Colposcopy today

A brief digression of the advent and development of colposcopy is described, along with its advantages in the prevention and diag- nosis of uterine cervical cancer.

Possible relation between borderline ovarian cancer and endocervical adenocarcinoma: case report

Case: The patient, a 74-year-old women was diagnosed with intestinal-type endocervical adenocarcinoma that developed after 11 years from borderline ovarian cancer. The diagnosis was based on biopsy and magnetic resonance imaging; hysterectomy with pelvic lymphadenectomy was then performed.

Conservative management of epithelial ovarian cancer

We are currently faced with a progressive delay in the age at which women conceive for the first time. This raises the possibility of the appearance of gynecologic disorders that may affect fertility, including neoplasms of the ovary. Fertility-sparing surgery is defined as the preservation of ovarian tissue in one or both adnexa and/or the uterus. Borderline ovarian tumor should be treated with conservative surgery. Salpingo-oophorectomy, or even ovarian cystectomy, are the procedures of choice, with recurrence rates of 2-3% and up to 20% if a simple cystectomy is performed. Cystectomy is indicated in patients with bilateral borderline tumors or in patients with a residual ovary. Borderline tumors with invasive peritoneal implants behave as an invasive cancer in 10-30% of cases with a survival rate of 10-66% compared with 100% in borderline tumors without invasive implants. Prophylactic oophorectomy is recommended when desire of conception has been accomplished. Conservative surgery in invasive epithelial ovarian cancer is limited to Stage IA, grade 1 tumor, and in some highly selected grade 2 tumors of serous, mucinous or endometrioid type, well-encapsulated and free of adhesions. The standard oncological surgical procedure with preservation of the uterus and normal appearing ovary is recommended. This includes salpingo-oophorectomy, excision of any suspicious peritoneal lesion, multiple peritoneal biopsies, appendectomy (particularly in mucinous tumors), and pelvic and paraaortic lymphadenectomy.

Role of microsatellite instability in borderline ovarian tumors

This study was designed to establish the role of microsatellite instability (MSI) in the development of sporadic tumors of the ovary. The instability of 6 microsatellites (BAT25, BAT26, NME1, D17S250, D5S346 and D2S123) was determined by comparing MSI in healthy and tumoral tissue in each of 40 patients undergoing surgery for a sporadic ovarian tumor. BAT26 and D2S123 instability was detected in borderline tumors, and ovarian carcinomas were found to present instability in the microsatellites BAT25, NME1 and D17S250. Our findings indicate that microsatellite instability lacks a significant role in the appearance or progression of sporadic ovarian tumors.

Myometrial trophoblastic implant as a complication of surgically induced first-trimester termination of pregnancy

Persistent trophoblastic tissue has been described in the abdominal cavity after surgical treatment of tubal ectopic pregnancy. More infrequently the cause of the ectopic trophoblast is linked to uterine perforation due to surgically induced termination of pregnancy (TOP). Ultrasonographic images may suggest an ectopic pregnancy. A case of myometrial trophoblastic tissue implantation following surgically induced first-trimester TOP is described.

The role of colposcopy in modern gynecology

The purpose of this review is to demonstrate that colposcopy, introduced in 1925--which is, notably before the development of great technological advances in modern gynecology--continues to be a valid technique without essential innovations to the original method described at the beginning of the last century. Colposcopy was developed in Germany during the rise of Nazism with the Second World War being an important barrier for the spread and diffusion of the technique. Colposcopy, however, continued to progress in a few countries such as Spain, Italy, Brazil, France and Switzerland. When colposcopy was introduced in the United States during the 70s, its use was mostly restricted to specialists who were almost exclusively dedicated to cervical pathology and knowledgeable about cytopathology, anatomic pathology, and colposcopy and who were competent both in the diagnosis and treatment of cervical lesions. These circumstances were completely different from what happened in the majority of European countries where colposcopists were trained as gynecologists and their histocytological knowledge, which was focused on the lower genital tract, was somewhat more extensive than that acquired by specialists in gynecology. There are two clearly different trends in relation to the use of colposcopy with characteristic geographic distribution: countries with an Anglo-Saxon influence in which colposcopy is performed selectively, and countries with a German medical inheritance in which colposcopy is carried out routinely during a standard general gynecological consultation. However, this difference is not restrictive and by no means can it be stated that colposcopy is systematically being used by all European or Latin American gynecologists for reasons related to training in the colposcopic technique. In 1977, we introduced the concept of dynamic colposcopy with the aim of differentiating it from the descriptive immobility of the original classification of Hinselmann (1954) that had remained almost unchanged by his immediate followers. Briefly, the objective was to turn colposcopy into a diagnostic tool able to identify the pathological substrate corresponding to traditional colposcopic images. We established ten differential signs that allow us to classify an ATZ area as subsidiary or not to be biopsied. The classification system proposed in Rome (International Federation of Cervical Pathology and Colposcopy [IFCPC], 1990) supports our original concept because by identifying major or minor changes in the original images, a diagnosis of the severity of the lesion can be established. With regard to specificity, the figures range between 48% and 10% with 96% for sensitivity. Obviously, a wide range of colposcopic specificity must be related to the expected efficacy of the method. When after biopsy of an atypical colposcopic image, only a low-grade lesion is detected, should this be considered a false positive colposcopic result? Although histopathologic findings are accepted as the "gold standard"...it is well known that a certain degree of subjectivity can be present. Inter- and intra-observer differences (when the same pathologist is reviewing the diagnosis after a certain time lapse) may be present. It has been argued that microbiopsy under colposcopic control gives rise to a wide error range and that it cannot be considered representative of the lesion. It is likely that this situation may occur when colposcopy-guided biopsy is performed by inexperienced hands or when biopsy is limited to small and insufficient sampling. A very important colposcopic sign, such as complete visual inspection of the squamocolumnar junction is frequently missed. Any lesion with boundaries in the endocervix, cannot be simply assessed by means of microbiopsies from the ectocervix unless there is no doubt regarding the severity of the lesions. Microcolpohysteroscopy (MCH) may be of great value in these cases by showing the limits of endocervical involvement.

