High-grade histologic lesions in women with low-grade squamous intraepithelial lesion cytology from a region of Thailand with a high incidence of cervical cancer

OBJECTIVE

To evaluate the prevalence of and predictors for underlying significant lesions in women with low-grade squamous intraepithelial lesion (LSIL) smears.

METHODS

Records were retrospectively reviewed for 208 women with LSIL who underwent colposcopy and histological evaluation from October 2004 through April 2009.

RESULTS

Mean age of the patients was 38.5 years. Forty-four (21.2%) women were nulliparous; 20 (9.6%) women were postmenopausal; 29 (13.9%) women tested positive for HIV. Thirty-three (15.9%) women were current users of combined oral contraceptive pills. The pathological results of initial colposcopic evaluations were: 63 (30.3%) with cervical intraepithelial neoplasia (CIN) 2-3; 62 (29.8%) with CIN 1; 4 (1.9%) with cervical cancer; and 79 (38.0%) with no epithelial lesion. Current use of combined oral contraceptive pills, a positive HIV test, and multiparity were significant independent predictors for high-grade disease.

CONCLUSION

Approximately one-third of women with LSIL in our population have underlying significant lesions. Current use of combined oral contraceptive pills, a positive HIV test, and multiparity are significant predictors for high-grade lesions.

Carcinosarcoma arising in uterine didelphys after tamoxifen therapy for breast cancer: a case report

The occurrence of uterine cancer in breast cancer patients who received tamoxifen treatment, is well described. 72 our knowledge, an association between uterine anomaly and uterine carcinosarcoma in these patients had not been reported. We present a case of uterine carcinosarcoma occurring in uterine didelphys of a 72-year-old breast cancer patient, who had been treated with tamoxifen for 5 years. The patient presented with large pelvic mass. The uterine anomaly was not recognized preoperatively. The patient died of disease 5 months after diagnosis. Postmenopausal women taking tamoxifen should be closely monitored for symptoms of endometrial lesions.

Leiomyosarcoma with osteoclast-like giant cells of the uterus: a case report and literature review

The presence of osteoclast-like giant cells (OGC) has been reported as a rare and distinct feature in uterine leiomyosarcoma. To present knowledge, 11 cases have been described in the English literature. The authors report an additional example in a 35-year-old woman who presented with a pelvic mass. Pulmonary metastasis was detected by the preoperative CT scan. The hysterectomy specimen revealed a 11.5 cm intramural mass with hemorrhagic and necrotic center The histologic examination revealed pleomorphic sarcoma with OGC. The neoplastic cells were immunoreative for smooth muscle actin and desmin. Minor intermixing component of conventional leiomyosarcoma and leiomyoma were identified at the periphery of the malignant component. The patient died of disease after 16 months of diagnosis. To our knowledge, this is the youngest case of uterine leiomyosarcoma with OGC. Leiomyosarcoma with OGC has an aggressive clinical course. The tumor may occur in young patient and may arise from pre-existing leiomyoma.

Colposcopy audit for improving quality of service in areas with a high incidence of cervical cancer

OBJECTIVE

To audit routine colposcopy performance using 8 standard requirements of the National Health Service Cervical Screening Programme (NHSCSP).

METHODS

Records of women who underwent colposcopy for abnormal cervical cytology between January and December 2008 at Chiang Mai University Hospital, Thailand, were reviewed.

RESULTS

The standard requirements were not achieved in 2 practices: (1) the proportion of women who had recordings of visibility of the transformation zone (96.6%) did not achieve the NHSCSP requirement of 100%; and (2) the rate of excisional biopsy (87.8%) was lower than the 95% minimum required.

CONCLUSION

Colposcopic performance at Chiang Mai University Hospital was generally favorable. However, re-audit is necessary to ensure that unmet standards of performance are improved and achieved standards are maintained.

Recurrent rates with cervical intraepithelial neoplasia having a negative surgical margin after the loop electrosurgical excision procedure in Thailand

LEEP conization has become the treatment of choice in patients presenting with high grade intraepithelial lesions (HSILs), especially in cases with negative surgical margins. However, surveillance after such treatment is necessary due to the potential for recurrence. To evaluate the recurrent rate in patients with negative surgical margins after HSIL treatment with LEEP, the medical records of such patients treated between January 2000 and June 2007 were reviewed. All of them subsequently underwent Pap smears every 4-6 months to detect the recurrence of cervical intraepithelial neoplasia. There were 272 patients in the study period. Of these, 9 (3.3%) developed abnormal Pap smears with a median follow up of 12 months. The abnormal smears featured: atypical squamous cells of undetermined significance in 5 cases; atypical squamous cells where high grade squamous cell intraepithelial lesion cannot be excluded in 2 cases; and low grade squamous intraepithelial lesions in the 2 remaining cases. Further investigation with colposcopic directed biopsies were conducted in all who exhibited an abnormal Pap smear and only 3 of them (1.1%) showed cervical dysplasia at biopsy. In conclusion, the patients with HSIL who were treated with LEEP and have negative surgical margins have a very low recurrence rate.

