Gynecologic cytology from the perspective of the Laboratory Proficiency Testing Program, Ontario, Canada

The accumulated test results from annual proficiency testing of approximately 150 cytology laboratories during the period 1977-1992 were analyzed. Several features of the test program are presented, including the adaptability of the uniform diagnostic terminology that was in use throughout. Observations include the impact of screening by a technologist; the better diagnostic performance generally, but not exclusively, in larger-volume laboratories; the degree of reproducibility of reporting in the laboratory; the ease of diagnosis in some diagnostic categories; and patterns observed in "false negative" and "false positive" rates. The follow-up analysis of suboptimal performance is recorded, and remedial and educational aspects are emphasized. The impact of levels of performance on the specific population being screened is correlated with the data on laboratory caseloads and with hospital vs. nonhospital laboratories.

Lichen sclerosus

Lichen sclerosus, usually appearing in the dermatologic literature under the names of lichen sclerosus et atrophicus, balanitis xerotica obliterans, and kraurosis vulvae, is an inflammatory disease with a multifactorial origin. A past association of lichen sclerosus and genital squamous cell carcinoma is not as close as once thought. Once considered primarily a surgical problem, especially when the genitals were involved, lichen sclerosus will respond to a variety of systemic and topical therapies.

Clinical presentation of gynecologic infections among Indian women

OBJECTIVE

To study the clinical presentation of different gynecologic infections among Indian women.

METHODS

This was a cross-sectional study of 257 women that included clinical, cytologic, colposcopic, and microbiologic screening for various gynecologic infections.

RESULTS

Human papillomavirus (HPV) was the leading infection, affecting 127 (49.4%) women; however, overt warts were only seen in seven (2.7%) patients. Women infected with HPV had a 60.3-fold higher risk of developing a bleeding ectopia compared to those with other infections; women with an unhealthy cervix and cervical ectopias also had an increased risk of HPV infection (7.6- and 2.8-fold, respectively). Bacterial vaginosis, detected in 33.5% of the women studied, had an increased risk of bleeding ectopia (9.3-fold), cervical ectopia (3.1-fold), cervicitis (2.9-fold), vaginitis (6.9-fold), and cervical hypertrophy (2.1-fold). Chlamydial infection, detected in 23.3% of the patient population, was associated with an eightfold increase in the risk of an unhealthy cervix and a fourfold increase in risk of a hypertrophied cervix. Immunoglobulin-A antibodies to the herpes simplex virus were detected in 53 (20.6%) women. More than half (55.2%) of the women had two or more infections, and the mean delay of seeking medical treatment was 7-13 months.

CONCLUSION

The specific finding of bleeding cervices was associated with HPV and bacterial vaginosis, hypertrophied cervices with chlamydia and bacterial vaginosis, and unhealthy cervices with chlamydia and HPV infections.

[Pathological changes in the urogenital tract and mammae of culled sows from an industrial pig production unit]

In an industrial pig production unit 101 sows were culled because of reproduction failure. All the sows had a previous history of MMA, PHS, SUGD. All the sows were crosses of the two breeds Large White and Landrace. 101 sows were examined postmortem for pathologic changes. Changes were found in the kidney (38.6%), pyelum (49.5%), ureter (52.5%), bladder (100%), urethra (100%), uterus (50.5%), cervix (31.7%), vagina (28.7%), ovaries (51.5%), mammary gland (100%). Since 100% of the pathologic findings happened simultaneously in the urinary tract as well as in the mammary gland and just over 50% of the investigated cases had pathologic changes in the genital organs as well, the results suggest that MMA, PHS, and SUGD must be regarded as different manifestations of the same pathological entity of the urogenital organs of the sow. The authors introduce the term SUGD to denominate the conflicting terminology around the periparturient reproductive failure syndrome complex.

Adnexal torsion: can the adnexa be saved?

OBJECTIVE

Our purpose was to identify which cases of adnexal torsion may be managed with adnexal conservation.

STUDY DESIGN

A retrospective chart review was conducted on all patients diagnosed with adnexal torsion between February 1983 and February 1993 at four hospitals in the Emory University system.

RESULTS

Fifty-nine patients ranging in age from 23 months to 73 years (mean 31.9 years) were reviewed. Almost half of the patients were nulliparous. Lower abdominal pain (83%) and an adnexal mass (72%) were the most common presenting findings, but in general clinical findings were nonspecific. Most patients were treated with extirpative therapy of the affected adnexa. Untwisting of the adnexa was performed in 10 patients; however, adnexal conservation was accomplished in only one patient. There were no thromboembolic complications in any of the patients.

