[Laryngeal Tuberculosis Diagnosed in a Pathological Laboratory in Senegal (2011-2015)]. / La tuberculose laryngée diagnostiquée dans un laboratoire d'anatomie pathologique du Sénégal (2011­2015).

Laryngeal tuberculosis (LT) is a rare disease. The therapy for LT is easy but the diagnosis remains a challenge for the pathologist and the laryngologist because of the absence of specific signs. The objective was to analyze the epidemiological and pathological profiles of LT cases in Dakar (Senegal) with a view to better understand this pathology. This study was a retrospective and descriptive of LT cases diagnosed in pathology laboratories in Senegal during five years (2011-2015). The LT was found in 9 cases. The mean age at diagnosis was 41.9 years (18/58) without sex predominance (sex-ratio = 0.8). Tobacco intoxication (3/9), tuberculosis contagion (1/9), HIV immunodepression (2/9), and diabetes (1/9) were the various risk factors found. Dysphonia was a constant symptom (9/9) associated with dysphagia (2/9) and cervical adenopathy (1/9). The macroscopic presentation was tumoral-like (7/9) and erythematosus and fibrinoid (2/9). The LT was of glottic seat in all the cases (9/9) with participation on top-glottic in two of the cases. The biopsy was performed in all patients. It reported tuberculous granuloma in four cases (4/9), tuberculoid granuloma in one case (1/9), and chronic lymphocytic laryngitis in four cases (4/9). CT-scan of the lungs was pathological in five patients (5/9). Evolution was favorable in all cases under "conventional tuberculosis treatment" over a period of six months. The diagnosis of LT requires a high collaboration between the laryngologist and the pathologist.

La tuberculose laryngée (TL) est une affection rare de diagnostic difficile à cause de l'absence de signes spécifiques. L'objectif de cette étude rétrospective était d'analyser les profils épidémiocliniques et anatomopathologiques des cas de TL diagnostiqués dans un laboratoire d'anatomie pathologique du Sénégal. Il s'agissait d'une étude rétrospective et descriptive des cas de TL sur cinq ans (2011­2015). La TL a été retrouvée dans neuf cas. L'âge moyen au diagnostic était de 41,9 ans (18/58) sans prédominance de sexe (sex-ratio = 0,8). Le tabagisme (3/9), le contage tuberculeux (1/9), l'immunodépression au VIH (2/9) et le diabète (1/9) étaient les différents facteurs de risque retrouvés. La dysphonie était un symptôme constant (9/9), accompagnée d'une dysphagie (2/9) et d'adénopathies cervicales (1/9). L'aspect macroscopique était pseudotumoral (7/9) et érythématoblanchâtre (2/9). La TL était de siège glottique dans tous les cas (9/9), avec participation sus-glottique dans deux cas. La biopsie systématique notait un granulome tuberculeux dans quatre cas (4/9), un granulome tuberculoïde dans un cas (1/9) et une laryngite chronique lymphocytaire dans quatre cas. L'évolution était favorable dans tous les cas sous traitement médical. Le diagnostic de la TL nécessite une collaboration parfaite et étroite entre l'otorhinolaryngologue et le pathologiste.

Pathological overview of chronic gastritis in Senegal: results of upper gastrointestinal tract endoscopies.

The aim of this study was to determine the prevalence of gastritis in upper endoscopies performed for clinical signs suggestive of gastritis among 100 patients in a tropical country. Chronic gastritis (CG) was present among 81%, including CG due to Helicobacter pylori (n = 61, 75.3%), reactive CG (n = 14), and autoimmune CG (n = 6). The gastritis was located in the stomach antrum (55.7%, n = 40), fundus (3.3%, n = 2), or both (41% n = 25). Median age at diagnosis was 35 years (14/80). This CG was associated with signs of stomach activity (27.9%, n = 17), atrophy (13.1%, n = 8), metaplasia (9.8%, n = 6), and dysplasia (8.2%, n = 5). The 14 patients with reactive CG had a mean age of 31 years and all were coffee-drinkers. This CG was not associated with precancerous lesions. Autoimmune CG, present in 6% of the population, was diagnosed at a mean age of 55 years (range: 45; 67). These involved fundal atrophy with metaplasia and were associated with dysplastic lesions (66.7% n = 4).

