2019 ASCCP Risk-Based Management Consensus Guidelines: Updates Through 2023

ABSTRACT

This Research Letter summarizes all updates to the 2019 Guidelines through September 2023, including: endorsement of the 2021 Opportunistic Infections guidelines for HIV+ or immunosuppressed patients; clarification of use of human papillomavirus testing alone for patients undergoing observation for cervical intraepithelial neoplasia 2; revision of unsatisfactory cytology management; clarification that 2012 guidelines should be followed for patients aged 25 years and older screened with cytology only; management of patients for whom colposcopy was recommended but not completed; clarification that after treatment for cervical intraepithelial neoplasia 2+, 3 negative human papillomavirus tests or cotests at 6, 18, and 30 months are recommended before the patient can return to a 3-year testing interval; and clarification of postcolposcopy management of minimally abnormal results.

Cervical Cancer Screening: A Review

Importance

Each year in the US, approximately 100 000 people are treated for cervical precancer, 14 000 people are diagnosed with cervical cancer, and 4000 die of cervical cancer.

Observations

Essentially all cervical cancers worldwide are caused by persistent infections with one of 13 carcinogenic human papillomavirus (HPV) genotypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. HPV vaccination at ages 9 through 12 years will likely prevent more than 90% of cervical precancers and cancers. In people with a cervix aged 21 through 65 years, cervical cancer is prevented by screening for and treating cervical precancer, defined as high-grade squamous intraepithelial lesions of the cervix. High-grade lesions can progress to cervical cancer if not treated. Cervicovaginal HPV testing is 90% sensitive for detecting precancer. In the general population, the risk of precancer is less than 0.15% over 5 years following a negative HPV test result. Among people with a positive HPV test result, a combination of HPV genotyping and cervical cytology (Papanicolaou testing) can identify the risk of precancer. For people with current precancer risks of less than 4%, repeat HPV testing is recommended in 1, 3, or 5 years depending on 5-year precancer risk. For people with current precancer risks of 4% through 24%, such as those with low-grade cytology test results (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesion [LSIL]) and a positive HPV test of unknown duration, colposcopy is recommended. For patients with precancer risks of less than 25% (eg, cervical intraepithelial neoplasia grade 1 [CIN1] or histologic LSIL), treatment-related adverse effects, including possible association with preterm labor, can be reduced by repeating colposcopy to monitor for precancer and avoiding excisional treatment. For patients with current precancer risks of 25% through 59% (eg, high-grade cytology results of ASC cannot exclude high-grade lesion [ASC-H] or high-grade squamous intraepithelial lesion [HSIL] with positive HPV test results), management consists of colposcopy with biopsy or excisional treatment. For those with current precancer risks of 60% or more, such as patients with HPV-16-positive HSIL, proceeding directly to excisional treatment is preferred, but performing a colposcopy first to confirm the need for excisional treatment is acceptable. Clinical decision support tools can facilitate correct management.

Conclusions and Relevance

Approximately 100 000 people are treated for cervical precancer each year in the US to prevent cervical cancer. People with a cervix should be screened with HPV testing, and if HPV-positive, genotyping and cytology testing should be performed to assess the risk of cervical precancer and determine the need for colposcopy or treatment. HPV vaccination in adolescence will likely prevent more than 90% of cervical precancers and cancers.

Use of Uterine Characteristics to Improve Fertility-Sparing Diagnosis of Adenomyosis

Objective: To describe patient demographics, determine accuracy of clinical diagnosis, and evaluate reliability of laparoscopic uterine characteristics in the diagnosis of adenomyosis. Materials and Methods: Enrollment included 117 patients undergoing laparoscopic hysterectomy for benign indications. Intraoperatively, the attending surgeon predicted uterine weight; evaluated the presence of fibroids; and commented on the uterus' shape, color, and consistency while probing it with a blunt instrument. A prediction was also made about whether final pathology would reveal adenomyosis. Standardized video recordings were obtained at the start of the case. Each video was viewed retrospectively twice by three expert surgeons in a blinded fashion. Uterine characteristics were reported again with a prediction of whether or not there would be a pathologic diagnosis of adenomyosis. These data were used to calculate inter-and intrarater reliability of diagnosis. Results: Women with adenomyosis were more likely to complain of midline pain as opposed to lateral or diffuse pain (p = 0.048) with no difference in the timing of the pain (p = 0.404), compared to patients without adenomyosis. Uterine tenderness on examination was not an accurate predictor of adenomyosis (p = 0.566). Preoperative diagnosis of adenomyosis by clinicians was poor, with an accuracy rate of 51.7%. None of the intraoperative uterine characteristics were significant for predicting adenomyosis on final pathology, nor was any combination of the features (p = 0.546). Retrospective video reviews failed to reveal any uterine characteristics that generated consistent inter- or intrarater reliability (Krippendorff's α < 0.7) in making the diagnosis of adenomyosis. Conclusions: Clinical and video diagnosis of adenomyosis have low accuracy with no uterine characteristics consistently or reliably predicting adenomyosis on final pathology. (J GYNECOL SURG 34:183).

