Amnios con cobertura antibiótica: eficacia en pacientes sometidas a conización / Amnions with antibiotic coverage: efficacy in patients undergoing conization

Objetivo: Comparar la evolución de la cicatrización en pacientes en quienes se aplicó amnios con cobertura antibiótica, con otro grupo en que no se aplicó, posterior a la realización de conización cervical en la consulta de patología cervical del Hospital Central de San Cristóbal, entre febrero y mayo de 2023. Métodos: Estudio experimental, comparativo, aleatorizado, longitudinal. Incluyó 66 pacientes, aleatorizadas en dos grupos: grupo 1 (control): no se aplicó el amnios (n = 30/45,5 %) y grupo 2 (experimental): se aplicó el amnios tratado con antibióticos (n = 36/54,5 %). La investigadora preparó, en quirófano, el amnios de placentas obtenidas por cesárea o parto vaginal. Se obtuvo consentimiento informado de donantes y receptoras. Resultados: Al día 14, ninguna paciente del grupo 1 presentaba epitelización. En el grupo 2, una paciente (2,7 %) tenía 50 % de epitelización y 35 (94,6 %) habían alcanzado el 100 % (p < 0,001). La epitelización fue total en 13,3 % del primer grupo y 94,6 % del segundo (Odds Ratio de 227 (IC 95 %: 24,0 a 2157,0; p < 0,001). No hubo ningún caso de infección cervical. Cinco pacientes (16,7 %) del grupo 1 y una del grupo 2 (2,8 %) presentaron ectopias (p = 0,051). No hubo asociación entre epitelización completa o parcial y características clínicas (p ˂ 0,05). Conclusión: El amnios con cobertura antibiótica se asocia a mejor evolución de la cicatrización en pacientes con conización cervical. Se comprobó su eficacia como terapéutica médica al ser aplicada sobre la herida operatoria(AU)

Objective: To compare the evolution of healing in patients in whom amnion with antibiotic coverage was applied, with another group in which it was not applied, after cervical conization performed in cervical pathology consultations of the San Cristobal Central Hospital, between February and May 2023. Methods: Experimental, randomized, longitudinal comparison. It included 66 patients, randomly divided into two groups. Group 1: in which amnion was applied (n = 36/54.5 %); Group 2: no treatment (n = 30/45.5%). The researcher prepared the amnions of placentas obtained by cesarean section or vaginal delivery, in the operating room. Informed consent was obtained from both donors and recipients. Results: On day 14, none of the patients in the group 1 had epithelialization. In the group 2, one patient (2.7%) had 50% epithelialization and 35 (94.6%) had reached 100% (p < 0.001). Epithelialization was total in 13.3% of the first group and 94.6% of the second group (Odds Ratio of 227 (95% CI: 24.0 to 2157.0; p < 0.001). There were no cases of cervical infection. Five patients (16.7%) in the group 1 and one in the group 2 (2.8%) had ectopias (p = 0.051). There was no association between complete or partial epithelialization and clinical characteristics (p ˂ 0.05). Conclusion: Amnion with antibiotic coverage is associated with better healing outcomes in conized patients. Its effectiveness as a medical therapy was proven when placed on the surgical wound(AU)

The top hat procedure does not impact the management of women treated by LEEP in cervical cancer screening

Abstract Objective: To describe Top-hat results and their association with margin status and disease relapse in a referral facility in Brazil. Methods: A retrospective study of 440 women submitted to LEEP to treat HSIL, in which 80 cases were complemented immediately by the top hat procedure (Top-hat Group - TH). TH Group was compared to women not submitted to Top-hat (NTH). The sample by convenience included all women that underwent LEEP from January 2017 to July 2020. The main outcome was the histological result. Other variables were margins, age, transformation zone (TZ), depth, and relapse. The analysis used the Chi-square test and logistic regression. Results: The TH Group was predominantly 40 and older (NTH 23.1% vs. TH 65.0%, p<0.001). No difference was found in having CIN2/CIN3 as the final diagnosis (NTH 17.0% vs. TH 21.3%, p=0.362), or in the prevalence of relapse (NTH 12.0% vs. TH 9.0%, p=0.482). Of the 80 patients submitted to top hat, the histological result was CIN2/CIN3 in eight. A negative top hat result was related to a negative endocervical margin of 83.3%. A CIN2/CIN3 Top-hat result was related to CIN2/CIN3 margin in 62.5% (p=0.009). The chance of obtaining a top hat negative result was 22.4 times higher (2.4-211.0) when the endocervical margin was negative and 14.5 times higher (1.5-140.7) when the ectocervical margin was negative. Conclusion: The top hat procedure did not alter the final diagnosis of LEEP. No impact on relapse was observed. The procedure should be avoided in women of reproductive age.