CONCLUSIONS

Adnexal torsion is a diagnostic challenge, often with nonspecific symptoms. There is growing evidence that untwisting the involved adnexa to observe for tissue reperfusion and viability is safe. However, significant delay in surgical intervention may result in irreversible tissue necrosis, rendering the adnexa unsalvageable.

Primary infertility: characteristics of women in North America according to pathological findings

STUDY OBJECTIVE

To determine, in women with primary infertility, whether specific characteristics or behavioural factors are associated with the various pathological conditions identified as contributing to the infertility.

DESIGN

Case-control study.

SETTING

Seven institutions in the USA or Canada.

PARTICIPANTS

Study subjects were 1750 women who presented with primary infertility, among whom the main pathological cause of infertility was male factor (417), tubal obstruction (231), endometriosis (194), luteal phase defects (153), other ovulatory problems (193), cervical abnormalities (92), and polycystic ovarian disease (84) and 1765 control women who delivered their first child at the same institution.

MAIN RESULTS

Except for tubal obstruction and polycystic ovarian disease, the characteristics and behaviours of the women with infertility did not differ appreciably according to the pathological conditions recorded. Women with tubal obstruction had had more sexual partners, an earlier age at first intercourse, were more likely to have used an intrauterine device but less likely to have used a condom, and were more likely to have smoked cigarettes and to have used various recreational drugs than the other women. Women with polycystic ovarian disease were more obese, had had fewer sexual partners, and were less likely to have used cigarettes, contraceptives, and recreational drugs than the other women.

CONCLUSIONS

Sexually transmitted infections seem to increase the risk of tubal obstruction but not other causes of infertility. Obesity is associated with polycystic ovarian disease. These data offer few clues to the aetiology of infertility attributed to endometriosis, cervical abnormalities, luteal phase defects, other ovulatory defects, or to male factors.

Immunological events in regressing genital warts

Little is known of the in vivo role of the immune system in controlling human papillomavirus infection in the genital tract. The authors have studied 125 closely monitored patients with genital warts. Of these 125 patients, wart regression was seen in 28 patients. This study provides evidence that clearance of human papillomavirus from the genital tract is characterized by an active cell-mediated immune response. Regressing warts (n = 14) contained significantly more T lymphocytes (P < .05, Wilcoxon rank sum test) and macrophages (P < .01) than did nonregressing controls (n = 14). CD4-positive lymphocytes predominated in regression, both within the wart stroma and the surface epithelium, where there was a significant change in the ratio of CD4+ to CD8+ cells (P < .01). Lymphocytes in regression also showed greater expression of activation markers, and the majority were of the "antigen-experienced" phenotype. There was no difference in Langerhans cell numbers, although there was significant induction of the immune accessory molecules HLA-DR and ICAM1 (P < .05) on keratinocytes, and E-selectin and VCAM1 (P < .05) on endothelial cells in regressing warts. The changes in regression are consistent with a delayed-type hypersensitivity reaction to foreign antigen, and the ability to induce and mount such a response may be a critical determinant of effective natural immunity to the genital HPVs. Specific targeting of delayed-type hypersensitivity responsiveness may increase the efficacy of strategies for immuno-intervention against HPV infection in the genital tract.

Isolation and serological characterization of porcine reproductive and respiratory syndrome (PRRS) viruses from pigs with reproductive and respiratory disorders in Japan

Three porcine reproductive and respiratory syndrome viruses (PRRSVs) were successfully isolated from stillborn piglets and fattening pigs derived from different herds affected either with an epizootic reproductive failure or a severe chronic respiratory distress in Japan. The isolates were reacted with antisera against both European (Lelystad virus) and American (strain 46448) PRRSVs in indirect immunofluorescence (IIF). However, cross immunoperoxidase monolayer assay revealed the close serological relationships between the Japanese isolates and American PRRSV, but not between the Japanese isolates and the European PRRSV. The data of preliminary serological survey with IIF technique showed a high frequency of antibody positive pigs against both Japanese isolate and the American PRRSV, whereas a low frequency of antibody positive pigs against the European PRRSV, on herds which have had clinical episodes of PRRS-like diseases. These results indicate that PRRSVs are prevalent in Japan, and suggest that the antigenicities of the prevalent PRRSVs are more closely related to those of the American than the European PRRSVs.

