Evaluation of CO(2) laser excision or vaporization for the treatment of vulvar intraepithelial neoplasia.

OBJECTIVE: Our objective was to evaluate the results of laser surgery in patients with vulvar intraepithelial neoplasia (VIN). METHODS: From January 1990 to December 1996, 52 patients with histologically proven VIN were treated with CO(2) laser vaporization or laser excision. The analysis included anamnestic characteristics, clinical aspects, types of treatment, correlation of the preoperative biopsy with the excised pathologic specimen, and follow-up results. RESULTS: Fourteen women underwent laser vaporization, and 38, laser excision. Of the patients submitted to vaporization, 11 were cured in one session (75%), 1 required two procedures, and 2 other patients, who underwent more treatments, eventually developed invasive squamous cell cancer 5 and 7 years from the initial treatment. The cure rate for laser excision was better, as a single session of treatment was curative in 33 of 38 patients (87%). In 3 cases the pathology report on the excised specimen showed an unrecognized invasive lesion (12%) and the women underwent radical surgery. The 2 remaining patients, both affected by multifocal disease, experienced recurrences and were treated with laser excision 2 and 3 years after the primary treatment, respectively. Symptom relief was obtained in all patients studied with both laser vaporization and excision. CONCLUSIONS: Excisional laser surgery is an effective treatment for patients with VIN. In addition, CO(2) laser excision allows evaluation of the operative specimen and detection of occult early invasion with good preservation of vulvar morphology; laser vaporization, while retaining good cosmetic results, is less effective in VIN treatment and does not allow evaluation of the surgical specimen.

Risk factors for high-grade cervical intraepithelial neoplasia in patients with mild cytological dyskaryosis: human papillomavirus testing versus multivariate tree analysis of demographic data.

The objective of this study was to compare the use of molecular hybridization by hybrid capture methodology for human papillomavirus (HPV) with the use of demographic and lifestyle variables as intermediate triage in patients with cytological mild dyskaryosis. The study was designed as a prospective study using regression tree analysis of demographic data in consecutive patients who were subjected to colposcopic evaluation at the colposcopy clinic at the First Department of Obstetrics and Gynaecology, University of Milan (Milan, Italy). A total of 177 women were subjected to colposcopy because of a single routine Pap smear showing mild dyskaryosis. A structured interview, sampling for HPV testing for the detection of viral DNA by hybrid capture methodology, and colposcopic evaluation with cervical biopsies were performed for each subject. The accuracies of molecular hybridization for HPV and of the classification model based on the demographic and lifestyle variables in predicting patients with histologically high-grade cervical intraepithelial lesions were measured. The classification model based on the demographic and lifestyle variables showed comparable results with molecular hybridization for HPV (specificity, 0.75 versus 0.73; sensitivity, 0.61 versus 0.67, respectively). The use of demographic and lifestyle variables appears to be a simple and economic possibility for triaging patients with mild dyskaryotic smears in a screening program.

Doctorline: a private toll-free telephone medical information service. Five years of activity: old problems and new perspectives.

UNLABELLED: Introduction; Healthcare professionals need to continually update their knowledge to provide care based on scientific evidence. In some cases it can be difficult to gain access to the different sources of medical information. In an attempt to overcome these problems, a toll-free telephone medical information service (Doctorline) was established. OBJECTIVE: To describe the development, aims, organization, and activities of this private service. METHODS: Doctorline is an independent, unbiased, toll-free medical information service that provides information on clinical, pharmacologic, and toxicologic issues; bibliographic searches; full-text articles; public and private clinics; details of forthcoming congresses; and legislative documentation. The service is available Monday through Friday, 1000 to 2000. Staff members are physicians trained in communication techniques, literature evaluation methodologies, and computerized database use. The main on-line facilities are MEDLINE, Micromedex-CCIS, and the Italian Formulary on CD-ROM. Books, bulletins, national and international drug formularies, and property files (i.e., directory of Italian public and private clinics) are also available. RESULTS: In 5 years, Doctorline has received 65 258 calls. Nearly 34% of the calls were made by general practitioners, followed by cardiologists (22%), orthopedists (15%), pharmacists (14%), gastroenterologists (13%), and urologists (10%). From 1991 to 1996, nearly 20% of the calls concerned pharmacologic issues, 43% nonpharmacologic issues, while the rest of the calls were for nonclinical requests. Approximately 21% of all questions received an answer during the same phone call (on-line answers); for the other answers (off-line answers) the mean +/- SD waiting time was 7.8 +/- 10.4 days. Although the nature of the questions has been recorded since 1991, data about the exact number of physicians who used the service are available only from 1994. Data from 1994 indicate that of the 52,181 physicians who could access the service, only 8817 (16.9%) called at least once, with a mean number of calls per physician of 3.9 (range 3.0-5.6). CONCLUSIONS: The future of Doctorline will depend on the quality and validity of the information provided (i.e., based exclusively on scientific evidence, independent of the source of funds), the promotion of the aims, organization, and clinical utility of the service (especially among physicians who made little or no use of the service), and differentiation of the service activities in relation to the physician's specific needs.

Cervicography and HPV DNA testing as triage criteria for patients with abnormal pap smear.