Uterine-sparing Laparoscopic Resection of Accessory Cavitated Uterine Masses

STUDY OBJECTIVE

To demonstrate surgical techniques utilized during uterine-sparing laparoscopic resections of accessory cavitated uterine masses (ACUMs). ACUMs represent a rare uterine entity observed in premenopausal women suffering from dysmenorrhea and recurrent pelvic pain. The diagnosis is made when an isolated extra-cavitated uterine mass is resected from an otherwise normal appearing uterus with unremarkable endometrial lumen and adnexal structures. Pathologic confirmation requires an accessory cavity lined with endometrial epithelium (and corresponding glands and stroma) filled with chocolate-brown fluid. Adenomyosis must be absent. Although the origin of ACUMs is currently unknown, the most common presentation is a 2-4 cm lateral uterine wall mass at the level of the insertion of the round ligament. Hence it has been hypothesized that gubernaculum dysfunction may be responsible for duplication or persistence of paramesonephric tissue leading to ACUM formation as a new Müllerian anomaly.

DESIGN

A stepwise surgical tutorial describing 2 laparoscopic ACUM resections using a narrated video (Canadian Task Force classification III).

SETTING

An academic tertiary care hospital.

PATIENTS

In this video, we present 2 patients who underwent uterine-sparing laparoscopic resections of their ACUM in order to preserve fertility (Case 1) or avoid the complications and surgical recovery time of a total laparoscopic hysterectomy (Case 2). Case 1 is a 19-year-old, gravida 0, para 0 woman with dysmenorrhea and recurrent pelvic pain who presented for multiple emergency room and outpatient evaluations. Transvaginal ultrasonography was unremarkable except for a 28×30×26mm left lateral uterine mass with peripheral vascular flow that was initially felt to be a leiomyoma or rudimentary uterine horn. MRI imaging, however, demonstrated this mass to be more consistent with an ACUM. This was based on the lack of communication between the lesion and the main uterine cavity exhibited by high T2 signal (compatible with endometrial tissue) surrounding low T2/high T1 signal in the dependent aspects (representing blood products). After counseling regarding treatment options including medical management with hormonal contraception, the patient elected for definitive fertility preserving laparoscopic resection. In contrast, case 2 is a 39-year-old, gravida 3, para 3 woman with a 2 month history or left lower quadrant pain following her last vaginal delivery. Transvaginal ultrasonography showed a 23×18×19mm cystic structure within the left uterine wall, which was confirmed to represent an ACUM on MRI. Although she had no desire for fertility preservation, the patient elected for surgical resection of the mass as opposed to a hysterectomy in order to minimize complications and recovery time.

INTERVENTIONS

Laparoscopic resection of ACUMs in patients desiring uterine preservation.

MEASUREMENTS AND MAIN RESULTS

Laparoscopic resection of the ACUMs was performed utilizing 2 different techniques. In both cases, dilute vasopressin was injected with a modified butterfly or spinal needle along the uterine-ACUM serosal interphase to aid with hemostasis. In patients desiring to preserve fertility (case 1) monopolar energy is utilized to make an incision along the ACUM serosa to help facilitate dissection. ACUM enucleation is then commenced in a circumferential manner along the ACUM and uterine myometrial interphase utilizing bipolar energy. In contrast to leiomyomas where dissection advances along the pseudocapsule, ACUM have poorly delineated borders with disorganized muscular fibers making dissection particularly difficult. A variety of instruments can be utilized to help in the sequential circumferential dissection in addition to a bipolar device including a single-tooth tenaculum, myoma hook, suction device or fine-needle grasper. Ultimately, the ACUM is transected off its uterine-myometrial attachment and hemostasis is obtain before closing the uterine defect in at least 2 layers using a 2-0 barbed V-Loc (Medtronic, Minneapolis, MN). If fertility preservation is no longer desired, the dissection can greatly be expedited by performing a salpingectomy and skeletonizing the ACUM from the leaves of the broad ligament (case 2). A monopolar L-hook can then be used to transect the ACUM from the remaining uterine body. While difficult, these cases can be completed laparoscopically in approximately 2 hours with minimal blood loss.