Risk Factors for Persistence or Recurrence of High-Grade Cervical Squamous Intraepithelial Lesions.

OBJECTIVES: to evaluate whether the colposcopic lesion size , age, kind of surgery, the status of the surgical margins and the expression of the p16 and Ki-67 immunomarkers are risk factors for persistence or recurrence of the lesion. METHODS: a cross-sectional, observational, retrospective study of patients submitted to cold knife conization (CKC) or the loop electrosurgical excision procedure for cervical intraepithelial neoplasia 2 or 3. The colposcopic lesion size, age, surgical method, involvement of the surgical margins, and p16/Ki-67 immunomarker expression were analyzed in relation to lesion persistence and recurrence. RESULTS: seventy-one women were treated with cold knife conization and 200 were treated with loop electrosurgical excision. Of these, 95 had cervical intraepithelial neoplasia 2, 173 had cervical intraepithelial neoplasia 3, 183 had free surgical margins, 76 had compromised margins, and 12 showed damage by processing artifact or fragments. Among the 76 cases with positive margins, 55, 11, and 10 showed endocervical margin involvement, ectocervical margin involvement, and both endocervial and ectocervical margin involvement, respectively. Of the 264 followed-up patients, 38 had persistent or recurrent disease. A multiple logistic regression indicated that positive endocervical margins are the only independent risk factor for the persistence/recurrence of cervical intraepithelial neoplasia. No significant association was identified between the colposcopic lesion size, age, surgery type, or p16/Ki-67 immunomarker expression and lesion persistence or recurrence.

Frequency of post-treatment disease after excisional procedure in stage IA1 squamous cervical carcinoma - a case series.

Early stages of cervical cancer in young women need conservative treatments. Electrosurgical therapies (LLETZ, LEEP, SWETZ, NETZ) have been recommended for these women. However, there are recommendations to perform a second excision when the specimen margins are not free of disease. This can lead to some important complications. This article aims to verify the frequency of residual invasive or microinvasive disease after the excisional procedure in women with IA1CC. Data on women with IA1CC diagnosed between 1990 and 2022, were retrieved from medical records. Post-treatment disease was detected during a second surgical procedure or postoperative follow-up. Among the 69 included women, three (4.3 percent; CI95 percent 0-9.2) had residual microinvasive lesions, while none showed invasive disease during a second procedure or follow-up. Only the age of 37 years or more was significantly related to the presence of preinvasive or microinvasive residual lesions. Nearly 80 percent of the women who underwent a second procedure showed no residual lesions. The absence of invasive disease in a second procedure or during the follow-up of these women and the large proportion of women with no residual lesion questions the need for a new surgical procedure even when the surgical margins of the initial specimen are involved.

Câncer de colo uterino na gestação / Cervical cancer in pregnancy

PONTOS-CHAVE • A incidência de câncer durante a gestação tem aumentado devido à tendência das mulheres em postergar a gravidez. O câncer de colo de útero é a terceira neoplasia mais comumente diagnosticada durante o período gestacional. • O rastreamento e o diagnóstico devem se dar como nas pacientes não gestantes; a citologia oncótica cervical é o exame obrigatório do pré-natal, e a colposcopia com biópsia pode ser realizada em qualquer período da gestação. • A gestação complicada pelo diagnóstico de um câncer deve sempre ser conduzida em centro de referência e por equipe multidisciplinar. • A interrupção da gestação em situações específicas, para tratamento-padrão, é respaldada por lei. • A quimioterapia neoadjuvante é uma alternativa segura de tratamento durante a gestação, para permitir alcançar a maturidade fetal. Apresenta altas taxas de resposta, sendo relatada progressão neoplásica durante a gestação em apenas 2,9% dos casos. O risco de malformações fetais decorrentes da quimioterapia é semelhante ao da população geral. Contudo, a quimioterapia está associada a restrição de crescimento intraútero, baixo peso ao nascer e mielotoxicidade neonatal. • Na ausência de progressão de doença, deve-se levar a gestação até o termo.

Recurrence in Cervical High-Grade Squamous Intraepithelial Lesion: The Role of the Excised Endocervical Canal Length-Analysis of 2,427 Patients.