[Pathological profiles of retinoblastoma in Senegal]. / Aspects anatomopathologiques du rétinoblastome au Sénégal.

OBJECTIVES: Describe the macroscopic and microscopic profiles of retinoblastoma (RB) in Senegal and correlate histological criteria with progression to establish severity factors. METHODOLOGY: We realized a retrospective study over 10 years (January 2005-December 2014). Only patients (n=67) who underwent histological analysis of the enucleation specimen (n=68) were followed until the end of the study. RESULTS: The tumor measured an average of 3.8cm (2/4.5). Endophytic tumor development was observed in 55 cases (80.8%), exophytic in 6 cases (8.9%) and mixed in 7 cases (10.3%). Retinal detachment was present in 13 cases (19.2%). The RB was well differentiated in 11 cases (16.2%), moderately differentiated in 31 cases (45.6%) and undifferentiated in 26 cases. Optic nerve (ON) invasion was present in 18 cases (26.5%). The tumor was extraretinal in 37 cases (54.4%). The anterior chamber was invaded in 6 cases (8.8%). The global survival at 2 years was 84% and 70% at 5 years. On multivariate analysis, well differentiated tumors and stage pT1 were associated with remission. Retrolaminar ON invasion, massive choroidal invasion and stage pT3 were risk factors for recurrence. Poor tumor differentiation, invasion of the ON resection margin, tumor invasion through the sclera, and stage pT4 were predictive of death. CONCLUSION: The pathologist is a principal actor in the management of RB because his account guide the post-surgical management strategy.

[Human papilloma viruses: other risk factor of head and neck carcinoma]. / Les papillomavirus humains : un autre facteur de risque des carcinomes des voies aérodigestives supérieures.

Head and neck carcinoma (HNC) occupy the sixth place as the most frequent type of cancer worldwide. Next to alcohol and tobacco intoxication, other risk factors (RF) are suspected, including the human papilloma viruses (HPVs). The aim of this study was to highlight the prevalence of HPVs and histo-epidemiological characteristics of HNC HPV+ in Senegal. This is a prospective, multicenter preliminary study of 18 months (January 1, 2012-June 30, 2014). The cases of HNC histologically confirmed in Senegal were then sent to the bio-pathology department of the Curie Institute in Paris to search HPVs. In the 90 included cases, the PCR technique was successful in 54 cases (60%). HPVs were found in seven cases, that is, a prevalence of 13%. HPVs were associated with 5 cases of hypopharyngeal carcinoma and 2 cases of carcinoma of the oral cavity. Patients with HNC HPV+ had a median age of 42 years against 49 years for HPV-patients. Three patients (42.8%) with HPV+ carcinomas were smokers. Of the 47 HPV-patients, 40 patients (87.1%) had alcohol intoxication and/or smoking. The concept of oral sex was refuted by all our patients. Squamous cell carcinoma was the only histological type found. HPV+ cell carcinoma showed no specific histological appearance. HPVs are another certain RF of HNC in Senegal. The major therapeutic and prognostic impact of HPVinduced cancers requires the systematic search of the viruses by the PCR technique.

[NK/T-cell Lymphoma of nasal-type: A rare affection with a poor prognosis]. / Lymphome T/NK de type nasal : une pathologie rare de mauvais pronostic.

INTRODUCTION: NK/T cell lymphoma of nasal-type was described in 1933 as a malignant midfacial granuloma. The diagnosis of this rare affection is clinical and immunohistopathological. We report a case of NK/T cell lymphoma diagnosed at an advanced stage. OBSERVATION: A 60-year-old man with no particular medical history presented since seven months with a left nasal obstruction associated with a purulent and fetid rhinorrhea followed by a centrifugal midfacial necrosis. Blood tests showed an inflammatory syndrome. The CT-scan of the face showed a filling of the nose and sinus by a tissular process and a lysis of the bone walls. Three series of biopsies (le last being performed under general anesthesia) were necessary to get the diagnosis of NK/T cell lymphoma. The standard histology showed a malignant proliferation made of round and spindle-shaped lymphoid-like cells and angiocentric arrangement. The cells were CD 2+, CD 3+, CD 5+ and CD 56+. The spontaneous evolution was fatal one month after diagnosis in a context of septic shock. CONCLUSION: NK/T cell lymphoma of nasal-type is a rare disease but should be evocated in patient with midfacial necrosis of centrifugal evolution. The diagnosis certainty is made on immunohistopathological analysis. Multiple biopsies, made at distance from necrotic areas and under general anesthesia may be necessary.