CONCLUSIONS

ACUMs are hypothesized to represent a previously under recognized Müllerian anomaly linked to gubernaculum dysfunction that occurs in premenopausal women with dysmenorrhea and chronic pelvic pain. Uterine and fertility sparing laparoscopic resection is possible but challenging due to poorly defined planes.

Radiofrequency volumetric thermal ablation of fibroids: a prospective, clinical analysis of two years' outcome from the Halt trial

BACKGROUND

Although most myomas are asymptomatic, quality of life is compromised for many women with uterine fibroid disease. Twelve-month outcomes from the Halt Trial have been reported in the literature. Here we analyze the clinical success of radiofrequency volumetric thermal ablation (RFVTA) of symptomatic uterine fibroids at two years of follow up.

METHODS

Prospective, multicenter, outpatient interventional clinical trial of fibroid treatment by RFVTA in 124 premenopausal women (mean age, 42.4 ± 4.4 years) with symptomatic uterine fibroids and objectively confirmed heavy menstrual bleeding (≥160 to ≤500 mL).Outcome measures included: subject responses to validated questionnaires, treatment-emergent adverse events, and surgical re-intervention for fibroids at 24 months postprocedure. Continuous and categorical variables were summarized using descriptive statistics and means and percentages. Comparisons between visits were based on t-tests using repeated measures models. P-values < 0.05, adjusted for multiplicity, were statistically significant.

RESULTS

One hundred twelve subjects were followed through 24 months. Change in symptom severity from baseline was -35.7 (95% CI, -40.1 to -31.4; p<.001). Change in health-related quality of life (HRQL) was 40.9 (95% CI, 36.2 to 45.6; p < .001). HRQL subscores also improved significantly from baseline to 24 months in all categories (concern, activities, energy/mood, control, self-consciousness, and sexual function) [p<.001]. Six patients underwent surgical re-intervention for fibroid-related bleeding between 12 and 24 months providing a re-intervention rate of 4.8% (6/124).

CONCLUSION

Radiofrequency volumetric thermal ablation of myomas significantly reduces symptom severity and improves quality of life with low surgical re-intervention through 24 months of follow up.

Cervical dysplasia in pregnancy: a multi-institutional evaluation

OBJECTIVE

This study was undertaken to identify the prognostic indicators associated with postpartum regression of cervical dysplasia diagnosed in pregnancy.

STUDY DESIGN

A retrospective cohort study of pregnant women referred for colposcopy from 2004-2007 at four academic centers.

RESULTS

One thousand seventy-nine patients were identified. Colposcopic impression by cervical cytology is detailed later in the text. Of patients who underwent biopsy, results correlated with or were less severe than colposcopic impression in 83% with CIN 1 and 56% with CIN 2/3. Fifty-seven percent had follow-up postpartum, with 61% reverting to normal. Resolution of cervical dysplasia was inversely associated with smoking (P = .002). No progression to cancer occurred during pregnancy.

CONCLUSION

Colposcopic impression in pregnancy correlated with cervical biopsy results and postpartum colposcopic findings when performed by expert colposcopists. A high proportion of cervical dysplasia regressed postpartum. Cervical biopsies in pregnancy may not be necessary unless invasive cancer is suspected.

Laparoscopic management of vaginal evisceration: case report and review of the literature

Vaginal evisceration is a rare condition that presents with protruding mass, vaginal bleeding, and pelvic pain. Vaginal evisceration is most commonly associated with previous vaginal surgery but may occur spontaneously, and represents a surgical emergency. We report a case of vaginal evisceration in a 42-year-old premenopausal woman 6 months after hysterectomy. This case shows the value of laparoscopy in management of vaginal evisceration.

Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies

STUDY OBJECTIVE

The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences.

DESIGN

Observational case series (Canadian Task Force classification II-3).

SETTING

Large, urban, university teaching hospital.

PATIENTS

All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed.

INTERVENTIONS

Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate.

MEASUREMENTS AND MAIN RESULTS

From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH.

CONCLUSIONS

Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.

A 14-Week Abdominal Pregnancy After Total Abdominal Hysterectomy

BACKGROUND

Pregnancy after hysterectomy is rare. Because this clinical phenomenon is so uncommon, the diagnosis is not always considered in the evaluation of pain in a reproductive-aged woman after hysterectomy. Delay in diagnosis can result in potentially catastrophic intra-abdominal bleeding.

CASE

A 31-year-old multigravida underwent a total abdominal hysterectomy for menometrorrhagia. She experienced several weeks of postoperative abdominal pain and ultimately was diagnosed with a 14-week size intra-abdominal pregnancy. Surgical evacuation of the fetus and products of conception were complicated by significant intra- operative bleeding.

CONCLUSION

In reproductive-aged women undergoing hysterectomy, it is vital to obtain preoperative urine hCG levels immediately before surgery and to consider ectopic pregnancy in the differential diagnosis of these women when severe or persistent abdominal pain occurs postoperatively.

Colposcopically obtained images of vulvar, vaginal, and cervical epithelium for assessment of safety of intravaginal agents among normal adolescent females: comparison with in vivo exam and interobserver agreement

OBJECTIVES

This study was designed to assess identification of epithelial abnormalities of both in vivo examination as compared with colposcopically obtained images and interobserver assessment of the same images of the lower genital tract in healthy women.

MATERIALS AND METHODS

Ninety women between the ages of 14 and 21 years were recruited for a phase II trial of a vaginal Lactobacillus crispatus capsule. All women underwent a baseline and 1-week colposcopic examination. Multiple genital tract areas were evaluated for abnormalities and photographed. The original examiner and two experienced colposcopists reevaluated all images masked to previous interpretations. Agreement was evaluated using kappa statistics.

RESULTS

The representative kappa statistics for direct observation vs photographic interpretation for the vulva, vagina, and cervix are: 37%, -2%, and -4%, respectively. The kappa statistics comparing the three observers ranged from 1% to 39%. CONCLUSIONS.: There is poor agreement between in vivo exams and photographic interpretation, and interobserver assessments of lower genital tract photographs.

Human Papillomavirus Testing Following Loop Electrosurgical Excision Procedure Identifies Women at Risk for Posttreatment Cervical Intraepithelial Neoplasia Grade 2 or 3 Disease

BACKGROUND

Loop electrosurgical excision procedure (LEEP) is the predominant treatment for cervical intraepithelial neoplasia grade 2 or 3 (CIN2+) in the United States, yet following treatment approximately 10% of women are diagnosed again with CIN2+, necessitating close follow-up of such patients.

METHODS

Surveillance strategies using cytology and/or human papillomavirus (HPV) testing were compared among women who underwent LEEP (n = 610) in the Atypical Squamous Cells of Undetermined Significance (ASCUS) Low-Grade Squamous Intraepithelial Lesion (LSIL) Triage Study. Cervical specimens, collected at 6-month visits for 2 years, were used for cytology, Hybrid Capture 2 (HC2) detection of carcinogenic HPVs, and PCR for genotyping of carcinogenic and noncarcinogenic HPV types. At exit, women had colposcopy for safety and disease ascertainment.

RESULTS

At the visit post-LEEP (median time: 4.5 months after LEEP), 36.9% [95% confidence interval (95% CI), 32.7-41.1%] of women were positive for carcinogenic HPV by PCR and 33.7% (95% CI, 29.7-37.9) had ASCUS or more severe (ASCUS+) cytology. The overall 2-year cumulative incidence of histologically confirmed posttreatment CIN2+ was 7.0%; this could be further stratified by the HPV risk category detected at the 6-month visit after LEEP. The 2-year risk associated with HPV16 positivity was 37.0%, significantly higher than for other carcinogenic HPV types (10.8%, P < 0.001), noncarcinogenic types (1.5%, P < 0.001), or testing HPV negative (0%). Post-LEEP cytology (using a positive threshold of ASCUS+) was 78.1% (95% CI, 60.0-90.7%) sensitive for detection of posttreatment CIN2+. By comparison, PCR for carcinogenic HPV and combination testing (using a positive result from carcinogenic HPV testing or cytology as the test threshold with HPV-negative ASCUS not referred) were significantly more sensitive (96.9% for each, P = 0.03); HC2 alone was nonsignificantly more sensitive (90.6%, P = 0.3). Specificity was similar for ASCUS+ cytology (69.1%, 95% CI, 64.6-73.3%) and PCR for carcinogenic HPV (67.1%, P = 0.5), yet was lower for HC2 (63.8%, P = 0.048) and combination testing (62.9%, P = 0.02).