OBJECTIVE: This study aimed to evaluate the influence of the excised canal length on relapse rates of cervical high-grade squamous intraepithelial lesion (HSIL) treated by loop electrosurgical excision procedure and to find a cut-off point, above which lower recurrence rates could be observed, with low probability of compromising future obstetric outcome, and the relationship with other individual factors related to HSIL recurrence. METHOD: This was a retrospective cohort study of 2,427 women diagnosed with cervical intraepithelial neoplasia CIN2+ who underwent cervical conization using the high-frequency loop electrosurgical excision procedure surgery technique, to analyze the role of endocervical canal length associated with individual factors in the recurrent disease after CIN2+ treatment and determine a cut-off point for the excised canal length needed to decrease the risk of disease relapse. RESULTS: In 2,427 cases, the relapse rate of HSIL treated was 12%. Compromised margins of conization, HIV+, and endocervical canal length were related directly to relapses ( p < .001). The cut-off point, by receiver operating characteristic curve, to calculate the endocervical canal length related to relapses was 1.25 cm of canal excised. Canal length of less than 1.25 cm increased the recurrence rate 2.5 times. Compromised margins and HIV+ increased recurrence rates by more than 5 times. CONCLUSION: Cervical HSIL recurrence was directly related to the endocervical canal length: excised canal length of 1.25 cm or more decreases recurrence rate; HIV and compromised margins increase the chance of recurrence by more than 5 times.

Conservative Treatment of Stage IA1 Cervical Carcinoma Without Lymphovascular Space Invasion: A 20-year Retrospective Study in Brazil / Tratamento conservador do câncer do colo do útero IA1 sem invasão linfovascular: estudo retrospectivo no Brasil

Abstract Purpose: To evaluate recurrence rates and risk factors among women with stage IA1 cervical cancer without lymph vascular space invasion managed conservatively. Methods: retrospective review of women with stage IA1 squamous cervical cancer who underwent cold knife cone or loop electrosurgical excision procedure, between 1994 and 2015, at a gynecologic oncology center in Southern Brazil. Age at diagnosis, pre-conization findings, conization method, margin status, residual disease, recurrence and survival rates were collected and analyzed. Results: 26 women diagnosed with stage IA1 squamous cervical cancer without lymphovascular space invasion underwent conservative management and had at least 12 months follow-up. The mean follow-up was 44.6 months. The mean age at diagnosis was 40.9 years. Median first intercourse occurred at age 16 years, 11.5% were nulliparous and 30.8% were current or past tobacco smokers. There was one Human immunodeficiency virus positive patient diagnosed with cervical intraepithelial neoplasia grade 2 at 30 months after surgery. However, there were no patients diagnosed with recurrent invasive cervical cancer and there were no deaths due to cervical cancer or other causes in the cohort. Conclusion: Excellent outcomes were noted in women with stage IA1 cervical cancer without lymphovascular space invasion and with negative margins who were managed conservatively, even in a developing country.

Resumo Objetivo: Avaliar recidiva e seus fatores de risco em mulheres com câncer do colo do útero estádio IA1 sem invasão do espaço linfovascular tratadas conservadoramente. Métodos: Estudo de coorte retrospectivo de pacientes com câncer do colo do útero IA1 escamoso submetidas a cone do colo do útero, entre 1994 e 2015, em um centro de ginecologia oncológica do sul do Brasil. Foram revisados e analisados idade no diagnóstico, achados pré-conização, método de conização, margens, doença residual, recorrência e sobrevida. Resultados: 26 mulheres diagnosticadas com câncer do colo do útero estádio escamoso sem invasão do espaço linfovascular foram submetidas a tratamento conservador, com seguimento mínimo de 12 meses. O tempo médio de seguimento foi 44,6 meses. A média de idade no diagnóstico foi 40,9 anos. A primeira relação sexual ocorreu aos 16 anos (mediana), 11,5% eram nulíparas e 30,8% eram tabagistas atuais ou passadas. Houve um caso de recidiva de neoplasia intraepitelial cervical grau 2 aos 30 meses em uma paciente com vírus da imunodeficiência humana. Não houve pacientes diagnosticados com câncer de colo do útero invasor recorrente, e não houve mortes por câncer do colo do útero ou outras causas. Conclusão: Os resultados observados após tratamento conservador em mulheres com câncer cervical escamoso IA1 sem invasão do espaço linfovascular com margens negativas foram excelentes, mesmo em um país em desenvolvimento.

