Underestimated Cervical Cancer among Women over 65 Years Old: Is It Time to Revise the Screening Target Age Group?

OBJECTIVE: To compare cytological and histological results from women > 64 years old who followed the Brazilian national cervical cancer screening guidelines with those who did not. METHODS: The present observational retrospective study analyzed 207 abnormal cervical smear results from women > 64 years old in a mid-sized city in Brazil over 14 years. All results were reported according to the Bethesda System. The women were divided into those who followed the screening guidelines and those who did not. RESULTS: Atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion cytology results were found in 128 (62.2%) cases. Of these, 112 (87.5%) had repeated cytology with positive results. The other 79 (38.1%) with abnormal results should have been referred to colposcopy and biopsy. Out of 41 (51.9%) biopsied women, 23 (29.1%) had a confirmed diagnosis of neoplasia or precursor lesion. In contrast, among the 78 (37.7%) biopsied patients, 40 (51.3%) followed the guideline recommendations, with 9 (22.5%) positive biopsies. Of the 38 (48.7%) women who did not follow the guidelines, there were 24 (63.1%) positive results. Women who did not follow the guidelines demonstrated higher chances of cancer and precursor lesions (odds ratio [OR]: 5.904; 95% confidence interval [CI]: 2.188-15.932; p = 0.0002). CONCLUSION: Women > 64 years old who did not follow the national screening protocol showed significant differences in the frequency of abnormal results and severity of diagnosis compared with those who followed the protocol.

OBJETIVO: Comparar os resultados citológicos e histológicos de mulheres > 64 anos que seguiram as diretrizes nacionais brasileiras de rastreamento do câncer do colo do útero com aquelas que não as seguiram. MéTODO: O presente estudo observacional retrospectivo analisou 207 resultados anormais de esfregaço cervical de mulheres > 64 anos de idade em uma cidade de médio porte no Brasil durante 14 anos. Todos os resultados foram relatados de acordo com o Sistema Bethesda. As mulheres foram divididas entre as que seguiram as diretrizes de rastreamento e as que não o fizeram. RESULTADOS: Resultados citológicos com células escamosas atípicas de significado indeterminado e lesão intraepitelial escamosa de baixo grau foram encontrados em 128 (62,2%) casos. Destes, 112 (87,5%) repetiram a citologia com resultados positivos. Os outros 79 (38,1%) com resultados anormais deveriam ter sido encaminhados para colposcopia e biópsia. Das 41 (51,9%) mulheres biopsiadas, 23 (29,1%) tiveram diagnóstico confirmado de neoplasia ou lesão precursora. Em contrapartida, entre as 78 (37,7%) pacientes biopsiadas, 40 (51,3%) seguiram as recomendações da diretriz, com 9 (22,5%) biópsias positivas. Entre as 38 (48,7%) mulheres que não seguiram as orientações, houve 24 (63,1%) resultados positivos. As mulheres que não seguiram as diretrizes demonstraram maiores chances de câncer e lesões precursoras (odds ratio [OR]: 5,904; intervalo de confiança [IC] de 95%: 2,188­15,932; p = 0,0002). CONCLUSãO: Mulheres > 64 anos que não seguiram a diretriz nacional de rastreamento apresentaram diferenças significativas na frequência de resultados anormais e gravidade do diagnóstico em comparação com aquelas que seguiram a diretriz.

Comparison of cervical cancer screening results among public and private services in Brazil.

OBJECTIVE: To compare the frequency of cervical smear test results between women seen in private and public health services in a medium-sized city in Brazil. METHODS: This was an observational analytical study analyzing cervical cytologic results over 16 years. Public data were collected from the Brazilian National Health System, and private refers to those collected at private clinics. RESULTS: The overall frequency of unsatisfactory/rejected results was higher in public service examinations (odds ratio [OR] 0.05; 95% confidence interval [CI] 0.04-0.06). The same occurred for atypical squamous cells of undetermined significance (ASC-US) (OR 0.90; 95% CI 0.85-0.95) and atypical squamous cells cannot exclude high grade intraepithelial lesions (ASC-H) (OR 0.55; 95% CI 0.47-0.64) categories. For low-grade squamous intraepithelial lesions, the frequency was higher among women from private services (OR 1.39; 95% CI 1.24-1.55). Among women aged 25-64 years, the frequency of high-grade squamous intraepithelial lesions was higher among women seen in the public service (OR 0.81; 95% CI 0.66-0.99). CONCLUSION: Brazilian public services showed higher frequencies of unsatisfactory/rejected results and higher rates of ASC-US and ASC-H. Focusing on pre-analytical phases and establishing an internal quality control program can help improve these rates even though national protocols guide them.