Discoveries about tubercolosis from autopsies: topographical and morphological profiles of lesions in dakar (Senegal).

Tuberculosis is endemic in Senegal. It is rate of increase and high mortality rate make it a major public health problem. The aim of this study was to describe the topographic, macroscopic, and microscopic aspects of tuberculosis lesions responsible for deaths in Dakar. This is a retrospective study of 158 autopsy reports, collected over 10 years, of deaths due to tuberculosis. The diagnosis of tuberculosis was essentially macroscopic; only equivocal cases had histological analysis. The average age at death was 47 years, and nearly all patients were men (all but 5). The largest percentage of deaths were in the 56-60 year old age group (21.6%, n = 34). Cachexia (70.3%), pallor (44.3%), and hemoptysis (20.9%) were found in the external examination of these corpses. Autopsy of the viscera showed pulmonary disease in 98.7% of cases (n = 156), both bilateral and extensive. Renal and pericardial disease were rare, found in respectively 3.8% and 2.5% of cases. Macroscopic aspects of tuberculosis were various and often related. Miliary tuberculosis (81%), small nodule tuberculosis (76.6%), and tuberculomas (62%) were the lesions most commonly encountered. Histologic analysis showed these lesions were of different ages. Tubercles (Koster follicles) were found consistently. Caseous necrosis was pathognomonic. Tuberculosis remains a deadly disease in Dakar, it mainly affects men and older individuals.

[Appendicitis schistosomiasis: unusual lesion about two cases in Senegal]. / Appendicite bilharzienne: une lésion rare à propos de deux cas au Sénégal.

Appendiceal schistosomiasis is a rare disease of only histopathological diagnosis. Appendectomy should be followed by treatment with praziquantel to avoid complications. We report two cases of appendiceal schistosomiasis while discussing the place of this infection in the pathogenesis of appendicitis. Finally we recommend a routine pathological examination of any part of appendectomy for better care for patients.

L'immunohistochimie dans le diagnostic des tumeurs des tissus mous

Les tumeurs des tissus mous (TTM) sont un ensemble heteroclite; rare et de diagnostic histopathologique parfois difficile. L'immunohistochimie constitue un moyen complementaire d'un apport decisif. Nous rapportons ici une serie de 36 TTM; dont le diagnostic comparatif a ete fait entre Dakar et Bordeaux avec parfois utilisation de l'immunohistochimie (IHC) dans cette derniere ville pour la confirmation du diagnostic definitif. L'IHC a permis de redresser le type histologique dans 100 % des tumeurs benignes (2/2) et dans 60 % des tumeurs malignes (6/10). Bien etant une aide incontournable; l'IHC ne peut ni remplacer ni preceder un examen histologique standard qui represente la cle du diagnostic a condition que le pathologiste soit experimente

Etude anatomo-pathologique du curage ganglionnaire dans les cancers pelviens

L'etude microscopique des produits de curage ganglionnaire donnent des renseignements interessants sur la conduite therapeutique post-operatoire. Aussi; avons-nous entrepris; de janvier 2003 a decembre 2012 de faire l'analyse microscopique des ganglions issus du curage effectue devant des cancers pelviens. Nous ainsi rassemble; durant la periode d'etude; 470 cancers pelviens dont 184 avaient beneficie d'un curage ganglionnaire (39;1 %). Le taux d'envahissement ganglionnaire etait de 19 % (n=35). Deux inconvenients avaient ete notes : le siege du curage non indique dans 35;9 % (n=66); l'effraction capsulaire et la taille tumorale omises dans plus de la moitie des comptes rendus. Les resultats des analyses microscopiques realisees ont permis l'ajustement du stade d'extension et l'adaptation de la therapie adjuvante

[Changes in oral mucosa of the partially edentulous who wear removable partial dentures ]. / Modification des muqueuses des cretes edentees dues au port de la prothese adjointe partielle en resine.

