mode of therapy (P=0.0187), and presence of co-existent squamous cell lesions (P=0.0184) were significant prognostic indicators in univariate survival analysis. Cox's multivariate survival analysis disclosed FIGO stage (P=0.001) and screening history (P=0.006) as the only significant independent predictors of the disease outcome. CONCLUSIONS: The present data emphasise the importance of early cervical AC as a disease of younger women, making early detection of its precursors (AIS) by regular PAP smear screening mandatory in prevention of disease progression. This can only be achieved by increasing the sensitivity of the PAP smear in detecting abnormal glandular cells in asymptomatic women.

Prognostic factors in ovarian cancer.

The improvement in the treatment of ovarian cancer is based on the recognition of the prognostic factors. The 5-year survival rate of 174 patients with epithelial ovarian malignancies after primary operation at the University Department of Obstetrics and Gynecology in Ljubljana and treated with adjuvant therapy at the Institute of Oncology in Ljubljana in the period 1970-1980 was 29.3% (56% for stage I, 36% for stage II, 23% for stage III and 4.5% for stage IV). The amount of residual tumor after the primary operation was prognostically very important (5-year survival in stage III in cases of residual tumor less than 2 cm is 46.6%, in tumor greater than 2 cm only 18.6%). The histological type of tumor, considering the stage, was not important prognostically. On the contrary the grade of differentiation was prognostically very important even in advanced cases: 5 year survival for stage III in cases of well differentiated serous tumors was 61%, in moderately and poorly differentiated cases it was only 7%. Younger patients have better prognosis than older ones, because the tumors are better differentiated, too. Since ovarian cancers are diagnosed too late in 65% of cases in advanced stages, today all efforts should be focussed on early diagnosis, which is probably the only factors that can lead to the dramatic fall of the mortality rate.