When is There no Benefit in Performing a Biopsy in the Suspicion of Intraepithelial Lesions of the Cervix? / Quando não há benefício em realizar biópsia na suspeita de lesões intraepiteliais do colo uterino?

Abstract Objective To evaluate whether colposcopy-directed biopsy is necessary to increase the accuracy of diagnosing cervical intraepithelial lesions in relation to colposcopy. Methods We performed a retrospective, observational study by analyzing medical records obtained fromHospital de Clínicas do Paraná fromFebruary 2008 to February 2018. Patients with results of Pap tests, colposcopy, colposcopy-directed biopsy, and surgical procedures (high-frequency surgery or cold conization) were included. Data such as quadrants involved during colposcopy and age differences were also analyzed. Results A total of 299 women were included. Colposcopy was found to have an accuracy rate of 76.25% (95% confidence interval [CI], 71.4-81.1). Among the highest-grade lesions, the accuracy rate was 80.5% (95% CI, 75.7-85.3). The accuracy rates for biopsy were 79.6% (95% CI, 75-84.2) and 84.6% (95% CI, 80-89.1) for the highest-grade lesions. High-grade lesions were accurately confirmed in 76.9% and 85% of patients with 1 and 2 or more affected quadrants, respectively. For women younger than 40 years, the accuracy rates were 77.6% and 80.8% for colposcopy and biopsy, respectively. For women 40 years or older, the accuracy rates were 72.5% and 76.3% for colposcopy and biopsy, respectively. Conclusion There is no difference between the accuracy of colposcopy and that of biopsy in diagnosing cervical intraepithelial lesions in relation with the result of conization. The patients who received the greatest benefit when biopsy was not performed were those with high-grade lesions at colposcopy, a lesion involving 2 or more quadrants, and those younger than 40 years.

Resumo Objetivo Avaliar se a biópsia colpodirigida é necessária para aumentar a acurácia diagnóstica nas lesões intraepiteliais de colo uterino em relaçãoà colposcopia. Métodos Estudo retrospectivo, observacional, incluindo pacientes submetidas a colposcopia, biópsia colpodirigida, e procedimento cirúrgico (cirurgia de alta frequência ou conização a frio), no período de fevereiro de 2008 a fevereiro de 2018, no Hospital de Clínicas da Universidade Federal do Paraná. Dados como número de quadrantes da lesão presentes na colposcopia, número de fragmentos retirados nas biópsias e diferenças por idade também foram analisados. Resultados Um total de 299 mulheres foram incluídas. Foi encontrada uma acurácia de 76,25% (intervalo de confiança [IC] 95% 71,4-81,1) entre a colposcopia e a conização, sendo 80,5% % (IC 95% 75.7-85.3) nas lesões de maior grau. A acurácia da biópsia foi de 79,6% (IC 95% 75-84,2), sendo 84,6% (IC 95% 80-89,1) nas lesões de maior grau. Pacientes com 1 quadrante acometido tiveram confirmação de 76,9% nas lesões de maior grau, enquanto as com 2 quadrantes acometidos apresentaram o mesmo resultado em 85% dos casos. A acurácia com a biópsia de 1 fragmento foi de 78% e com2 ou mais fragmentos 80%. Paramulheres com menos de 40 anos, a acurácia foi de 77,6% e 80,8% para colposcopia e biópsia, respectivamente. Para mulheres com 40 anos ou mais, a acurácia foi de 72,5% e 76,3% para colposcopia e biópsia, respectivamente. Conclusão Não há diferença entre a acurácia da colposcopia e a da biópsia colpodirigida no diagnóstico de lesões intraepiteliais cervicais em relação ao resultado da conização. As pacientes que tiveram o maior benefício quando a biópsia não foi realizada foram as que apresentaram lesão de alto grau na colposcopia e aquelas com menos de 40 anos, não existindo benefício emrealizar biópsia previamente a conização neste grupo de pacientes.

The value of the endocervical margin status in LEEP: analysis of 610 cases.