Risk factors for genital papillomavirus infection in populations at high and low risk for cervical cancer

This study sought to determine risk factors for genital infection with papillomavirus (HPV) in Panamanian women 20-49 years old. Subjects were randomly selected from Herrera and Panama provinces (cervical cancer incidence 79 and 25/100,000, respectively). Participants were interviewed to determine sexual behavior. Cervicovaginal lavage specimens were obtained to test for HPV DNA by commercial dot blot hybridization. HPV-16/18 DNA was detected significantly more frequently (5%) in Panama than Herrera (2%) samples (P = .002). Clearly, infection with high-risk HPV types alone cannot account for the differences in cervical cancer incidence between the two populations. HPV-16/18 detection decreased with increasing years of sexual experience among all women in Panama and among women with multiple partners in Herrera. However, HPV-16/18 detection did not change with sexual experience among monogamous women in Herrera. Thus, the epidemiology of HPV is complex and reflects both virus- and population-specific factors.

Fibrous hamartoma of infancy in the genital region: findings in 15 cases

Fibrous hamartoma of infancy is a benign myofibroblastic proliferation that typically occurs in the axillary or shoulder region of male infants. We describe 15 cases of this condition, which involved the inguinal region in 5, scrotum in 5, spermatic cord in 1, perineum in 1, labium majus in 1, the suprapubic region in 1 and the pubic area in 1. Patient median and mean ages were 10 and 6.7 months, respectively (range 2 to 24). No case was reported to be congenital. Median and mean tumor size was 3 cm. (range 0.5 to 6). The microscopic features were identical to those seen in fibrous hamartoma of infancy occurring in more typical sites and consisted of 3 components: 1) fascicles of myofibroblasts, 2) disorganized mature adipocytes and 3) small rounded primitive mesenchymal cells. Immunohistochemically, the myofibroblastic component expressed muscle specific actin and vimentin, and the primitive component expressed vimentin only. There was no evidence of increased cellular proliferation in the primitive cell component using proliferating cell nuclear antigen antibodies. Of the 15 lesions 1 recurred locally and 14 were apparently cured by local excision. Awareness of this presentation of fibrous hamartoma of infancy may avert misdiagnosis of more aggressive lesions, especially infantile fibromatosis or rhabdomyosarcoma.

Assessment of cervicovaginal smear adequacy. The Bethesda System guidelines and reproducibility

Criteria for assessing adequacy of cervicovaginal smears according to the Bethesda System include cellular composition and quantity, specimen preservation, fixation, and absence of obscuring elements. The reproducibility of adequacy assessment using these parameters was the focus of this study. Specimens were chosen to include a wide spectrum of clinical history and adequacy interpretations, but excluded cases with epithelial abnormalities and those judged "limited" because of insufficient transformation zone component. The 114 specimens were independently evaluated twice by five reviewers, with interceding randomization. Full interobserver concordance was obtained in 50.4% of cases, with consensus reached by three or more observers in 97.4% of cases. Of 2280 paired interpretations, 74% (1692) concurred. Pairwise kappa values for interobserver agreement ranged from .71 to .54 (very good to fair), with overall kappa = .61. Interobserver agreement for each category was near excellent for "satisfactory" (kappa = .73), good for "unsatisfactory" (kappa = .63), and only fair for "satisfactory but limited" (kappa = .48). Paired intraobserver reproducibility (agreement for two separate readings by the same observer) ranged from 69% to 77% (average, 74%), with good to fair kappa values (.66-.51). These findings indicate that the specimen adequacy guidelines of the Bethesda System provide good inter- and intraobserver reproducibility. The "satisfactory but limited" category appears to show the lowest concordance. Problem areas include evaluation of adequate minimum cellularity and estimation of number of cells obscured.

[Requirements in preoperative diagnosis of gynecologic diseases of the pelvis]

Correct diagnosis of disease, staging of malignancies and detection of primary or secondary abnormalities of the adjacent pelvic organs are the basic requirements of preoperative diagnostic procedures in gynecological disorders. The latter is usually done by ultrasound, intravenous pyelography and endoscopic examination of the bladder and the colon. The diagnosis of disease with respect to malignancies of the uterus, vagina and vulva can usually be made by clinical examination and histology obtained by biopsy. On the other hand, ovarian tumors cannot be sufficiently differentiated by clinical methods. Ultrasound, magnetic resonance imaging and computed tomography may be helpful, but definitive diagnosis usually requires a surgical approach. This is also true for staging of gynecological malignancies. Nevertheless, improvements in preoperative diagnostic procedures allow individualized planning of surgery and improved staging in patients treated primarily by radiotherapy.