CONCLUSIONS

According to the evidence presented here, it can be concluded that "colposcopy is in good health" and that probably the popularity of this technique in the field of gynecology would increase if cytopathologists and gynecologists' tasks were limited to their own fields rather than turning them into improvised specialists for their counterpart disciplines. The coordinating role of the gynecologist as a specialist for integral women's health should continue to be defended and in this respect, colposcopy should be considered a routine technique in daily practice.

Endometrial cancer: factors affecting survival

PURPOSE

To evaluate the influence in survival of clinical and pathological findings in patients with endometrial cancer.

METHODS

In 152 women treated for endometrial cancer from 1982 to 1996, personal, obstetrical and oncological data, histology, grade, myometrial invasion, peritoneal cytology, FIGO stage and treatment were correlated with survival.

RESULTS

Mean age was of 60.3 +/- 11.1 years old. Eight patients had a previous history of other neoplasms (seven of them gynecological). The mean clinical complaint was abnormal uterine bleeding. The most common histological type was endometrioid (84.9%), only 51 cases did not show myometrial invasion and 119 women were in Stage I at diagnosis. Peritoneal cytology was negative in 113 patients. Seven patients out of 85 in whom lymphadenectomy was performed showed metastasis. Seventeen of the patients died. The factors influencing survival were age, myometrial invasion and lymph node metastasis.

CONCLUSION

Lack of myometrial invasion, absence of lymph node metastasis and age younger than 60 years seem to be the most significant predicting factors of survival.

Lymphadenectomy in ovarian cancer

Current guidelines for the surgical staging of ovarian cancer include the removal of retroperitoneal lymph nodes (pelvic and aortic). In most centres this is achieved by means of laparotomy, but advanced laparoscopic techniques have also been performed and still further prospective controlled studies with long-term follow-up are necessary to validate the efficacy. Lymph node sampling, short of complete dissection, should be avoided because it may be insufficient to detect metastasis. In any case, laparoscopic lymphadenectomy as well as open surgery, should be in the hands of properly trained subspecialists in gynaecologic oncology. Of 97 patients with ovarian carcinoma studied in our hospital, 68% were treated by means of complete staging laparotomy (FIGO). Lymphadenectomy was spared in 14 cases with stage I tumours (mainly serous) without changes in overall survival. In 15% metastases in pelvic lymph nodes were present. In the same proportion aortic lymph nodes were positive. In 5.5%, aortic metastases were present in the absence of pelvic involvement.

Role of color Doppler ultrasonography in the diagnosis of endometriotic cyst

We studied the role of color Doppler ultrasonography in the distinction between endometriomas and other adnexal masses. Three hundred and fifty-two ovarian lesions were studied, comparing sonographic diagnosis with pathologic findings. On color Doppler sonography, an endometriotic cyst usually appeared as a cystic lesion with diffuse internal echoes and low vascularization. The sensitivity and specificity of color Doppler transvaginal sonography in detecting endometriotic cysts were 91.8% and 95.3%, respectively. The positive and negative predictive values were 95.5% and 91.5%, respectively. In our experience, transvaginal sonography with color Doppler interrogation is a useful technique in the diagnosis of pathologic ovarian conditions, including cystic endometriosis.

Epidemiology of preinvasive lesions

OBJECTIVE

Review of epidemiological data on pre-invasive cervical lesions.

MATERIAL AND METHODS

Literature review and analysis of data from our Department.

RESULTS

Prevalence of data on preinvasive cervical lesions varies widely and depends on factors such as differences among countries or regions and among ethnic groups, and especially, differences in the type of population studied. Most important risk factors are: number of sexual partners, smoking, contraceptive use, HPV, age at first intercourse, and screening.

CONCLUSIONS

In order to reduce risk, pap smears should be performed regularly, safe sex practices should be recommended, and the use of tobacco products should be avoided.

Invasive micropapillary carcinoma. Distinct features of a poorly recognized variant of breast carcinoma

INTRODUCTION

Invasive micropapillary carcinoma (IMC) is a histological variant of breast cancer with a poor prognosis.