Hydronephrosis after radical hysterectomy: a prospective study

One part of the operative procedure of radical hysterectomy (RH) is the dissection of the ureter from its overlying tissue and this may result in injury to the ureteric adventitia. This might induce ureteric obstruction and consequently produce hydronephrosis. The objective of this prospective study was to evaluate the incidence of hydronephrosis after RH in patients with early stage cervical cancer. From July 2006 through March 2007, 77 patients with IA2-IIA cervical cancer who planned to undergo radical hysterectomy and pelvic lymphadenectomy (RHPL) received urinary tract ultrasonography 5 times (one day before surgery and 7 days, 6 weeks, 3 months and 6 months after the operation) from one radiologist. Patients who had hydronephrosis before surgery, suffered intraoperative ureteric injury, or were lost follow-up at 7 days after surgery were excluded from the study. Urinary tract ultrasonography was performed on 77, 55, 52 and 52 patients at each visit. Right hydronephrosis was detected in 16, 7, 5 and 3 patients, and left hydronephrosis in 16, 11, 3 and 1 , at 7 days, 6 weeks, 3 months and 6 months, respectively, after the operation. Hydronephrosis persisted in 8 patients (15%) after 3 months. Two of these had undergone exploratory laparotomy for lysis of ureteral adhesions. One patient who developed hydronephrosis had local recurrence and received further treatment with concurrent chemoradiation therapy. In conclusion, the incidence of persistent hydronephrosis over 3 months after RHPL was 15%, even without intra-operative ureteric injury. However, only a few cases required surgical intervention.

Clinical outcome of the ovarian clear cell carcinoma compared to other epithelial ovarian cancers when treated with paclitaxel and carboplatin

Ovarian clear cell carcinoma (OCCC) has an aggressive histology. Our aim was to evaluate the progression free survival (PFS) of OCCC patients compared to other epithelial histology patients when treated with surgery followed by carboplatin and paclitaxel (PT) regimen. The medical records of them who treated with PT regimen at Chiang Mai University Hospital between January 2004 and December 2008 were reviewed. 67 ovarian clear cell patients were compared to 121 non-clear cell ovarian cancer patients. The mean age of OCCC patients was younger than that of the non-clear cell group (46.7 vs. 51.2 years old, P= 0.001). OCCC patients presented in early stage more often than the non-clear cell group (76.1% vs. 38.0%, P= 0.001). The surgical procedures in both groups were not significantly different. The complete response rates of OCCC patients and other epithelial histology patients were 65.7% and 55.3%, respectively (P= 0.01). With a mean follow-up time of 25 months, the 3-year PFS rates of OCCC and non-clear cell patients in early stages were not significantly different (65.4% vs. 64.2%, P= 0.45). However, in the advanced stage, the 1-year PFS rate of OCCC patients was significantly lower than that of non clear cell patients (6.3% vs. 49.6%, P= 0.001). In conclusion, patients were commonly younger and presented in earlier stages than non-clear cell ovarian cancer patients. In early stages, clear cell ovarian cancer patients had similar outcomes to other epithelial ovarian histology patients, whereas the outcome was very poor in advanced stages.

Successfully conservative treatment of large cervical choriocarcinoma with profuse vaginal bleeding

Primary choriocarcinoma of the uterine cervix is a rare disease. The accurate diagnosis of such a disease is difficult to achieve because of its rarity. Furthermore, the majority of cases presented with abnormal vaginal bleeding that could be caused by other more common conditions including, threatened abortion, cervical polyp, cervical pregnancy, or cervical cancer. In the present report, the authors present a case of large cervical choriocarcinoma with life-threatening vaginal bleeding, which was initially misdiagnosed as a cervical cancer The active cervical bleeding was successfully controlled with selective uterine arterial embolization. Remission of cervical choriocarcinoma was accomplished with combination chemotherapy without the need of hysterectomy.

Outcome of loop electrosurgical excision for HIV-positive women in a low-resource outpatient setting

OBJECTIVE

To assess outcome in HIV-positive women undergoing the loop electrosurgical excision procedure (LEEP).

METHOD

A prospective study was conducted with 789 outpatients undergoing LEEP at Chiang Mai University Hospital between October 2004 and June 2008.