Isolated vasculitis involving the female genital tract: clinicopathologic spectrum and phenotyping of inflammatory cells

Isolated vasculitis involving the female genital tract (IVF) is rare. Although both giant cell arteritis (GCA) and polyarteritis nodosa (PAN) types of involvement have been documented, several clinicopathologic features of IVF are not clearly understood. We wish to report two cases of IVF (one GCA and one PAN) and compare them with previously reported cases. Including our two cases, we found a total of 33 reported cases of IVF, which included 18 GCA and 15 PAN. In cases of GCA, all parts of the female genital tract were involved with roughly comparable frequency, whereas in the case of PAN, the cervix is uniformly involved, with the vulva and myometrium being affected once and twice, respectively. In all cases of GCA and most cases of PAN, the vasculitis represented an incidental finding upon microscopic examination of the female genital tract removed for unrelated problems; however, in one case of PAN, vaginal bleeding probably related to vasculitis-induced cervical ulcer was reported. In either category, no clearcut pattern of predisposing factors was identified and, at the time of diagnosis, none of the patients had any diseases known to be associated with vasculitis, such as connective tissue disease, rheumatoid arthritis, or drug hypersensitivity. Although antineutrophilic cytoplasmic antibodies were recently described as sensitive and specific markers for systemic vasculitis, tests for these antibodies were not done on previously reported cases and were negative for both current cases. Long-term follow-up in IVF indicates that even without any specific treatment for vasculitis, systemic involvement did not occur.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopically assisted vaginal hysterectomy

The list of gynecologic operations that can be performed by operative laparoscopy has expanded rapidly and now includes hysterectomy, yet there has been little critical assessment of the clinical outcome and complications of these procedures. This report is a retrospective review of 119 laparoscopically assisted vaginal hysterectomies (LAVHs). The most common indications were pelvic pain, menorrhagia, pelvic mass and uterine myomas. Of the 119 women, 94 (79%) had one or more factors considered to be absolute or relative contraindications to vaginal hysterectomy. The average operating time was 79 +/- 3 (SEM) minutes, with an estimated blood loss of 135 +/- 10 mL and an average length of hospitalization of 59 +/- 2 hours. Intraoperative complications were limited to vaginal entry into the bladder in one patient. Sixteen women had estimated blood losses > 300 mL; none received a blood transfusion. To more accurately describe the laparoscopic procedure performed, a staging system classifying the extent of the laparoscopic portion of the procedure is presented. Such a system is helpful for assessing the risk/benefit ratio of LAVH. While the findings of this study suggest the potential advantages of LAVH, future studies will be required to determine the specific efficacy of the procedure.

Behçet's disease in South African blacks: report of five cases

Behçet's disease is a multisystemic disorder characterized by oral and genital ulcers. Most commonly seen in the Middle East and Japan, it is rare in black Africans. Behçet's disease in five South African blacks is reported. The patients had a mucocutaneous type of the disease, similar to the form prevailing in Western Europe and the United States. One of the patients had neurologic manifestations, and none had uveitis. In four patients genital and cutaneous lesions responded to administration of dapsone, colchicine, or both.

Hyaluronan and myeloperoxidase in human peritoneal fluid during genital inflammation

The changes in concentration of hyaluronan (HYA) and myeloperoxidase in peritoneal fluid (PF) were studied during genital intraperitoneal inflammation. PF were collected from 111 women undergoing laparatomy for adhesiolysis and reconstructive surgery of the fallopian tubes, or laparoscopy in search of causes of infertility or low abdominal pain. When the number of leukocytes in the PF had been counted, the fluid samples were centrifuged and the supernatants analyzed for the concentrations of HYA and of myeloperoxidase. During genital inflammation, whether post-operative or postinfectious, leukocytosis and elevated levels of HYA and myeloperoxidase were found in the PF. Concentrations of these substances in the PF may be usable as clinical markers for genital inflammation.

Hyaluronan and myeloperoxidase in human peritoneal fluid during genital inflammation

The changes in concentration of hyaluronan (HYA) and myeloperoxidase in the peritoneal fluid (PF) were studied during genital intraperitoneal inflammation. PF were collected from 111 women undergoing laparotomy for adhesiolysis and reconstructive surgery of the fallopian tubes or laparoscopy in search of causes of infertility or low abdominal pain. When the number of leukocytes in the PF had been counted, the fluid samples were centrifuged and the supernatants analyzed for the concentrations of HYA and myeloperoxidase. During genital inflammation, whether postoperative or postinfectious, leukocytosis and elevated levels of HYA and myeloperoxidase were found in the PF. Concentrations of these substances in the PF may be usable as clinical markers for genital inflammation.