MATERIAL AND METHODS

Pathological findings of 15 cases of IMC are compared with those of 144 invasive duct carcinoma (IDC) and 10 invasive papillary carcinoma (IPC).

RESULTS

Only 33% of cases were diagnosed in stage I. Mean tumor size was 2.3 cm. Nuclear grade 3 was found in 60% of cases, aneuploidy in 78%, and 92% had hormone receptors. Nine patients showed lymph node metastasis. Tumor size, nuclear grade, mitotic rate and lymph node involvement were higher in IMC when compared with IDC grade I and IPC, but not when compared with IDC grade II and III. Four cases of IMC (27%) recurred before two years. Recurrences and lymph node metastases showed the same architectural pattern as the primary tumor.

DISCUSSION

IMC shows a high incidence of lymph node involvement and a high early recurrence rate.

Hyperprolactinemia: an inductor of neoplastic changes in endometrium? A report of two cases

Estrogen-dependent endometrial carcinomas habitually arise through a precursor lesion such as endometrial hyperplasia. The hormonal environment of these patients remains unclear. Two cases of neoplastic changes in the endometrium of patients with a chronic hyperprolactinemia are presented. Despite the treatment with bromocriptine both patients developed endometrial adenocarcinomas. Possible mechanisms involved in the pathogenesis of these tumors are discussed.

Survival in cervical cancer

PURPOSE OF INVESTIGATION

To analyze survival rates for cervical cancer cases seen in our institution.

METHODS

All cervical cancer cases seen between 1982 and 1996 were included. Survival analysis was performed using the Kaplan-Meier estimator.

RESULTS

One hundred forty nine cases were analyzed, with a mean age of 50 years. Overall, 5-year survival was 73%. Disease-free survival ranged from 68% at 12 months to 6% at 5 years. For women under 40 years of age, 5-year survival was 74%, while for those older than 40 years it was 69%.

CONCLUSION

The results seen in our Department are similar to those found in other developed countries.

Microcolpohysteroscopy: myth or reality?

OBJECTIVES

Our aim was to compare the diagnostic accuracy of microcolpohysteroscopy (MCH) and colposcopy-directed biopsies in the detection of precancer and cancer of the uterine cervix.

PATIENTS AND METHODS

Between January and December 1994, a total of 174 patients underwent colposcopic and MCH examinations. Direct biopsies were obtained under colposcopic and MCH guidance. Diagnostic accuracies of the two methods were compared using the chisquare test and the kappa coefficient.

RESULTS

Colposcopy showed an overall diagnostic accuracy of 39.7% (69 of 174) with a sensitivity of 50.5%, specificity of 23.2%, positive predictive value of 50%, and negative predictive value of 23.5%. The percentage of agreement between MCH diagnosis and histological findings was 92.4% for cervical intraepithelial neoplasia lesions, 92.5% for human papillomavirus, and 100% for invasive cancer. Of the total 174 cases, colposcopy examination was considered satisfactory in 134 (77%) and unsatisfactory in 40 (23%). In the 40 cases when the limits of the squamocolumnar epithelium could not be seen at colposcopy, satisfactory MCH examinations were obtained in cervical lesions measuring no more than 10 mm in endocervical depth (29 cases), and unsatisfactory MCH examinations were obtained in cervical lesions measuring at least 10 mm of endocervical depth (11 cases). The overall MCH failure rate was 6.3% (11 of 174).

CONCLUSIONS

MCH appears more reliable than colposcopy and is capable of showing lesions undetectable by colposcopy.

Transvaginal sonographic appearance of functional ovarian cysts

Knowledge of the nature of ovarian lesions is important in order to establish the correct treatment and, especially, to detect ovarian cysts that do not require surgical treatment. With the purpose of demonstrating the utility of transvaginal sonography with colour Doppler of ovarian functional ovarian cysts, 378 ovarian tumours were studied, comparing sonographic diagnosis with pathological findings. Sensitivity and specificity of colour Doppler transvaginal sonography to detect functional ovarian cysts were 84.6 and 99.2% respectively. Positive and negative predictive values were 98 and 93.5% respectively. In our experience, transvaginal sonography with colour Doppler is a useful technique in the diagnosis of ovarian pathology.

The European study of assisted reproduction families: family functioning and child development

Findings are presented of a European study (conducted in the UK, Italy, Spain and The Netherlands) of family relationships and the social and emotional development of children in families created as a result of the two most widely used reproductive technologies, in-vitro fertilization (IVF) and donor insemination (DI), in comparison with control groups of families with naturally conceived child and adoptive families. Mothers of children conceived by assisted reproduction expressed greater warmth towards their child, were more emotionally involved with their child, interacted more with their child and reported less stress associated with parenting than mothers who conceived their child naturally. Similarly, assisted reproduction fathers were found to interact more with their child and to contribute more to parenting than fathers with a naturally conceived child. With respect to the children themselves, no group differences were found for either the presence of psychological disorder or for children's perceptions of the quality of family relationships. The findings relating to the quality of parenting and the socio-emotional development of the children were similar in each of the four countries studied.