RESULTS

The 70 HIV-positive women (8.9%) were younger (P<0.001) and had a lower parity (P<0.001) than the remaining women. The proportion of women undergoing LEEP for persistent low-grade lesions was higher (8.6% vs 1.9%) and the prevalence of margin involvement was higher (60.0% vs 49.4%) among the HIV-positive women. After adjusting for age, parity, menopausal status, size of excised lesion, and histopathologic result, HIV infection was not significantly associated with LEEP complications (adjusted odds ratio, 0.41; 95% confidence interval, 0.15-1.15).

CONCLUSION

The higher risk of resection margin involvement in HIV-infected women was not associated with LEEP complications.

Clinical relevance of atypical squamous cells of undetermined significance by the 2001 bethesda system: experience from a cervical cancer high incidence region

The aim of this study was to evaluate the underlying lesions and factors predicting cervical intraepithelial neoplasia (CIN) 2+ in women who had 'atypical squamous cells of undetermined significance' (ASC-US) on cervical cytology in the region with a high incidence of cervical cancer. This study was prospectively conducted at Chiang Mai University Hospital, Chiang Mai, Thailand. All women with ASC-US cytology undergoing colposcopic evaluation between October 2004 and August 2008 were recruited. During the study period, 208 women were enrolled. Mean age was 44.4 years. The histopathologic results at the initial evaluation were as follows: CIN 2-3, 21 (10.1%); adenocarcinoma in situ, 3 (1.4%); cancer, 5 (2.4%); CIN 1, 26 (12.5%); and no lesions, 153 (73.6%). Multivariate analysis revealed that nulliparity (adjusted odds ratio [aOR] =4.09; 95% confidence interval [CI] = 1.04-16.10) and current oral contraceptive use (aOR=2.85; 95%CI= 1.14-7.15) were independent predictors for having CIN 2+ at the initial colposcopy. At the median follow-up time of 6.7 months, CIN 2-3 lesions were additionally detected in 2 women. In conclusion, ASC-US cytology in our population has a relatively high prevalence of underlying invasive carcinoma. Nulliparity and current oral contraceptive use are independent predictors for harboring CIN 2+.

Accuracy of intra-operative frozen sections in the diagnosis of ovarian masses

The accuracy of frozen section diagnosis in the intraoperative evaluation of ovarian masses is very important with regard to surgeon selection of appropriated operating procedures. For evaluation in our institute, the records of 127 patients with ovarian masses submitted for intraoperative frozen sections between January 2001 and December 2005 were reviewed. After exclusion of 4 completely infarcted masses and 11 cases with deferred frozen section diagnoses, 112 were analyzed for diagnostic accuracy by comparing with the final histologic results. We found sensitivity in the diagnosis of benign, borderline and malignant tumors to be 100%, 84%, and 92 %, respectively, with specificities of 92.7%, 97.9%, and 100%, respectively. The overall accuracy with frozen sections was 94 %. Among 18 patients with deferred or discordant diagnoses, mucinous tumors accounted for 72 % of cases. No over-diagnosis of malignancy or misdiagnosis of metastatic lesions as primary ovarian cancer by frozen sections was observed. In conclusion, the accuracy of intraoperative frozen section for the diagnosis of ovarian masses is high. Frozen sections also help in the evaluation of metastatic tumors to the ovary. Mucinous tumors constitute an important group causing diagnostic discrepancies.

Outcome of interval debulking in advanced ovarian cancer patients

Interval debulking and neoadjuvant chemotherapy have been used in management of advanced epithelial ovarian cancer for many years in order to achieve optimal residual disease and reduce surgical morbidity. The present study was conducted to evaluate the outcomes of advanced ovarian cancer patients treated with these two approaches prior to cytoreductive surgery in Chiang Mai University Hospital between January 2001 and December 2006. The medical records of 29 patients who met the criteria were retrospectively reviewed. Most had stage IIIC serous cystadenocarcinomas. We found that the 5-year progression free survival and overall survival were 10% and 22% while the median values were 13 months and 34 months, respectively. Multivariate analysis showed that a suboptimal residual tumor volume was a statistically significant adverse prognostic factor for overall survival. In conclusion, interval debulking surgery and neoadjuvant chemotherapy before cytoreductive surgery lead to a more favorable outcome with advanced epithelial ovarian cancers.

Routine prophylactic application of Monsel's solution after loop electrosurgical excision procedure of the cervix: is it necessary?

AIM

To determine the benefit of an immediate application of Monsel's solution after loop electrosurgical excision procedure (LEEP) of the cervix for preventing postoperative bleeding.