PURPOSE: To describe the results of 610 patients who underwent LEEP and evaluate factors related to a negative margin. METHODS: A retrospective study of patients treated by LEEP at a colposcopy referral service in Campinas, Brazil, 2017-2019. Patients were referred to treat high-grade squamous intraepithelial lesion or adenocarcinoma in situ suspected by cytology and colposcopy (screen-and-treat) or by biopsy. Descriptive analysis was performed by frequencies as a function of the status of the margins (negative or positive). Factors associated with margin status were assessed by regression. RESULTS: The endocervical, ectocervical or both margins were negative in 82.4%, 75.7% and 65.9%, respectively. Age, sexual debut, parity, menopause status, smoking and hormonal contraception showed no difference in the proportion of negative margins. Both margins were negative in 66.1% of patients with transformation zone type(TZ) 1, 73.1% of TZ 2, and 54.7% of TZ 3 (p = 0.015). The endocervical negative margin was obtained in 78.0% of patients submitted to excision I (loop 10 mm) and 82.5% to excision II (loop 15 mm) (p = 0.016). Having the sexual debut at 18 years or older or being submitted to an excision type II doubled the chance of negative endocervical margin (1.98;1.04-3.77 and 1.95; 1.18-3.21, respectively). CONCLUSION: The proportion of negative endocervical margin was 78% in excision I and 86% in excision II. Sexual onset and excision type II increased the chance of obtaining a negative endocervical margin.

Efectividad del cono LEEP en pacientes con lesiones intraepiteliales de alto grado en la Unidad de colposcopia del Servicio de Ginecología del Hospital de la Mujer / Effectiveness of the LEEP cone in patients with high-grade intraepithelial injuries in the colposcopy Unit of the Gynecology Service of La Mujer Hospital

OBJETIVO. Determinar la efectividad del CONO LEEP en pacientes con lesión intraepitelial de Alto Grado (LIE AG). MATERIAL Y MÉTODO. Estudio de tipo descriptivo, retrospectivo y transversal que incluyo a 68 pacientes quienes fueron sometidas a CONO LEEP por lesiones intraepiteliales de alto grado en el año 2014 en la unidad de colposcopia del Hospital de la Mujer. Se analizó la efectividad a través de la persistencia y/o recidiva de los controles posteriores en el año 2015. RESULTADOS. 33 pacientes realizaron control PAP posterior al CONO LEEP siendo el resultado citológico negativo para lesión intraepitelial más frecuente llegando a un porcentaje de 91% (30 pacientes). Se identificó que el 9% (3 pacientes) presento persistencia al tratamiento con CONO LEEP. CONCLUSIONES. El estudio determino la efectividad del procedimiento en las pacientes que acudieron a control citológico, se estimó en 91 %, lo cual demuestra que la conización es un método de ALTA EFECTIVIDAD con un 9% de persistencia encontrándose en los rangos esperados de persistencia de la NIC que es entre el 5 y el 17% de acuerdo a protocolos de Brasil, México y España.

OBJETIVE. To determine the effectiveness of the LEEP CONE in patients with High Grade Intraepithelial Lesion (HLL). MATERIAL AND METHOD. A descriptive, retrospective and crosssectional study that included 68 patients who underwent LEEP CONE for high-grade intraepithelial lesions in 2014 in the colposcopy unit of La Mujer Hospital. The effectiveness was analyzed through the persistence and / or recurrence of subsequent controls in 2015. RESULTS. 33 patients underwent PAP control after the LEEP CONE, the cytological result being negative for the most frequent intraepithelial lesion, reaching a percentage of 91% (30 patients). It was identified that 9% (3 patients) presented persistence to treatment with LEEP CONE. CONCLUSIONS. The study determined the effectiveness of the procedure in patients who attended cytological control, it was estimated at 91%, which shows that conization is a HIGH EFFECTIVENESS method with a 9% persistence, being in the expected ranges of persistence of the NIC which is between 5 and 17% according to the protocols of Brazil, Mexico and Spain.

Neoplasia intraepitelial escamosa cervical de alto grau: abordagem ambulatorial / High-grade cervical intraepithelial neoplasia: outpatient approach

As neoplasias intraepiteliais cervicais correspondem a alterações identificadas por rastreamento citológico cervical e estudo histológico, pós-biópsia incisional guiada por colposcopia ou procedimento diagnóstico excisional. Podem ser tratadas com abordagens conservadoras e procedimentos excisionais. A vacinação anti-HPV e o tratamento excisional oportuno constituem, respectivamente, prevenção primária e secundária contra o câncer do colo uterino.(AU)

Cervical intraephitelial neoplasms correspond to changes identified by cervical citological screening and histological study, post-incisional biopsy guided by colposcopy or excisional diagnostic procedure. They can be treated with conservative approaches and excision procedures. Anti-HPV vaccination and timely excional treatment are primary and secondary prevention against cervical cancer, respectively.(AU)