PURPOSE: to confirm or infirm structural modification of oral mycosis at the summit after fifteen days of wearing removable resin partial dentures. METHODS: our study took place at the health center of Rufisque in Senegal from January to July 1998, involved fourteen patients divided into two groups according to sex: seven males and seven females who came for removable resin partial dentures. The macroscopic examination was conducted through to inspection and touching of mycosis at the level of toothless summit before the wearing of the denture. A biopsy was conducted on each patient before and after the wearing of the resin dentures. Tissue reaction was appreciated qualitatively through morphological analysis. RESULTS: Before the wearing of the removable resin partial dentures 92.9% of patients had epithelial hyperplasia; 7.1% epithelial hypoplasia and 85.7% keratosis at the level of the chorion the number of collagen fibbers (28.6% discrete, 50% moderate, 21.4% important), fibroblasts (35.7% discrete; 42.9% moderate ; 21.4% important), inflammatory cells (71.4% discrete; 28.6% moderate; 0% important) and for blood vessels (64% discrete; 35.70% moderate; 0% important) after fifteen days of wearing partial denture. After fifteen days of the wearing removable resin partial dentures: 85.7% of patients had epithelial hyperplasia; 14.3% normal epithelial and 100% de keratosis at the level of the chorion the number of collagen fibbers (14.3% discrete; 21.4% moderate; 64.3% important), fibroblasts (42.9% discrete; 42.90% moderate; 14.3% important), inflammatory cells (50% discrete, 35.7% moderate: 14.3% important), blood vessels (43% discrete; 28.6% moderate; 28.6% important). CONCLUSION: Biopsies of the summit are reliable contribution; they provide precise information on the quality of tissue supporting resin partial dentures. This tissues may seem healthy appearance (inspection and touching) but show sign of suffering at this anatomy-pathological examination.

[Uterine leiomyoma at the surgical department of the Teaching Hospital of Dakar. Report of 140 cases operated in two years]. / Les fibromes utérins à la clinique chirurgicale du CHU de Dakar: à propos de 140 cas opérés en deux ans.

Uterine leiomyomas due to complications in particular mechanical and haemorrhagic constitute a frequent motive of consultation to the surgical department at the university hospital of Dakar. To precise its epidemiologic, clinical and therapeutic aspects, a prospective study of two years (1995-1996) was made. Hundred and forty patients operated for uterine leiomyoma in our department were brought together. Uterine leiomyoma represent 58.82% of the gynaecological disorders operated to the surgical department. These gynaecological affection constitute 15% of the whole surgical pathology. The edge of age most concern was the decade 49-59 years old. The infertility and the low parity were found in 55.14% of the cases. The average delay of consultation was 39 months. The clinical symptoms amounted it metrorrhagia (72%) abdominal or pelvic pains (77.1%) and increase of the volume of the belly (96.4%). The overall reoperating rate was 3.5%. The pelvic ultrasonography allowed to confirm the diagnosis in 84.28% of the cases. The under umbilical laparotomy (90.9%) was the main surgical way. The sub-total hysterectomy was carried out in 35.72% of the cases. The average duration of hospitalization was 9 days and the mortality 0.7%. Main postoperative complications were parietal abscess (16 cases), evisceration (2 cases) and eventration (2 cases). Histological examination realized in 48.06% of the cases confirmed the diagnosis of uterine leiomyoma in every case. In 17.82% of the cases leiomyoma were associated to another lesion and in two cases it was a neoplasm of the uterine cervix. Uterine leiomyomas are frequent in Dakar. Their often impressive volume and metrorrhagia dominant their occasion of diagnosis. Their sufficiently early diagnosis have to noticeably reduce their radical surgery indications in this benign pathology whose association with cervix uterine cancer stays very rare in our daily practical experience.

[Death from ammonia poisoning: anatomo-pathologic features]. / Décès par intoxication àl'ammoniac: aspects anatomo-pathologiques.

The authors report the results of a chronological study of anatomo-pathological aspects observed in the autopsy of subjects who died after a heavy ammonia poisoning. It is about a retrospective study based on the medico-legal autopsies of 91 cases of death an industrial ammonia tank explosion which occurred inside a factory in Dakar (SONACOS), on the 24th of March 1992. The census of the dead has been made during the three months following the explosion. The victims were between 3 months and 74 years old. Among the 91 dead there were 15 women and 76 of the male sex. The recent lesions were discovered in the subjects who died during the first three days. The consisted of some extended cutaneomucous burns, a sharp lung oedema sometimes associated with a pulmonary emphysema. Later on, results show that deaths are rather caused by the after effects of a pneumopathy (pulmonary infection, bronchiectasis, pulmonary fibrosis). Ammonia belong to the irritating and caustic gas. The intensity of the lesions and the mortal risk are proportional to the quantity of gas per m3 of air. If the lesions described in our research have similarities with the published description, the latter mentions only a few cases of death. The originality of our series is particularly found in the intensity of the lesions and the number of deaths. This shows the insufficiency of both means of prevention and emergency assistance.