METHODS

This randomized controlled trial was conducted at Chiang Mai University Hospital, Chang Mai, Thailand. Women who were scheduled for LEEP were approached for participation in the study. The primary endpoint was the duration of uncomplicated vaginal bleeding. Secondary endpoints were the incidence of persistent vaginal bleeding, and postoperative complications including severe early bleeding, severe delayed bleeding and infection.

RESULTS

Between October 2004 and May 2006, 285 women with an abnormal Pap-smear, who had undergone LEEP, were randomly allocated to the Monsel's group (n = 140) or control group (n = 145). The baseline outcomes were similar between the two groups. In the Monsel's group, the duration of uncomplicated vaginal bleeding was significantly shorter (P < 0.001) and the occurrence of persistent vaginal bleeding was significantly lower (P = 0.014) than in the control group. The occurrence of severe complications that required treatment, including bleeding and infection, was not significantly different between the two groups (P = 0.379).

CONCLUSION

An application of Monsel's solution after LEEP appears to reduce the duration of postoperative vaginal bleeding, but does not significantly prevent severe complications. Such practice may not be necessary if adequate hemostasis is achieved using electrical cauterization.

Epstein-Barr virus–associated smooth muscle tumor presenting as a vulvar mass in an acquired immunodeficiency syndrome patient: a case report

Smooth muscle tumors in immunocompromised patients have a strong association with Epstein-Barr virus (EBV) infection. EBV-associated smooth muscle tumors (EBV-SMT) are considered as a distinct group of smooth muscle tumors with different clinicopathologic features from conventional smooth muscle tumors. A 31-year-old female patient presented with a 2-cm mass at the left labium majus, the clinical diagnosis of which was a Bartholin lesion. She had acquired immunodeficiency syndrome diagnosed 29 months before. Excisional biopsy revealed a cellular tumor composed of round- to spindle-shaped cells with mild to moderate nuclear atypia. The tumor cells were immunoreactive for smooth muscle actin and muscle actin (HHF-35). Evidence of EBV infection was confirmed by in situ hybridization for EBV-encoded small RNA-1. To our knowledge, this is the first case of EBV-SMT presenting as a vulvar mass. EBV-SMT should be included in the differential diagnoses of mesenchymal tumor in patients with immunosuppression and in the differential diagnoses of smooth muscle tumor in uncommon sites, including the vulva.

Cervical intraepithelial neoplasia II-III with endocervical cone margin involvement after cervical loop conization: Is there any predictor for residual disease?

AIM

To determine the clinicopathological predictors for residual disease in women who have had cervical intraepithelial neoplasia (CIN) II-III with endocervical cone margin involvement after loop electrosurgical excision procedure (LEEP).

METHODS

All of the women who had CIN II-III on LEEP specimens with endocervical margin involvement, and underwent subsequent surgical treatment including repeat LEEP or hysterectomy at Chiang Mai University Hospital between May 2003 and June 2006 were reviewed.

RESULTS

During the study period, 85 women who matched the study inclusion were identified. The mean age was 48.6 years. Fifty-two women (61.2%) were postmenopausal. The most common Pap smear before LEEP was high-grade squamous intraepithelial lesion (HSIL) (65.9%), followed by squamous cell carcinoma (21.2%). Twenty-five women (29.4%) had concurrent ectocervical and endocervical cone margin involvement. Residual disease was noted in 44 women (51.8%, 95%CI = 40.7-62.7) of whom six had unrecognized invasive squamous cell carcinoma, while the remaining 38 had CIN II-III. Only extensive endocervical cone margin involvement (3-4 quadrants) was noted as the significantly independent predictor for residual disease (aOR = 14.2, 95% CI = 3.6-55.8; P < 0.001).

CONCLUSION

Extensive endocervical cone margin involvement after LEEP for CIN II-III is a strong predictor for residual disease. Therefore, the number of involved quadrants should be evaluated to plan further management.

Lymphovascular space invasion as a prognostic determinant in uterine cancer

The objective of this study was to evaluate the clinical significance of lymphovascular space invasion (LVSI) in patients with uterine cancer in terms of lymph node metastasis, recurrence and survival rate. A total of 190 patients with newly diagnosed uterine cancer who underwent total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), omentectomy, peritoneal washing or ascitic fluid collection, and pelvic/paraaortic lymph node sampling at Chiang Mai University Hospital between January 1999 and December 2004 were evaluated. All medical records and histopathologic slides were retrospectively reviewed to determine the relationship between LVSI and clinicopathological characteristics. LVSI was present in 79 patients (42%) and significantly correlated with lymph node metastasis (p0.001), BMI 25 kg/m2 (p0.001), advanced FIGO stage (p 0.001), poor histologic grade (p0.001), and deep uterine invasion (p0.001). Patients with LVSI, when stratified by FIGO stage, also had a significant lower 5-year survival rate. For those who had disease recurrence, LVSI and histologic grade were found to be independent prognostic factors in a multivariate analysis. LVSI was one of the prognostic determinants for disease recurrence and associated with poor survival in patients with uterine cancer.

