Cervical Neoplasia

Human papillomavirus (HPV) in pregnancy - An update

Human papilloma viruses (HPV) are small epitheliotropic DNA viruses, of which there are 200 genotypes, 40 of which are known to cause genital infections and are also oncogenic. HPV is the most common sexually transmitted infection. Clinical features vary from asymptomatic (identified at routine cervical cancer screening) to large lesions on the vulva, vagina, cervix and some extragenital sites. Its prevalence in pregnancy varies from 5.5% to 65% depending on age, geography and gestational age (increasing with gestational age). Infection in pregnancy has been associated with adverse outcomes such as spontaneous miscarriage, preterm birth, placental abnormalities and fetal growth restriction. However, the evidence for these adverse outcomes is varied. Besides being oncogenic (and thus associated with cancer of the cervix in pregnancy), vertical transmission to the fetus/neonate can cause neonatal infections, especially juvenile-onset recurrent oral and respiratory papillomatosis (JORRP). Where there are very large lesions on the vulva, delivery may be obstructed. Diagnosis in pregnancy is mainly by viral PCR or from the clinical appearance of the characteristic lesions on the vulva. Treatment is local by either surgical or laser excision or application of trichloroacetic acid. Podophyllin/podophyllotoxin is contraindicated in pregnancy. HPV Infection is not an indication for caesarean delivery as this has not been shown to prevent vertical transmission. For those diagnosed at routine cervical cancer screening, management should follow guidelines for cervical cancer screening in pregnancy. Vaccination is currently not recommended for pregnant women, although studies on those inadvertently vaccinated in pregnancy have not shown any adverse effects on either the fetus or mother.

Four categories of LEEP for CIN of various areas: a retrospective cohort study

PURPOSE

To compare the effectiveness and safety of loop electrosurgical excision procedures (LEEP) with four different excisions in treating cervical intraepithelial neoplasia (CIN) of different areas.

METHODS

Four hundred and sixty-six cases of CIN were treated with different types of LEEP. Following visual inspection with acetic acid and Lugol's iodine, LEEP were performed to excise the transformation zone to a 20-25 mm depth with a 2-3 mm margin. Four categories of procedures are described below: (i) LEEP-A for lesion ≥2/3 of cervical area: conization of ≥2/3 of cervical tissue. (ii) LEEP-B for ≥1/3 but <2/3: conization of 1/3 to <2/3. (iii) LEEP-C for <1/3: conization of <1/3. (iv) LEEP-D: endocervical canal resection.

RESULTS

The cases included 108 of CIN I, 232 of CIN II, and 106 of CIN III (not including carcinoma in situ) patients. No positive margin was found in any specimens. The cure rates for LEEP-A, B, C, and D were 99.1%, 98.5%, 100.0%, and 93.2%, respectively (p > .05). The pregnancy rate at two years after LEEP was significantly higher in groups C and D compared to group A (p < .05).

CONCLUSIONS

Four categories of LEEP are highly effective in the treatment of CIN when appropriately applied. However, large loop excision may lead to adverse obstetric outcomes in pregnancy.

Obstetrical prognosis of patients with cervical intraepithelial neoplasia (CIN) after "coin-shaped" conization

PURPOSE

Uterine cervical conization is related to adverse pregnancy outcomes in subsequent pregnancies. To deal with this problem, we started conservative coin-shaped conization for reproductive-aged patients with cervical intraepithelial neoplasia (CIN). Here we report both the obstetrical and oncological impacts of this operation in comparison with the standard cone-shaped resection.

METHODS

A total of 401 women 44 years old or younger were treated in our hospital by CO2 laser conization between 2003 and 2012, and subsequently 50 patients became pregnant. The patients were divided into two groups, a standard cone-shaped conization group (until 2008) and a shallow coin-shaped conization group (beginning in 2008). The pregnancy courses and oncological prognoses of these two groups were studied.