[Cytological detection of cervical cancer in black Africa: what are the perspectives?]. / Le dépistage cytologique des cancers du col utérin en Afrique noire: quelles perspectives?

The authors report the study of the cytological screening for cervical cancer in Africa on the basis of the experience from four West African countries (Ivory Coast, Guinea, Mali and Senegal). The study reveals that in all these countries, the yearly coverage is inferior to one cervical vaginal cytological screening per 100 women of 15 years of age and above. This rate (< 1%) is too weak to act on the rate of mortality and morbidity of cervical cancer. Consequently, the authors advise like WHO the African authorities to define and to apply cervical cancer screening programs to reach the following goal: carry out one cervical vaginal cytology in each woman near the age of 40. Cervicography can be associated.

HIV-1, HIV-2, human papillomavirus infection and cervical neoplasia in high-risk African women.

OBJECTIVE: To determine the effect of HIV-1 and HIV-2 infection on the prevalence of cervical human papillomavirus (HPV) and squamous intraepithelial lesions (SIL) in a population of high-risk women in Senegal. DESIGN AND PARTICIPANTS: Cross-sectional study among 759 female commercial sex workers, including 68 with HIV-1, 58 with HIV-2, 14 with HIV-1 and 2, and 619 without HIV infection. RESULTS: Overall, HPV was detected in 43% of women by polymerase chain reaction (PCR), and in 7% by Southern transfer hybridization, with 7.4% of all women having SIL. The mean CD4 count was 820, 1205, and 727 x 10(6)/l for those with HIV-1, HIV-2, and dual HIV-1 and 2 infections, respectively, and 1447 x 10(6)/l for those without HIV infection. Both HIV-1 and HIV-2 were associated with HPV, as detected by PCR [HIV-1 odds ratio (OR), 2.9; 95% confidence interval (Cl), 1.7-4.9; HIV-2 OR, 1.7; 95% Cl, 1.0-2.9]. HIV-2 was also associated with cervical SIL, and although the association between HIV-1 and SIL did not attain statistical significance, a trend was apparent (HIV-1 OR, 1.8; 95% Cl, 0.7-4.7; HIV-2 OR, 2.9; 95% Cl, 1.2-7.2). CONCLUSIONS: Despite less immunosuppression with HIV-2, both HIV-1 and HIV-2 were associated with detection of HPV. HIV-2 was also associated with SIL. Further studies are needed to examine the risks of high-grade SIL and invasive cervical cancer with HIV-1 versus HIV-2 infection.

PIP: Between February 1990 and March 1993, 759 female commercial sex workers who attended sexually transmitted disease (STD) clinics in Dakar, Thies, and Mbour, Senegal, were interviewed and underwent a general physical and detailed gynecologic examination so researchers could ascertain the influence of HIV-1 and HIV-2 infection on the prevalence of cervical human papillomavirus (HPV) and squamous intraepithelial lesions (SIL) in this high-risk population. Most lesions were low-grade SIL. 619 had neither HIV-1 nor HIV-2 infection. 9%, 8%, and 2% had HIV-1, HIV-2, and concurrent HIV-1 and HIV-2 infection, respectively. Polymerase chain reaction revealed that 43% had HPV infection, while Southern transfer hybridization found only 7%. HIV-1 infected women faced a significant increased risk for HPV (adjusted odds ratio [AOR] = 2.9) as also did HIV-2 infected women (AOR = 1.7). Both these groups also faced an increased risk for SIL (AOR = 1.8 and 2.9, respectively), but the increased risk was not significant. Similarly, women infected with both HIV-1 and HIV-2 faced an increased risk of HPV and SIL (AOR = 4.9 and 5.2, respectively). Among women with HIV infection, women with HPV had a lower CD4 count and CD4/CD8 ratio (854 vs. 1033 million/l, p = 0.08, and 0.88 vs. 1.17, p = 0.05, respectively) than women with no detectable HPV. HIV-positive women with SIL had a lower CD4/CD8 ratio than HIV-positive women without SIL (0.65 vs. 1.03; p = 0.003). HIV-2 women exhibited lower immunosuppression than HIV-1 women. These findings show that both HIV-1 and HIV-2 infection were associated with HPV and SIL. The researchers expressed interest in longitudinal studies designed to examine the risk of high-grade SIL, the direct precursor of invasive cervical cancer, among HIV-infected women.

