The fluorescence imaging for laparoscopic and laparotomic endometrial sentinel lymph node biopsy (FILLES) trial: Siriraj gynecologic sentinel node of endometrial cancer (SiGN-En) study

BACKGROUND AND OBJECTIVES

The objective of this study is to establish the detection rate of sentinel lymph node (SLN) biopsies and to determine the sensitivity and false-negative rate of SLN biopsies compared with those of systematic pelvic and para-aortic lymphadenectomies in endometrial cancer.

METHODS

This prospective cohort study enrolled patients with endometrial cancer who were scheduled for surgical staging. Patients with a history of chemotherapy or radiotherapy, an abnormal liver function test, or an allergy to indocyanine green (ICG) were excluded. All patients underwent surgical staging with an ICG injection at the cervix. SLNs were identified by a near-infrared fluorescent camera. All SLNs were sent to a pathologist for ultrastaging.

RESULTS

From November 2019 to June 2023, 142 patients underwent SLN mapping and surgical staging. SLNs were not detected bilaterally in 8 patients. The detection rate of the SLN biopsies in this study was 91.2%. Thus, the accuracy of the SLN biopsies was 97.6%. The sensitivity for finding metastatic SLNs was 84.2%, with a negative predictive value of 97.22%.

CONCLUSIONS

A SLN biopsy in endometrial cancer has a high detection rate and high accuracy. However, surgical expertise and a learning curve are required.

Prevalence of Abnormal Anal Cytology in Women with Abnormal Cervical Cytology

OBJECTIVE

The aim of this study was to evaluate the prevalence of abnormal anal cytology in women presenting with abnormal cervical cytology (intraepithelial lesion or cervical cancer) at the largest tertiary university hospital in Thailand.

METHODS

A cross-sectional prospective study design was used. Anal cytology was performed on 145 women with abnormal cervical cytology between June 2014-Octoble 2014. If abnormal anal cytology was detected, anoscopy was performed with biopsy in any suspicious area of precancerous change.

RESULTS

Prevalence of abnormal anal cytology was 5.5% (8 patients). Of 8 patients, six patients presented with low-grade squamous intraepithelial lesion, one patient with high-grade squamous intraepithelial lesion, and one with atypical squamous cell cannot exclude high-grade squamous intraepithelial lesion. Abnormal anoscopic impression was found in 3 cases, as follow: The first case showed faint acetowhite lesion and anoscopic impression was low grade squamous intraepithelial lesion; the second case was reported as human papillomavirus (HPV) change by anoscopic impression; and the third case showed dense acetowhite lesion with multiple punctation and pathologic examination showed anal intraepithelial neoplasm III (AIN3). The last patient underwent wide local excision of AIN3 with split-thickness skin graft reconstruction. Final pathology confirmed AIN3 with free resection margin.

CONCLUSION

Prevalence of abnormal anal cytology was 5.5%  in patients with abnormal cervical cytology. The prevalence might be support anal cytology screening in this group of patients.

Comparison of oncologic outcomes of unanticipated cervical carcinoma in women undergoing inadvertent simple hysterectomy and those undergoing surgical treatment after preoperative diagnosis

OBJECTIVES

To determine the proportion of women with undiagnosed cervical carcinoma before simple hysterectomy and its causes and to compare the oncologic outcomes of women diagnosed and treated with standard therapy to those undergoing inadvertent simple hysterectomy with subsequent treatment.

METHODS

Medical records were reviewed for patients with cervical carcinoma who underwent hysterectomy between 1 January 2004 and 31 December 2014. Demographic data, chemotherapeutic agents, and response rates were analyzed using descriptive statistics. The categorical variables were compared using chi-square or Fisher's exact test. The continuous data were compared using the independent t-test and Mann-Whitney test, as appropriate. The Kaplan-Meier method was used to evaluate the survival outcomes.

RESULTS

Of the 526 patients with cervical carcinoma who underwent hysterectomy, 57 patients (10.8%) were diagnosed with cervical carcinoma after simple hysterectomy. After excluding 121 patients with invasion of <3 mm and without lymphovascular space invasion (LVSI), 353 patients were preoperatively diagnosed with cervical carcinoma stage IA1 with LVSI to IIA and underwent proper surgical treatment. Fifty-two patients were encountered for inadvertent hysterectomy. Forty-four of 52 patients in the inadvertent hysterectomy group consented to subsequent treatment, with 43 patients receiving concurrent chemoradiotherapy and one undergoing additional surgery. The median time before subsequent treatment initiation was 1.6 months [0.5-9.2 months]. The 5-year DFS rates of the standard surgical treatment group and inadvertent hysterectomy group were 88.4% vs. 93.2%, respectively (P = 0.147). The 5-year OS rates of the standard surgical treatment group and the inadvertent hysterectomy group were 98.9% vs. 100%, respectively (P = 0.767).

CONCLUSIONS

Women with cervical carcinoma who had small tumors and underwent inadvertent simple hysterectomy with appropriate consequent management had oncologic outcomes comparable to those in the standard surgical treatment group.