RESULTS

Cone height reduction of about 3 mm was done. However, there were no significant differences between the two groups with regard to the occurrence of oncological complications. In the standard conization group, 18 of the 25 patients delivered at term. In the coin-shaped conization group, 20 of the 25 patients delivered at term. There were no significant differences between the two groups with regard to the occurrence of various obstetrical complications. However, the reduction rate of cervical length over the pregnancy was smaller in the coin-shaped group and the number of patients with a short cervix length of 2 cm or less was smaller in the coin-shaped group.

CONCLUSIONS

Although conservative coin-shaped conization did not markedly improve the obstetrical prognosis, this operative procedure improved the reduction rate of uterine cervical length over the pregnancy without any increase in oncological complications.

Diagnostic imaging of cervical intraepithelial neoplasia based on hematoxylin and eosin fluorescence

Background

Pathological classification of cervical intraepithelial neoplasia (CIN) is problematic as it relies on subjective criteria. We developed an imaging method that uses spectroscopy to assess the fluorescent intensity of cervical biopsies derived directly from hematoxylin and eosin (H&E) stained tissues.

Methods

Archived H&E slides were identified containing normal cervical tissue, CIN I, and CIN III cases, from a Community Hospital and an Academic Medical Center. Cases were obtained by consensus review of at least 2 senior pathologists. Images from H&E slides were captured first with bright field illumination and then with fluorescent illumination. We used a Zeiss Axio Observer Z1 microscope and an AxioVision 4.6.3-AP1 camera at excitation wavelength of 450–490 nm with emission captured at 515–565 nm. The 32-bit grayscale fluorescence images were used for image analysis.

Results

We reviewed 108 slides: 46 normal, 33 CIN I and 29 CIN III. Fluorescent intensity increased progressively in normal epithelial tissue as cells matured and advanced from the basal to superficial regions of the epithelium. In CIN I cases this change was less prominent as compared to normal. In high grade CIN lesions, there was a slight or no increase in fluorescent intensity. All groups examined were statistically different.

Conclusion

Presently, there are no markers to help in classification of CIN I-III lesions. Our imaging method may complement standard H&E pathological review and provide objective criteria to support the CIN diagnosis.

High-grade squamous intraepithelial lesions in pregnant and non-pregnant women

OBJECTIVES

To evaluate if the prevalence of cervical smear results varies between pregnant and non-pregnant women stratified by age group.

STUDY DESIGN

Observational analytical study with a total sample of 1,336,180 pregnant and non-pregnant women, aged between 20 and 34 years, who underwent cervical cancer screening in the Primary Health Care of the national health system in the area of Campinas in Brazil during the period of 2005-2009. The source is the information system for cervical cancer screening. Data collected on abnormal cervical smears were analyzed using the Chi-square test and Fisher's exact test and the magnitude of the association between pregnancy and high-grade squamous epithelial lesions was analyzed by odds ratio (OR) and estimated values with confidence intervals (CI) of 95%.

RESULTS

15,190 pregnant women and 395,961 non-pregnant women were analyzed and fulfilled the inclusion criteria. Regardless of age, no statistical differences were observed for high-grade squamous intraepithelial lesion prevalence (OR 0.90; CI 0.66-1.23). Taking into account the five-year age groups, however, low-grade squamous intraepithelial lesion was less prevalent in pregnant women aged 20-24 (OR 0.71; 0.54-0.95) and 25-29 years (OR 0.56; 0.35-0.89); also, atypical squamous cells of undetermined significance was more prevalent in non-pregnant women aged 25-29 years (OR 0.72; 0.54-0.97).

CONCLUSION

The study showed that the cytological prevalence of high-grade squamous intraepithelial lesion was similar in pregnant and non-pregnant women, regardless of age. The results indicate that there are no reasons for specific approaches to cervical cancer screening for pregnant women. The examination should be carried out only on pregnant women who have not been tested according to current recommendations.