CONCLUSION

Women who tested positive after LEEP for carcinogenic HPV types, especially HPV16, had high risk of subsequent CIN2+. HPV-based detection methods, alone or in combination with cytology, may be useful to incorporate in post-LEEP management strategies.

Focused assessment of surgical performance: difficulty with faculty compliance

OBJECTIVE

This study evaluated faculty compliance in the use of the global surgical rating scale of the Objective Structured Assessment of Technical Skills to rate resident surgical performance after every endoscopic procedure.

STUDY DESIGN

For this prospective cohort study, 4 faculty members in the Minimally Invasive Gynecology Surgery Program were asked to rate resident surgical performance using the Objective Structured Assessment of Technical Skills instrument after every case. Faculty compliance was analyzed with respect to the influence of the resident or surgical case characteristics. Faculty and residents completed surveys about the value of the case-by-case ratings.

RESULTS

Faculty members used the Objective Structured Assessment of Technical Skills instrument 36% of the time (range, 26%-60%). Faculty member compliance did not vary according to resident or surgical case characteristics. Faculty members did not think the forms had much impact on whether they gave feedback. Residents thought the opportunity to read their ratings was helpful.

CONCLUSION

Faculty member compliance with case-by-case surgical performance evaluation of the residents was low.

The distribution of neoplasia arising on the cervix: results from the ALTS trial

OBJECTIVE

This study was undertaken to evaluate the topographic distribution of precancerous intraepithelial lesions on the cervix.

STUDY DESIGN

We studied the distribution of cervical biopsies and location of acetowhite lesions as determined by cervigrams among women who underwent a colposcopic examination and biopsy during the ASCUS-LSIL Triage Study (ALTS).

RESULTS

More biopsies were taken in the 12 o'clock (41.4%) and 6 o'clock (28.4%) quadrants than in 3 o'clock and 9 o'clock quadrant (15.8% and 14.5%, respectively) (P<.001). The proportion of abnormal histology per biopsy, and the grade of neoplasia, did not vary significantly by position. Cervigrams demonstrated visible intraepithelial lesions and acetowhitening more common on the anterior and posterior quadrants of the cervix.

CONCLUSION

More cervical intraepithelial neoplasia might develop at the anterior and posterior lips of the cervix. However, the evidence is weak and confounded by a tendency of the anterior and posterior quadrants to be acetowhite even in the absence of cervical intraepithelial neoplasia.

The impact of endometrial ablation technique at a large university women's hospital

OBJECTIVE

To determine the effect of ThermaChoice uterine balloon system on the practice patterns of endometrial ablations performed at a large university-based teaching hospital.

STUDY DESIGN

A retrospective chart review was conducted of 226 patients who underwent endometrial ablation. Data were analyzed to determine any change in the type and rate of ablations performed since the introduction of second-generation technologies. Multivariate logistic regression models were used to estimate adjusted risk factors for subsequent admission.

RESULTS

A total of 72.1% of all cases were performed with the ThermaChoice uterine balloon. The postoperative admission rate was significantly higher after a balloon procedure (13.7% versus 3.1%, P=.02), with a 10.6% overall incidence of admission. Adjusting for confounding variables, more women were admitted after a balloon procedure, compared with women undergoing hysteroscopic ablation (odds ratio 5.0; 95% CI: 1.1, 22).

CONCLUSION

Second-generation endometrial ablation technologies represent frequently utilized and proficient treatment modalities for dysfunctional uterine bleeding. Notwithstanding their facilitative design, clinicians should not lose sight of potential limitations of these new procedures.