Benefício da vacinação contra o HPV em pacientes submetidas a conização para remoção de lesão intra-epitelial cervical de alto grau / Benefit of HPV vaccination in patients undergoing conization to remove a high-grade cervical intraepithelial lesion

RESUMO Objetivo: Realizar uma breve revisão bibliográfica que mostre as mais recentes evidências científicas que permitam determinar se há benefícios em vacinar contra o HPV (Papilomavírus Humano) mulheres que já realizaram conização para tratamento de lesões pré- -malignas do colo do útero. Método: Foram revisados 5 artigos atualizados e específicos ao tópico, além de estudos em outras fontes bibliográficas. Resultados: Todos os artigos estudados revelaram forte fator protetivo da vacina em relação à recorrências de apresentação da patologia. Conclusão: Nossa revisão não indicou efeito terapêutico próprio da vacinação, mas indicou que há papel adjuvante ao tratamento cirúrgico, sendo uma associação em favor da proteção da mulher já tratada para a patologia relacionada ao HPV. PALAVRA-CHAVE: Conização, vacina, HPV, NIC, LEEP

ABSTRACT Objective: To carry out a brief literature review showing the latest scientific evidence to determine whether women who have already undergone conization for the treatment of pre-malignant lesions of the cervix are benefited from the vaccine against HPV (Human Papillomavirus). Method: Five updated and topic-specific articles were reviewed, as well as studies in other bibliographic sources. Results: All articles studied revealed a strong protective factor of the vaccine in relation to recurrent presentation of the pathology. Conclusion: Our review did not indicate a therapeutic effect of vaccination itself, but it indicated that there is an adjuvant role to surgical treatment, being a combination in favor of protecting women who have already been treated for HPVrelated pathology. KEYWORDS: Conization, vaccine, HPC, CIN, LEEP

Conservative treatment of microinvasive squamous cell carcinoma of the cervix stage IA1: Defining conization height to an optimal oncological outcome.

OBJECTIVE: This paper searches an ideal cone height for stage definition and safe treatment of cervical microinvasive squamous carcinoma stage IA1 (MIC IA1), avoiding excessive cervix resection, favoring a future pregnancy. METHODS: A retrospective study was performed involving 562 women with MIC IA1, from 1985 to 2013, evaluating cone margin involvement, depth of stromal invasion, lymph vascular invasion, conization height, and residual uterine disease (RD). High-grade squamous lesions or worse detection was considered recurrence. Univariate and multivariate regression analyses were performed, including age, conization technique (CKC, cold-knife, or ETZ, excision of transformation zone), and pathological results. Conization height to provide negative margins and the risk of residual disease were analyzed. RESULTS: Conization was indicated by biopsy CIN2/3 in 293 cases. Definitive treatments were hysterectomy (69.8%), CKC (20.5%), and ETZ (9.7%). Recurrence rate was 5.5%, more frequent in older women (p = 0.030), and less frequent in the hysterectomy group (p = 0.023). Age ≥40 years, ETZ and conization height are independent risk factors for margin involvement. For ages <40 years, 10 mm cone height was associated with 68.6% Negative Predictive Value (NPV) for positive margins, while for 15 mm and 25 mm, the NPV was 75.8% and 96.2%, respectively. With negative margins, the NPV for RD varied from 85.7-92.3% for up to 24 mm cone height and 100% from 25 mm. CONCLUSION: Conization 10 mm height for women <40 years provided adequate staging for almost 70%, with 10% of RD and few recurrences. A personalized cone height and staging associated with conservative treatment are recommended.

Neoadjuvant chemotherapy in early-stage cervical cancer (<2 cm) before conization for fertility preservation: is there any advantage over upfront conization?