An alternative method for smear preparation of fine-needle aspiration cytology of cystic thyroid lesions: Evaluation of sample adequacy.

BACKGROUND: Cystic thyroid lesions represent one of the most common causes of unsatisfactory fine-needle aspiration sampling. Thus, it is important to access the maximum number of follicular cells from cystic fluid in order to reduce unsatisfactory rates. We compared the traditional method of smearing with an alternative one. METHODS: For each thyroid nodule, two smears were collected. Each smear was prepared using a distinct approach: either using the traditional technique or the alternative. Clinical data were taken from cytopathological request forms. The cytological aspects of the smears (eg, adequacy and number of cells) were observed during microscopy analysis. No cases were found to be suspicious for malignancy during ultrasound analysis (categories TR1 or TR2 according to ACR TI-RADS). RESULTS: Thirty-five cases were analyzed. For smears prepared using both the traditional and the alternative techniques, 20 and 4 cases, respectively, were unsatisfactory. In the 20 unsatisfactory traditional smear cases, 9 (45%) showed enough cells for diagnosis in cytospin and/or cell block samples; the four unsatisfactory alternative method cases showed the same. There was a statistical difference between the two methods of collecting a smear concerning sample adequacy (P < .001), but there was no statistical difference regarding the cellularity (P = .842). CONCLUSION: In our data, the alternative method of using only one slide and the needle tip had higher rates of adequate sampling. Since it is cost effective and does not change the cytological analysis, this proposed alternative method can be useful in cases of cystic thyroid lesions.

Identification of fungal diseases at necropsy.

The purpose of the Death Verification Service is to elucidate the causes of deaths that occur without medical assistance and of ill-defined deaths. In recent decades, the epidemiological reality of fungal infections has changed due to the rise in opportunistic infections chiefly in immunocompromised patients. A study of fungal diseases in autopsies performed in the Death Verification Service of the Medicine School in São José do Rio Preto between January 2000 and December 2009 was made. Sixty-seven cases of fungal disease, most involving men (70%), were found in 4824 autopsies. Cryptococcosis was the most prevalent (45%), followed by paracoccidioidomycosis, candidiasis, histoplasmosis, aspergillosis and mucormycosis. Associations between AIDS (n=14) and fungal diseases were identified for cryptococcosis (36%), candidiasis (28.5%) and histoplasmosis (28.5%). Pneumonia, AIDS and fungal diseases were evident in 26% of the cases, with the most prevalent etiologies being Cryptococcus neoformans (55.5%) and Histoplasma capsulatum (22%). Pneumonia alone occurred in 43% of cases, with cryptococcosis (53%) and paracoccidioidomycosis (33%) being the main infectious agents. Diabetes mellitus was associated with candidiasis in two cases and aspergillosis in one. One case of renal transplantation linked to paracoccidioidomycosis and one case of bone marrow aplasia with mucormycosis were reported. Despite the reduction in the number of autopsies over recent decades, these findings suggest that this procedure is useful to provide additional data on the etiology, underlying disease and specific risk factors, essential for quality control and to improve treatment protocols.

Histoplasmosis as cause of penile ulcer in acquired immune deficiency syndrome (AIDS): three case reports.

BACKGROUND: Histoplasma capsulatum is the causative agent of American histoplasmosis. The relationship between disseminated histoplasmosis and AIDS has been well established. Widespread hematogenous dissemination of Histoplasma capsulatum in HIV positive patients can cause a plethora of clinical manifestations; virtually any organic system can be affected. However, genital ulceration by H. capsulatum in patients with AIDS is a real challenge during investigation of the infection due to the great variety of differential diagnoses that are involved. METHOD: The diagnosis was performed by histopathologic study; H. capsulatum was detected by silver staining (Grocott staining) and confirmed by immunocytochemistry. RESULTS: We report three cases of histoplasmosis in patients with AIDS, in which we observed genital ulcers, an unusual form of presentation of this disease. In one of these cases, the treatment resulted in total cure. CONCLUSION: The cases reported herein are to illustrate the plurality of pathologies and clinical manifestations, which may affect immunocompromised patients. The correct diagnosis of fungal diseases in these patients following well established treatment will improve the prognosis.