Spontaneous Regression Rate of Low Grade Cervical Intraepithelial Lesions Diagnosed from Colposcopy

Objective: To evaluate the spontaneous regression rate and its associated factors of low grade intraepithelial lesionsafter colposcopy in Thai women.Material and Methods: A retrospective study of the data of Thai women, not younger than 21 years old with liquidbased cervical cytology of atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL), who had received colposcopic examination with histologically proven cervical intraepithelial neoplasia grade 1 (CIN1) or human papillomavirus (HPV) infection. All patients underwent cytologic tests as the follow-up method for at least 2 years at the Gynecology Clinic, Siriraj Hospital. Analyzed data included patient characteristics, cervical cytological and pathological results, colposcopic findings and evidence of cytological regression. The correlations between each variable and regression status were then measured.Results: Data of a total of 154 patients who completed 2 years of follow-up were reviewed. One hundred and two patients had cytologic regression, showing a regression rate of 66.2%. There was 31.8% persistent abnormal cytology, and 2.0% progressed to high-grade cervical intraepithelial lesions. All patients with persistence or progression of cervical cytology had no invasive lesion. The only factor significantly related to cytologic regression was the pattern of colposcopic findings (p-value=0.041). The HPV-specific lesion on the colposcopy showed the significant pattern with an odds ratio of 3.5 (95% confidence interval=1.2-10.1, p-value=0.028).Conclusion: Women who had initial cervical cytology of ASC-US or LSIL with colposcopic histological confirmation of CIN1 or HPV infection had spontaneous regression, about two-thirds within 2 years of follow-up time. Thus, conservative management in these patients should be considered.

Comparison of Siriraj liquid-based solution and standard transport media for the detection of high-risk human papillomavirus in cervical specimens

PURPOSE

To evaluate the performance of Siriraj liquid-based solution for human papillomavirus (HPV) DNA testing compared with standard transport media.

METHODS

This cross-sectional study enrolled 217 women aged 30 years or older who attended for cervical cancer screening or had abnormal cervical cytology, or were diagnosed with cervical cancer at the Department of Obstetrics-Gynecology, Siriraj Hospital from March 2015 to January 2016. We excluded patients with a history of any cervical procedures, hysterectomy, or previous treatment with pelvic irradiation or chemotherapy. Two cervical specimens were collected from each participant. The standard Cervi-Collect Specimen Collection Kit was used to preserve the first sample, and Siriraj liquid-based solution was used for the second one. All samples were sent for HPV DNA testing using the same standard high-risk HPV assay. HPV test results were recorded and statistically analyzed.

RESULTS

The results showed agreement between standard transport media and Siriraj liquid-based solution for HPV DNA testing, at a kappa value of 0.935 (P < 0.001). We found no discorrelation for the detection of HPV 16, which accounts for approximately 50% of cervical cancers. The relative sensitivity of Siriraj liquid-based solution and standard transport media in patients with high-grade cervical intraepithelial neoplasia or worse (CIN2+) is 98% (50/51). The relative specificity of Siriraj liquid-based solution and standard transport media in patients with non-CIN2+ is 98.1% (102/104).

CONCLUSION

Siriraj liquid-based solution showed almost perfect agreement with the standard transport media for HPV DNA testing. This solution, costing 2 to 3 times less than the commercially available standard media, may be an alternative option for HPV DNA testing.

Agreement between colposcopic diagnosis and cervical pathology: Siriraj hospital experience

AIM

To evaluate the agreement between colposcopic diagnosis and cervical pathology a retrospective chart review was performed.

MATERIALS AND METHODS

This study included 437 patients who underwent colposcopy and cervical biopsy or conization at Siriraj Hospital from October 2010 - December 2012. The patient clinical characteristics, cervical cytology results, colposcopic diagnoses, cervical pathology results were recorded and correlations between variables were analyzed.

RESULTS

Agreement of colposcopic diagnosis and cervical pathology was matched in 253 patients (57.9%). The strength of agreement with weighted Kappa statistic was 0.494 (p<0.001). Colposcopic diagnoses more often overestimated (31.1%) than underestimated (11%) the cervical pathology. Agreement of colposcopic diagnosis and cervical pathology within 1 grade was found in 411 patients (94.1%). Positive predictive value (PPV) of high grade colposcopy or more was 75.5%, whereas the negative predictive value (NPV) of insignificant and low grade colposcopy was 83.8%. False positives of high grade colposcopy or more were 21%. False negatives of insignificant or low grade colposcopy were 19.1%.

CONCLUSIONS

Strength of agreement between colposcopic diagnosis and cervical pathology was found to be only moderate. A biopsy at colposcopy should be performed at a gold standard level to detect high grade lesions.

Cervical adenoid basal carcinoma associated with invasive squamous cell carcinoma: a report of rare co-existence and review of literature

Cervical adenoid basal carcinoma (ABC) rarely can harbor associated malignancies like adenoid cystic carcinoma or squamous cell carcinoma (SCC), which express markedly different prognosis from a pure ABC, making an appropriate biopsy essential to provide a clear diagnosis and therapeutic plan. We report a 64-year-old asymptomatic lady with an abnormal cervical cytology, who underwent a conization to reveal an ABC with overlying microinvasive SCC. Doubtful resection margins led us to perform radical hysterectomy with lymph node dissection. Subsequent pathological examination showed a true invasive SCC co-existing with ABC, with invasion of the parametrium. Unlike the indolent course of many pure ABC patients, the prognosis of 11 previously reported co-existing invasive SCC with ABC patients appears to depend on the SCC component. Our case reiterates the importance of adequate biopsy with careful interpretation to cover the possibility of a co-existent malignancy. Besides, it presents an argument in favor of radical surgery for the primary treatment of suspicious associated malignancy, and supports adjuvant treatment according to the unfavorable extent of the co-existent invasive carcinoma.

Meigs' Syndrome with Elevated Serum CA125: Case Report and Review of the Literature

An elevated serum CA125 level in association with a pelvic mass, pleural effusion, and massive ascites usually signifies a dismal prognosis in a postmenopausal woman. However, surgery and histopathological examination are required for the correct diagnosis and treatment, since an elevated CA125 level can be falsely positive for ovarian malignancy. We present a case of Meigs’ syndrome due to right ovarian fibroma with elevated CA125 level in a postmenopausal woman.