Le cancer vesical au Senegal : experience du Laboratoire d'Anatomie Pathologique du C.H.U. de Dakar (Senegal)

Les cancers de vessie sont d'observation courante en pratique quotidienne urologique a Dakar. Entre janvier 1970 et decembre 1993; 82 cas de cancer vesical ont ete colliges au Laboratoire d'Anatomie et de Cytologie Pathologiques du CHU de Dakar. La prevalence de cette pathologie est situee a 2;3 pour cent de l'ensemble des cancers au Senegal. L'age moyen de survenue est de 46 ans avec atteinte plus precoce de la femme. Le carcinome malpighien est le type histologique le plus frequent (62;2 pour cent) et n'est pas toujours associe a des lesions bilharziennes

Cervical intraepithelial neoplasia and human papillomavirus infection among Senegalese women seropositive for HIV-1 or HIV-2 or seronegative for HIV.

Studies in various regions of the world have shown that women infected with HIV-1 are at increased risk for cervical human papillomavirus (HPV) infection as well as for cervical cancer precursor lesions. HIV infection and cervical cancer are both widespread in West Africa, but little is known about the relationship between HPV and HIV-2, which is the predominant type of HIV in the general population of many West African countries. To address this issue, we collected cervical samples for cytology and HPV analysis from 93 women presenting to the University of Dakar Infectious Disease Service (18 women with HIV-1 infection, 17 with HIV-2 infection, and 58 HIV seronegative controls). Compared to those without HIV infection, HIV seropositive women were 13.1 (95% CI = 2.4, 128) and 11.0 (95% CI = 3.5, 35.8) times more likely to have HPV detected using Southern transfer hybridization (STH) and the polymerase chain reaction (PCR) respectively. Detection of high and intermediate risk HPV types were significantly associated with HIV-1 and HIV-2 infection. Among HPV positive women, those with, as compared to those without HIV infection were more likely to harbour high risk HPV types (OR = 9.2, 95% CI = 0.97, 433). HIV-1 and HIV-2 seropositive women were 23.3 (95% CI = 2.9, 209) and 9.3 (95% CI = 1.1, 79) times more likely to have cytological diagnosis of dysplasia, respectively, than were HIV seronegative women. Biopsy-proven CIN 3 was found in one woman with HIV-1 and invasive cancer was found in one woman with HIV-2.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Studies in various regions of the world have shown that women infected with HIV-1 are at increased risk for cervical human papillomavirus (HPV) infection as well as for cervical cancer precursor lesions. HIV infection and cervical cancer are both widespread in West Africa, but little is known about the relationship between HPV and HIV-2, the predominant type of HIV in the general population of many West African countries. The authors report findings from their collection of cervical samples for cytology and HPV analysis from 93 women presenting to the University of Dakar Infectious Disease Service; 18 women infected with HIV-1, 17 with HIV-2, and 58 HIV seronegative controls. Compared to those without HIV infection, HIV seropositive women were 13.1 and 11.0 times more likely to have HPV detected using Southern transfer hybridization and the polymerase chain reaction, respectively. The detection of high and intermediate risk HPV types was significantly associated with HIV-1 and HIV-2 infection. Among HPV-positive women, those infected with HIV were more likely to harbor high-risk HPV types. HIV-1 and HIV-2 seropositive women were 23.3 and 9.3 times more likely to have a cytological diagnosis of dysplasia, respectively, than were HIV-seronegative women. Biopsy-proven cervical intraepithelial neoplasia (CIN) 3 was found in one woman with HIV-1 and invasive cancer was found in one woman with HIV-2. It remains unclear, however, whether HIV-1 and HIV-2 confer similar risks of developing CIN 2-3 and the potential of invasive cervical cancer.