BACKGROUND: Neoadjuvant chemotherapy before fertility-sparing surgery is an accepted option for patients with cervical tumors between 2 cm and 4 cm. There is a paucity of data regarding its role in patients with tumors <2 cm. Our objective was to compare the oncological and obstetrical outcomes between patients who underwent neoadjuvant chemotherapy before cervical conization versus upfront cervical conization in patients with cervical cancer with tumors <2 cm. METHODS: We conducted a systematic literature review and searched MEDLINE, EMBASE, and CINAHL (from 1995 to March 2020) using the terms: uterine cervix neoplasms, cervical cancer, fertility-sparing surgery, fertility preservation, conization, cone biopsy, and neoadjuvant chemotherapy. We included manuscripts with information on patients with tumor size <2 cm, lymph node status, follow-up, oncological and obstetrical outcome, and toxicity related to neoadjuvant chemotherapy. We excluded review articles or articles with duplicated patient information. RESULTS: We identified 12 articles, including 579 patients. For final analysis, 261 patients met inclusion criteria. The most common histology was non-squamous cell carcinoma (62%). Median follow-up time was 63.5 (range 7-122) months for the neoadjuvant chemotherapy group and 48 (range 12-184) months for the upfront cervical conization group. There was no difference in either overall survival (neoadjuvant chemotherapy group 100% vs upfront cervical conization 99.7%, p=0.79) or disease-free survival (neoadjuvant chemotherapy 100% vs upfront cervical conization 98.9%, p=0.59) between the groups. Fertility preservation rate was 81.4% versus 99.1% (p<0.001) favoring upfront cervical conization. No statistically significant differences were seen in live birth rate or pregnancy loss. Also, we found that all neoadjuvant chemotherapy patients reported chemotherapy-related toxicity (30.7% grade 3 and 69.2% grade 1-2). CONCLUSIONS: There was no difference in disease-free survival or overall survival between patients who underwent neoadjuvant chemotherapy followed by conization and upfront cervical conization. Patients who underwent upfront cervical conization had a higher fertility preservation rate.

Predictive Factors for Residual Disease After Conization in Cervical Cancer.

OBJECTIVE: The aim of this study was to evaluate predictive factors for the presence of residual disease after conization followed by definitive surgery in cervical cancer, and suggest a margin distance threshold that could predict residual disease. METHODS: We retrospectively analyzed a series of 42 patients with early-stage cervical cancer who underwent primary conization before definitive surgical treatment from March 2009 to May 2020. All conization specimens were reviewed for endocervical, ectocervical, and radial margins. Cases with residual disease in magnetic resonance imaging before definitive surgery were excluded. RESULTS: Thirty-three (78.6%) patients underwent hysterectomies and 9 (21.4%) trachelectomies ± lymph node staging. Twelve (28.6%) cases were stage IA1, 5 (11.8%) cases were stage IA2, 13 (31%) cases were stage IB1, 11 (26.2%) cases were stage IB2, and 1 (2.4%) case was stage IIIC1 [International Federation of Gynecology and Obstetrics (FIGO) 2019]. We found residual disease in 17 (40.4%) surgical specimens. Of the 20 patients with negative margins, there were still 3 (15%) cases with residual disease. Conversely, residual disease was identified in 14 (63.6%) of the 22 patients with positive cone margins (p = 0.001). Tumor size [odds ratio (OR) 1.71, 95% confidence interval (CI) 1.02-1.33] and positive endocervical margin status (OR 33.6, 95% CI 3.85-293.3) were related to a higher risk of residual disease in multivariate analysis. Notably, all patients with tumors larger than 2 cm had residual disease, in contrast to 29.4% in lesions up to 2 cm (p = 0.002). CONCLUSION: We found that tumor size and positive margin were predictive factors for residual disease. We could not suggest a reliable minimum margin distance threshold that could predict residual disease.

A randomized clinical trial of a new anti-cervical stenosis device after conization by loop electrosurgical excision.

BACKGROUND: The complications inherent to conization include vaginal bleeding, cervical stenosis, amenorrhea, dysmenorrhea, and deep dyspareunia. Cervical stenosis is the most important complication due to the clinical repercussions. Studies show rates of cervical stenosis ranging from 1.3 to 19% after the Loop Electrosurgical Excision Procedure (LEEP). OBJECTIVE: Our primary outcome was to compare the role of a new endocervical device to prevent cervical stenosis after LEEP in patients with high-grade squamous intraepithelial lesions (HSILs). METHODS: A randomized clinical trial was performed including phases II and III for evaluation of a new device for cervical stenosis prevention. In Phase II, we included 25 patients who underwent LEEP and placement of the device to assess its toxicity and efficacy. In phase III, we compared two groups (with and without the use of an anti-stenosis device) to evaluate its efficacy and safety. RESULTS: From August 2015 to June 2018, 265 participants were randomized (Phase II: 25, Phase III: 120 with DUDA and 120 without DUDA). The toxicity during phase II was observed in only one patient (4%) with pain grade > 7. There were 7 cases of toxicity during Phase III, 2 in the DUDA group (1.8%), and 5 in the No DUDA group (4.5%). The complications rate was numerically higher in the No DUDA group (2.5x higher) than the DUDA group, but this difference did not reach statistical significance (p = 0.52). The rate of cervical stenosis in DUDA group was (4-7,3%), and in No DUDA group was (4.3-5.8%) (p = 0.5). We did not find a significant difference when comparing the evolution at 3, 6, and 12 months in terms of cervical patency and visualization of the squamocolumnar junction (SCJ) during colposcopy. The DUDA group exhibited 15% to 19% nonvisualization of the SCJ, whereas that rate ranged from 10 to 12% in the No DUDA group. CONCLUSIONS: The rate of cervical stenosis was not different comparing the use of a new device, specifically produced to prevent cervical stenosis, compared to no use after LEEP procedure. This clinical trial opens up space for a discussion of the utility of using cervical stenosis devices after LEEP. Perhaps in another type of conization it can be evaluated to avoid cervical stenosis.