Cervicography and HPV DNA testing have been proposed as intermediate triage techniques for the management of patients with Pap smear showing minor-grade atypia. The aims of the present study of 221 patients with positive Pap smear (ages 16-65) were (1) to evaluate the association of cervicography and HPV DNA test with the probability of biopsy and final histology diagnosis of CIN2 or worse, (2) to identify the combinations of results on cervicography and HPV DNA test associated with the absence of such lesions, and (3) to estimate the cost of a potential triage protocol for patients with HPV-CIN1 smear. The probability of biopsy showed a univariate association with the severity of the smear result and the cervicography classification but not the HPV DNA test. In the multivariate analysis, only the cervicography result was a significant predictor of biopsy. The final histology diagnosis showed a univariate association with each of the three tests and a multivariate association with the degree of cytology positivity and the cervicography result. Among patients with HPV-CIN1 smears, only a negative cervicography (with any HPV DNA test result) was always associated with the absence of severe histologic lesions. This pattern accounted only for 7% of such patients. The additional costs of a potential triage protocol based on cervicography were estimated to exceed the savings resulting from the reduced colposcopy rate.

Determinants of high-grade dysplasia among women with mild dyskaryosis on cervical smear.

OBJECTIVE: To identify the epidemiologic characteristics of women who have mild dyskaryosis on cervical smear but cervical intraepithelial neoplasia (CIN) grade II or III at biopsy. METHODS: We analyzed information from 291 women (median age 33 years, range 17-69) observed for the first time with a single smear test showing mild dyskaryosis. All subjects underwent colposcopy, and histologic confirmation was obtained by biopsy. We compared the characteristics of women who had CIN I or no evidence of CIN with those of women with CIN II or III at biopsy. RESULTS: Twenty-eight women (10%) had CIN I at biopsy, 46 (15%) CIN II, and 23 (8%) CIN III. The frequency of CIN II or III tended to decrease with increasing education; compared with women reporting 11 or fewer years of education, the multivariate odds ratios (OR) of CIN II or III lesions was 0.5 (95% confidence interval [CI] 0.3-0.9) in those reporting 11 years of education or more. Compared with nulliparas, the OR of CIN II or III was 1.8 (95% CI 1.1-3.5) for parous women. Furthermore, compared with never-smokers, the OR of CIN II or III was 2.3 (95% CI 1.0-5.4) for current smokers. Ex-smokers were at increased risk, too; the estimated multivariate OR was 3.8 (95% CI 1.9-7.6). Compared with women reporting one sexual partner, the multivariate ORs of CIN II or III were 1.4 and 2.3 for women reporting two to three or four or more sexual partners, respectively (chi 2(1) trend = 6.65, P < .05). CONCLUSION: Our results show that smoking is a risk indicator of CIN II or III in women with a single smear showing mild dyskaryosis. Parous women, those of low social standing, and those reporting multiple sexual partners also are at increased risk of CIN II or III.

Operator variability in disease detection and grading by colposcopy in patients with mild dysplastic smears.

BACKGROUND: To determine interoperator variability in the colposcopic evaluation of patients with mild dysplastic smears, retrospective comparison of colposcopy and biopsy results in 856 patients examined by 11 colposcopists in the Outpatient Colposcopy Clinic of "L. Mangiagalli" Institute, Milano, was performed. METHODS: The patients underwent a complete colposcopic assessment and target biopsy on suspect areas if a screening smear showed mild dysplasia. Colposcopic findings and disease detection rate for each operator were compared. RESULTS: There was no significant (P > 0.05) difference in the recording of abnormal colposcopic findings. Significant differences were found, however, in abnormal transformation zone grading (P < 0.001), biopsy rate (P < 0.05), and squamocolumnar junction visualization (P < 0.005). There was no significant difference in overall disease detection (P > 0.5) but there was a statistically significant, inverse relation (r = -0.6, P < 0.01) between the high grade (cervical intraepithelial neoplasia grades 2 and 3) and low grade (human papillomavirus/cervical intraepithelial neoplasia grade 1) detection rate for each operator. CONCLUSIONS: High grade disease detection in patients with mild dysplastic smears is influenced the subjectivity of the colposcopic examination. This should be considered when planning optimal management for patients with mild dysplasia.

Endocervical detection of CIN. Cytobrush versus cotton.

Correct methods of sampling are essential for obtaining adequate smears for cytological diagnosis of cervicovaginal abnormalities. In this paper we report on 3 methods of sampling, Ayre spatula, cotton swab and cytobrush on 89 patients who underwent repeat smear and colposcopic examinations because of abnormal screening smears. The cytobrush device was better than Ayre spatula or cotton in collecting both endocervical and neoplastic cells. However, the combination of spatula and cotton was almost the same as spatula and cytobrush in recovering neoplastic cells. Therefore the rate of cervical intraepithelial neoplasia (CIN) diagnosis is more influenced by an adequate sampling of the endocervix than by the type of endocervical device.

[The diathermy loop and diathermic coagulation in the ambulatory treatment of intraepithelial cervical neoplasia]. / Ansa diatermica e DTC nella terapia ambulatoriale della CIN.

Ninety-four patients suffering from CIN, of which 28 CIN1, 37 CIN2 and 29 CIN3 were treated with Cartier diathermal loop (57 cases 60.6%) or DTC (37 cases 29.4%). GSC proved visible in all cases except for a group of 16 patients in whom the combined use of ethinylestradiol and microendocervicoscopy showed GSC localisation within 5 mm of the OUE. The latter cases were all treated with Cartier diathermal loop. Results two months after the intervention showed correction of the colposcopic and cytological examination in 85 cases (94.4%) and bioptic cure in 91 cases (96.8%). In two cases, histological examination showed CIN1 and in one case CIN2.