Human Papillomavirus L1L2-E7 Virus-Like Particles Partially Mature Human Dendritic Cells and Elicit E7-Specific T-Helper Responses From Patients With Cervical Intraepithelial Neoplasia or Cervical Cancer In Vitro

We evaluated the ability of autologous dendritic cells (DC) pulsed with recombinant human papillomavirus 16 L1L2-E7 virus-like particles (VLPs) to stimulate E7-specific CD4+ T-cell responses from normal donors and patients with cervical intraepithelial neoplasia lesions or cervical carcinoma in vitro. Exposure to VLPs partially matured DCs, as evidenced by upregulated expression of costimulatory and major histocompatibility complex molecules and the reduced capacity of treated DCs to process exogenous antigens. However, VLP treatment failed to promote strong expression of the CD83 or CCR7 markers or to modulate interleukin-12p70 secretion, indicators of terminal DC maturation. Notably, both normal donor- and patient-derived DCs behaved similarly after exposure to VLPs. A single round of in vitro stimulation of CD4+ T cells with DCs exposed to L1L2-E7 VLPs promoted specific anti-E7 responses in the majority of donors. In particular, DCs exposed to VLPs effectively stimulated type 1 biased E7-specific CD4+ T-cell responses in patients with premalignant cervical intraepithelial neoplasia I-III lesions, but type 2 or Treg biased responses in patients with cervical cancer. Given the high rate of CD4+ T-cell responses (14 [93%] of 15 patients) against DC-L1L2-E7 VLP stimulation, this vaccine modality could serve as a foundation for developing a general treatment option for patients with human papillomavirus 16-associated malignancies.

Endometrial thickness after misoprostol use for early pregnancy failure

OBJECTIVES

To assess if there was any potential relationship between endometrial thickness and final treatment outcome in women successfully treated with misoprostol for a first trimester anembryonic gestation, embryonic demise or fetal demise.

METHODS

Eighty women were treated with up to two doses of misoprostol 800 microg vaginally for early pregnancy failure. Subjects were scheduled to return 2 (range 1-4), 7 (range 5-9) and 14 (range 12-17) days after treatment. Transvaginal ultrasonography was performed at each follow-up visit.

RESULTS

The median endometrial thickness at each of the follow-up visits for women who had expelled the gestational sac was 14 mm, 10 mm, and 7 mm, respectively. The endometrial thickness at the first follow-up visit exceeded 15 mm in 20 subjects (36%) and 30 mm in four subjects (7%). Only three women had a suction aspiration for bleeding after documented expulsion. The endometrial thickness for these women was 11, 13, and 14 mm at the first follow-up visit.

CONCLUSIONS

There is no obvious relationship between increasing endometrial thickness and the need for surgical intervention in women treated with misoprostol for early pregnancy failure.

Disease-stage variance in functional CD4(+) T-cell responses against novel pan-human leukocyte antigen-D region presented human papillomavirus-16 E7 epitopes

Given the anticipated clinical importance of helper and regulatory CD4(+) T cells reactive against human papillomavirus-16 E7 in the cervical carcinoma setting, we performed this study to identify novel E7-derived T helper (Th) epitopes and to characterize functional anti-E7 Th responses in normal donors and patients with cervical intraepithelial neoplasia I-III or cervical cancer. Candidate pan-HLA-DR (D region) binding peptides were identified and synthesized based on results obtained using a predictive computer algorithm, then applied in short-term in vitro T-cell sensitization assays. Using IFN-gamma/IL-5 (interleukin 5) enzyme-linked immunospot assays as readouts for Th1-type and Th2-type CD4(+) T-cell responses, respectively, we identified three E7-derived T helper epitopes (E7(1-12), E7(48-62), and E7(62-75)), two of which are novel. Normal donor CD4(+) T cells failed to react against these E7 peptides, whereas patients with premalignant cervical intraepithelial neoplasia I-III lesions displayed preferential Th1-type responses against all three E7 epitopes. Th1-type responses were still observed to the E7(48-62) but not to the E7(1-12) and E7(62-75) peptides in cancer patients, where these latter two epitopes evoked Th2-type responses. Notably all responders to the E7(1-12) and E7(62-75) peptides expressed the HLA-DR4 or -DR15 alleles, whereas all responders to the E7(48-62) peptide failed to express the HLA-DR4 allele. Our results are consistent with a model in which cervical cancer progression is linked to an undesirable Th1- to Th2-type shift in functional CD4(+) T cell responses to two novel E7-derived epitopes. These peptides may prove important in vaccines to promote and maintain protective Th1-type antihuman papillomavirus immunity and in the immune monitoring of treated patients harboring HPV-16(+) malignancies.