Oncological and obstetrical outcomes after neo-adjuvant chemotherapy followed by fertility-sparing surgery in patients with cervical cancer ≥2 cm.

OBJECTIVE: There is significant debate between up-front radical trachelectomy versus neo-adjuvant chemotherapy before fertility-sparing surgery in patients with tumors ≥2 cm. The aim of this study was to report on the oncological and obstetrical outcome of neo-adjuvant chemotherapy followed by fertility-sparing surgery, in patients diagnosed with cervical cancer ≥2 cm. METHODS: This was a retrospective review of patients diagnosed with cervical cancer measuring ≥2 cm to ≤6 cm, who were scheduled to undergo neo-adjuvant chemotherapy before fertility-sparing surgery, at six institutions from four Latin American countries between February 2009 and February 2019. Data collected included: age, International Federation of Gynecology and Obstetrics (FIGO) 2009 stage, histology, tumor size, pre-treatment imaging work-up, chemotherapy agents and number of cycles, toxicity, clinical and imaging response rate, type of fertility-sparing surgery, pathology results, timing of lymphadenectomy, follow-up time, and obstetrical and oncological outcomes. RESULTS: A total of 25 patients were included, with a median age of 27 years (range 20-37): 17 patients had stage IB1, 7 had stage IB2 cervical cancer, and 1 patient had stage IIA1 (FIGO 2009); 23 patients had squamous cell carcinoma and 2 patients had adenocarcinoma. The median number of chemotherapy cycles was 3 (range 3-6) and no toxicity grade 3-4 was reported. Lymphadenectomy was performed before chemotherapy in 6 (24%) patients. After neo-adjuvant chemotherapy 20 patients were scheduled for radical trachelectomy (11 abdominal and 9 laparoscopic) and 5 patients for conization. After surgery, no residual disease was found in 11 patients (44%). Fertility was preserved in 23 patients (92%) and 10 patients became pregnant (43.5%). After a median follow-up time of 47 months (13-133), 3 patients had recurrent disease (3/23=13%), 2 were alive without disease, and 1 patient had disease at last contact. CONCLUSION: Neo-adjuvant chemotherapy followed by fertility-sparing surgery is feasible in well selected patients with cervical tumors ≥2 cm. Future studies should focus on the timing of lymphadenectomy and type of cervical surgery.

Células glandulares atípicas: abordagem ginecológica / Atypical glandular cells: gynecological approach

As células glandulares atípicas representam 0,2% a 2,1% dos resultados dos testes de Papanicolaou. Mesmo com essa baixa prevalência, tem um significado importante no diagnóstico do câncer cervical e endometrial, tendo em vista que tais células e subcategorias, associadas à idade da paciente, podem prenunciar um número expressivo de doença intraepitelial, doença invasiva do endocérvix, endométrio e até neoplasias anexiais. E não se pode esquecer do importante número de resultados histológicos benignos, identificados no seguimento dessas pacientes, muitas vezes assintomáticas.(AU)

Atypical glandular cells represent 0,2% to 2,1% of Pap test results even with this low prevalence has an important significance in the diagnosis of cervical and endometrial cancer, considering that such cells and subcategories associated with the patient's age can predict a significant number of intraepithelial disease, invasive disease of the endometrium, endocervix and even adnexial neoplasms; no forgetting the important number of benign histological results, identified in the follow up of these patients, often asymptomatic.(AU)