Magnetic resonance imaging confirmation of pulmonary artery aneurysm in Behçet's disease

Behçet's disease (BD) is a multisystem disorder thought to be the result of an autoimmune vasculitis. Patients classically present with the clinical triad of recurrent oral and genital ulcers and relapsing uveitis. Complications have been reported following pulmonary angiography to diagnose associated pulmonary artery aneurysms. We report a case of pulmonary artery aneurysm in BD confirmed by magnetic resonance (MR) imaging.

Genital lesions following long-term administration of clenbuterol in female pigs

Pathologic findings, lectin histochemistry, and nuclear estrogen receptors were studied in the reproductive organs of gilts treated with clenbuterol. A ration containing 1 ppm of clenbuterol was fed for 40 days to four Landrace x Large white, 9-month-old gilts, weighing 134 to 172 kg at slaughter (gilt Nos. 5-8). Four gilts (Nos. 1-4) served as controls. Treated animals had macroscopic lesions characterized by microcystic ovaries and uterine atrophy. Histopathologic lesions included atretic degeneration of many ovarian follicles, complete absence of functional corpora lutea, a reduction in the number of endometrial glands, and a decrease in cytoplasmic volume of endometrial and glandular epithelial cells. In ovaries, uterus, and vagina lectin histochemistry, performed with thirteen different biotinylated lectins, revealed a different staining distribution between control and treated gilts. The binding pattern of Ricinus communis agglutinin-I (RCA-I) and -II (RCA-II) in the ovaries of control gilts, displayed labeling of cytoplasm in theca interna cells of Graafian follicles. There was no labeling of the same cells in treated gilts. Labeling patterns with Griffonia simplicifolia agglutinin-I (GS-I), Phaseolus vulgaris agglutinin (PHA), RCA-I and RCA-II documented a difference in the vascularity of the theca interna between Graafian follicles of control and treated gilts. The GS-I and Ulex europaeus agglutinin-I (UEA-I) binding patterns in uterus and vagina of treated gilts when compared to control gilts suggested that there was a block of the cycling activity in the proliferative stage. Immunohistochemical staining for estrogen receptors in the endometrium was positive in all but one treated gilts, and negative to weakly positive in control gilts. Serum progesterone concentrations were decreased in treated animals when compared to control; estradiol concentrations were similar in both group of gilts. Cystic ovaries, uterine atrophy, and reduction in progesterone concentrations suggested that clenbuterol changed ovarian hormonal activity in treated animals.

Hydrocele of the canal of Nuck

The authors discuss hydrocele in the female processus vaginalis (hydrocele in the canal of Nuck) and present new case reports. The treatment of choice is surgical excision. The hydrocele is excised through a groin incision. The authors present four new cases.

Analysis of lower genital tract lesions clinically suspicious for condylomata using in situ hybridization and the polymerase chain reaction for the detection of human papillomavirus

The presence of human papillomavirus was analyzed in 123 biopsy specimens of lower genital tract lesions, clinically considered to be condyloma, using both in situ hybridization and the polymerase chain reaction. Using standard histologic criteria only 22% of the lesions could be diagnosed as condyloma, 17% had features suggestive but not diagnostic of condyloma and 61% lacked the histologic features of condyloma. Human papillomavirus was detected by in situ hybridization in 89% of the lesions with the histologic features of condyloma but in only 3% of the biopsy specimens lacking the histologic features of condyloma. Fifty percent of lesions that had histologic features suggestive, but not diagnostic for, condyloma contained human papillomavirus by in situ hybridization. Using polymerase chain reaction similar results were found. This study underscores the usefulness of human papillomavirus detection methods for analyzing histologically equivocal lesions of the lower genital tract.

The association of HLA-B5 antigen with specific manifestations of Behçet's disease

The HLA-B5 phenotype was investigated in 235 patients with Behçet's disease and in 100 healthy persons. HLA-B5 was more frequent in the patients (77 vs. 30% p < 0.001, relative risk = 7.8). The frequency of HLA-B5 was higher in patients with genital ulceration than without (82.3 vs. 63%, p < 0.01). Patients with thrombophlebitis showed a less frequent positivity of HLA-B5 antigen than the patients without thrombophlebitis (50 vs. 79.2%, p < 0.02). These results suggest that HLA-B5-related genes not only affect the development of Behçet's disease but also the occurrence of its clinical manifestations.