Optical detection of high-grade cervical intraepithelial neoplasia in vivo: results of a 604-patient study

OBJECTIVE

The purpose of this study was to assess the in vivo optical detection of high-grade cervical intraepithelial neoplasia (2/3+) on the whole cervix with a noncontact, spectroscopic device.

STUDY DESIGN

Cervical scanning devices collected intrinsic fluorescence and broadband white light spectra and video images from 604 women during routine colposcopy examinations at 6 clinical centers. A statistically significant dataset was developed of intrinsic fluorescence and white light-induced cervical tissue spectra that was correlated to expert histopathologic determination. On the basis of a retrospective analysis of the acquired data, a classification algorithm was developed, validated, and optimized.

RESULTS

Intrinsic fluorescence, backscattered white light, and video imaging each contribute complementary information to diagnostic algorithms for high-grade cervical neoplasia. More than 10000 measurements that were made on colposcopically identified tissue from >500 subjects were the basis for algorithm training and testing. Algorithm performance demonstrated a sensitivity of approximately 90%. This performance was confirmed by various training methods. With the use of a multivariate classification algorithm, optical detection is predicted to detect 33% more high-grade cervical intraepithelial neoplasia (2/3+) than colposcopy alone.

CONCLUSION

Full cervix optical interrogation for the detection of high-grade cervical intraepithelial neoplasia is feasible and appears capable of detecting more high-grade cervical intraepithelial neoplasia than colposcopy alone. With the use of this classification algorithm, a multisite, randomized controlled trial is underway that compares the combination of optical detection and colposcopy versus colposcopy alone.

Vasopressin during abdominal hysterectomy: a randomized controlled trial

OBJECTIVE

To investigate if the use of vasopressin during abdominal hysterectomy would decrease blood loss.

METHODS

Fifty-one patients undergoing abdominal hysterectomy with the diagnosis of leiomyomatous uterus were randomized and received either vasopressin 10 units/10 mL of normal saline or 10 mL of normal saline, injected 5 mL bilaterally, 1 cm medial to the uterine vessels into the lower uterine segment. The sample size was determined assuming a one-third reduction in total blood loss would be clinically relevant. A power analysis determined that 25 patients would be required in each group to assure a power of 0.80, at the.05 significance level.

RESULTS

Overall, the two groups were very similar with regard to their demographics, preoperative diagnosis, and relevant findings at the time of surgery. The mean total blood loss in the vasopressin and placebo groups was 445.41 mL and 748.42 mL, respectively. Total blood loss was significantly decreased by 40% in the vasopressin group compared with the placebo group (P <.001). There was no statistically significant difference between the two groups with respect to possible confounding variables or surgical complications.

CONCLUSION

Injection of vasopressin into the uterus at the time of abdominal hysterectomy significantly reduces blood loss without increasing morbidity. We have shown that it is a useful adjunct during abdominal hysterectomy.

Early pregnancy failure--current management concepts

Approximately one in four women will experience a miscarriage during her lifetime. For more than 50 years, the standard management of early pregnancy failure has been a dilatation and curettage (D & C). Typically, the procedure is performed in an operating room, which significantly increases cost. There is little objective information in the modem literature to prove that a D & C for all patients will lower morbidity or improve emotional well being. Treatment options include expectant management, D & C in an outpatient setting, and medical management with misoprostol (not approved by the U.S. Food and Drug Administration for treatment of early pregnancy failure). The medical literature supports that expectant management may result in more complications, including the need for "emergent" curettage, if clinicians do not understand the true normal course of expectant management. In general, women prefer some form of active management. Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration. Vaginal misoprostol will cause expulsion in 80% to 90% of women up to 13 weeks' uterine size or gestation, including patients who have a gestational sac present. However, these data come from only three trials involving a total of 42 subjects treated with vaginal misoprostol, and another study of 42 women who received vaginal misoprostol for "missed abortion" before a scheduled D & C. There is a significant lack of information from large-scale studies about when treatment is necessary and the relative efficacy, rates of side effects, and acceptability of these various treatment options for early pregnancy failure.