Appropriate interval for repeat excision in women undergoing prior loop electrosurgical excision procedure for cervical neoplasia

The objective of the present study was to evaluate the impact of intervals on complications and pathological examination in women undergoing a repeat loop electrosurgical excision procedure (LEEP) for cervical neoplasia. During October 2004 and January 2007, 78 women who had undergone repeat LEEP at Chiang Mai University Hospital, were prospectively evaluated. The mean age was 47.5 years (range; 27-69 years). The mean duration of uncomplicated vaginal bleeding was 4.4 days (range; 1-20 days). The occurrence of persistent vaginal bleeding was noted in 9 women. Among 78 women, 2 (2.56%) and 7 (8.97%) experienced intraoperative and postoperative hemorrhage, respectively. Six (7.69%) had postoperative infection. These complications were not significantly different from those observed in women undergoing first LEEP in the same period (P=0.56). There was no significant difference in the incidence of perioperative complications and the incidence of non-evaluable cone margins among women who undergoing repeat LEEP within 4-6 weeks, between 6-8 weeks, and more than 8 weeks after first LEEP. In conclusion, repeat LEEP could be safely performed 4-12 weeks after the first procedure without any impact on pathological specimen examination.

Factors affecting residual lesion in women with cervical adenocarcinoma in situ after cone excisional biopsy

The objective of this study was undertaken to evaluate the factors affecting residual lesion in women with adenocarcinoma in situ (AIS) on cervical conization specimens. The medical records of women with AIS who had no associated invasive carcinoma after cervical conization and underwent subsequent hysterectomy at Chiang Mai University Hospital were reviewed. During March 1998 and March 2006, 45 women were included for analysis. The mean age was 45.2 years (range, 30-66 years). Thirteen (28.9%) women presented with AIS on Pap smear. Thirty (66.7%) underwent loop electrosurgical excision procedure and the remaining 15 (33.3%) underwent cold-knife conization. Twenty (44.4%) women had mixed lesions of AIS and squamous intraepithelial lesion on cervical specimens. Surgical cone margins were clear in 25 (55.6%) women. Eighteen (40%) and two (4.4%) women had involved and non-evaluable cone margins, respectively. Residual lesion was noted in 14 (31.1%) hysterectomy specimens. There was no residual lesion in women with clear cone margins while 72% and 50% of women with involved and non-evaluable cone margins, had residual lesion, respectively. These differences were statistically significant (P<0.001). No significant association between the ECC results and the residual lesion was noted (P=0.29). In conclusion, approximately one-third of women with AIS on cervical conization have residual lesion on subsequent hysterectomy specimens. Only cone margin status is a significant predictor for residual lesion.

Outcomes of loop electrosurgical excision procedure for cervical neoplasia in human immunodeficiency virus-infected women

The objective of this study was to evaluate the treatment outcomes and complications in human immunodeficiency virus (HIV)-infected women undergoing loop electrosurgical excision procedure (LEEP) for cervical neoplasia. The medical record of 60 evaluable HIV-infected women who had abnormal Papanicolaou (Pap) smear and underwent LEEP following colposcopy at Chiang Mai University Hospital between May 1998 and June 2004 was reviewed. Thirty-one (51.7%) had associated genital infection at screening. Twenty-five (41.7%) had opportunistic infection, but only 18 (30.0%) were treated with antiretroviral therapy. The most common abnormal Pap smear was high-grade squamous intraepithelial lesion (46.7%), followed by low-grade squamous intraepithelial lesion (40.0%). Forty (66.7%) women had clear surgical margins after LEEP. Only one (1.7%) woman had severe intraoperative hemorrhage. Early and late postoperative hemorrhage were noted in three (5%) women of each period. Localized infection of the cervix was detected in seven (11.7%) women. Two (3.3%) women developed cervical stenosis at 6 months after LEEP. There was no significant difference in overall complications between HIV-infected women and the control group (P= 0.24). Among 60 HIV-infected women, no statistical difference in the rate of margins involvement (P= 1.00) and complications (P= 0.85) could be demonstrated between HIV-infected women who received antiretroviral therapy and those who did not. Disease-free rate at 6 and 12 months were 97.1% and 88%, respectively. These data demonstrated that LEEP appears to be safe and effective in HIV-infected women.