The vulvar mass in the prepubertal child

The differential diagnosis of the vulvar mass in the prepubertal patient is extensive and reported cases of a vulvar hamartoma in the literature are limited. The case presented in this work and review of the literature demonstrate that when considering the differential diagnosis of vulvar masses in the prepubertal female, hamartoma should be included. This review outlines the differential diagnosis of the vulvar mass and gives a comprehensive review of benign masses arising from embryonic remnants, those of mesenchymal origin as well as sarcoma botryoides-embryonal rhabdomyosarcoma and the embryonal sinus tumor.

A randomized, prospective comparison of pain after gasless laparoscopy and traditional laparoscopy

STUDY OBJECTIVE

To compare pain after laparoscopic tubal ligation by gasless laparoscopy versus carbon dioxide (CO2) pneumoperitoneum.

DESIGN

Prospective, randomized, single-blind comparison (Canadian Task Force classification I).

SETTING

Private obstetric-gynecology hospital associated with a university resident teaching program.

PATIENTS

Women age 21 to 42.

INTERVENTION

Single-puncture laparoscopic tubal ligation was performed with a silicone elastomer band. Gasless laparoscopy was performed with a Laprolift and traditional laparoscopy with CO2 pneumoperitoneum. Postoperative pain in the shoulder and periumbilical and lower pelvic regions was measured by visual analog scale on the day of surgery and postoperative days 1, 2, 3, 7, and 14.

MEASUREMENTS AND MAIN RESULTS

Of the 67 patients, 54 provided visual analog scales for analysis, 30 in the gasless group and 24 in the traditional group. No statistical difference was seen in scores for shoulder, periumbilical, and pelvic pain between techniques.

CONCLUSION

Patients undergoing gasless laparoscopy and traditional laparoscopy experience similar postoperative pain.

Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer

OBJECTIVE

To evaluate the sensitivity of the Pipelle endometrial suction curette in the detection of endometrial carcinoma in patients with known endometrial cancer.

STUDY DESIGN

A study was conducted using patients with known endometrial cancer undergoing a hysterectomy as part of a formal staging procedure. Endometrial biopsies were performed prior to each surgical procedure. Biopsy results were compared to the hysterectomy specimen for specimen adequacy and final histologic diagnosis.

RESULTS

The Pipelle biopsy was adequate for analysis in 63 of 65 patients (97%). Malignancy was detected by biopsy in 54 of 65 patients, for a sensitivity of 83 +/- 5% (mean +/- SD). Of the 11 patients with false negative results, 5 had tumors present in only an endometrial polyp. Three of the 11 patients had disease localized to < 5% of the surface area of the endometrium.

CONCLUSION

The Pipelle endometrial suction curette is an effective office device for evaluating patients at risk of endometrial cancer; however, tumors localized to a polyp or small area of endometrium may go undetected.

Reproductive function and outcome of pregnancy after liver transplantation in women

OBJECTIVE

To discuss menstrual function before and after liver transplantation, immunosuppression during pregnancy, outcome and management of pregnancy, and use of contraception in women after liver transplantation.

MATERIAL AND METHODS

We review the relevant medical literature and describe our clinical experience in the management of gynecologic and obstetric issues in recipients of liver transplants.

RESULTS

Menstrual abnormalities, such as amenorrhea, oligomenorrhea, irregular bleeding, and metrorrhagia, are common in women with liver disease and may often be the first clinical indication of liver dysfunction. Normal menstrual function is frequently restored after transplantation. Successful pregnancies have occurred in recipients of liver transplants, but such pregnancies are often complicated by preterm delivery, preeclampsia, and infection. Use of immunosuppressive medications should be maintained during pregnancy, and drug concentrations should be carefully monitored; none has been found to be teratogenic. Pregnancy does not seem to accelerate graft rejection. Barrier contraception or sterilization, if appropriate, seems to be the safest option for these patients.

CONCLUSION

Because liver transplantation leads to restoration of normal menstruation, female patients of reproductive age must be counseled about the possibility of pregnancy and the use of contraception. Pregnancy should be avoided for at least the first 6 months after transplantation. With specialized care and attention, pregnancies are generally associated with good outcomes.