European consensus statement on expert colposcopy.

BACKGROUND: Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease. AIMS: To provide expert guidance on complex colposcopy cases through published evidence and expert consensus. MATERIAL & METHODS: Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics. RESULTS & DISCUSSION: The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

European consensus statement on essential colposcopy.

This European consensus statement on essential colposcopy provides standards for the general colposcopist seeing women referred for colposcopy with an abnormal cervical screening test (including cytology and HPV tests) or with a clinically suspicious cervix. The article gives guidance regarding the aims and conduct of colposcopy. Recommendations are provided on colposcopy technique, the management of common colposcopy issues, treatment and follow-up of after treatment of CIN or early stage cervical. Colposcopists should make an informed decision on the management of each individual that is referred and organize appropriate follow-up. Cervical cancer is still a major health issue and the quality of care can only improve if there is a structured guidance for women with an abnormal smear or suspicious cervix.

The Role of Surgeons' Colposcopic Experience in Obtaining Adequate Samples by Large Loop Excision of the Transformation Zone in Women of Reproductive Age.

Introduction: There is insufficient reporting on the level of colposcopic training for the safe use of large loop excision of the transformation zone. The aim of this study was to perform a quality assessment of large loop excision of the transformation zone in women of reproductive age by evaluating the surgeons' colposcopic experience. Materials and Methods: A retrospective cohort study was performed on diagnostic or therapeutic large loop excision of the transformation zone. The following variables were analyzed: age, parity, indications for surgery, level of surgeon's colposcopic experience, definitive histological diagnosis, margin involvement, and the presence and type of artifacts interfering with the pathological interpretation. Patients were divided into three groups: group A - 75 patients treated by junior colposcopists; group B - 74 patients treated by experienced colposcopists, and group C - 117 patients treated by expert colposcopists. Results: Regarding the presence and diagnostic significance of the artifacts the groups were significantly different. Inadequate samples were the least frequent in group C. Artifacts precluding histological diagnosis were the most common in group A. The margins were predominantly inconclusive in group A. Conclusions: A high rate of artifacts is a disadvantage of the large loop excision of the transformation zone performed by surgeons less skilled for colposcopy. Although large loop excision of the transformation zone is considered to be a minor surgery, skills in colposcopy are an essential prerequisite for optimal results.

The need for accredited training in gynaecological oncology: a report from the European Network of Young Gynaecological Oncologists (ENYGO).

BACKGROUND: Primary data on training experiences of European gynaecological oncology trainees are lacking. This study aims to evaluate trainee profile, satisfaction and factors affecting the training experience in gynaecological oncology in Europe. PATIENTS AND METHODS: A web-based anonymous survey sent to ENYGO members/trainees in July 2011. It included sociodemographic information and a 22-item (1-5 Likert scale) questionnaire evaluating training experience in gynaecological oncology. Chi-square tests were used for evaluating the independence of categorical variables and t-test (parametric)/Mann-Whitney (non-parametric) tests for differences between two independent groups on continuous data. Cluster analysis was used to identify groupings in multivariate data and Cronbach's-alpha for questionnaire reliability. A multivariable linear regression model was used to assess the effect of variables on training satisfaction. RESULTS: One hundred and nineteen gynaecological-oncology trainees from 31 countries responded. The mean age was 37.4 (S.D, 5.3) years and 55.5% were in accredited training posts. Two clusters identified in the cohort (Calinski-Harabasz, CH = 47.35) differed mainly by accredited training (P = 0.003). The training-satisfaction score (TSS) had high reliability (Cronbach's alpha, 0.951) and was significantly associated with accredited posts (P < 0.0005), years of training (P = 0.001) and salary (P = 0.002). The TSS was independent of age (P = 0.360), working hours (P = 0.620), overtime-pay (P = 0.318), annual leave (P = 0.933), gender (P = 0.545) and marital status (P = 0.731). Accredited programme trainees scored significantly higher than others in 17 of 22 aspects of training. The areas of greater need included advanced laparoscopic/urological/colorectal surgery, radiation oncology, palliative-care, cancer genetics and research opportunities. CONCLUSIONS: Our data demonstrate the importance of accredited training and the need for harmonisation of gynaecological oncology training within Europe.

Fertility after the treatment of gynecologic tumors.

In a young woman with gynecologic cancer, preservation of fertility is possible. Fertility-sparing surgery may be safe in early ovarian cancer of certain histological subtypes such as ovarian tumors of low malignant potential, malignant ovarian germ cell tumors, and ovarian sex cord stromal tumors. For women with invasive epithelial ovarian cancer who have early-stage disease, fertility-sparing surgery may be an option. In some cases, fertility-sparing surgery may be followed by postoperative chemotherapy. The concept of fertility-preserving surgery in early cervical cancer has been adopted by several leading centers worldwide as an option for stage Ia and small Ib disease without the presence of lymphovascular involvement. Nonsurgical options such as hormonal therapy may be considered for women with early-stage, low-grade endometrial cancer. Improvements in cancer cure rates and the development of conservative treatments mean that many young women with early gynecologic cancer can hope to start a new pregnancy after the treatment. Patients are generally advised to wait 2 years after treatment for any malignancy before attempting pregnancy, but the optimal interval between cure and conception must be carefully determined by a multidisciplinary team including oncologist and obstetrician. Gynecologic surgery and hemotherapy can have an impact not only on fertility, but also on the course of a next pregnancy (increased risk of miscarriage and premature delivery, etc.) These risks must be taken into account by the obstetrician. Management of young women diagnosed with gynecologic cancer should be individualized, with the risk of conservative therapy balanced against the disadvantages of more radical treatment. The patient and the family should be extensively counseled. The alternatives to the traditional and standard radical procedures should be discussed, and the limitation of data regarding many conservative treatment options should be explained. The patients should be aware that by accepting fertility-sparing treatment they are assuming a small but undefined risk for recurrence of the disease. They need to know that these conservative therapeutic approaches are yet not considered "standard." Furthermore, patients need to be assessed for the realistic probabilities of achieving conception on the basis on their age, history, and infertility evaluation. Some of them will require assisted reproduction technology (ARTS) to help achieve a pregnancy, especially in vitro fertilization (IVF). They may also consider ovarian tissue, oocyte, or embryo cryopreservation before definitive cancer therapies. And, finally, patients also need to understand the risk of premature delivery and the consequences of prematurity. The care of the young patient with gynecologic malignancy is extremely complex and challenging. It necessarily requires a multidisciplinary approach with the close collaboration of gynecologist-oncologist, reproductive endocrinologist, and perinatologist.

Management of cervical cancer.

AIMS: The aim of the article was to review the current approach to management of cervical cancer. METHODS: The relevant literature has served as a source for review of different options applied in the management of cervical cancer. RESULTS: Treatment of invasive cervical cancer is affected by the stage of the disease, which is based on clinical evaluation. Microinvasive carcinoma of the cervix has limited metastatic potential and therefore is most likely curable by non-radical treatment. There is no standard management of stage Ib-IIa cervical carcinoma. Both radical surgery and radical radiotherapy have proven to be equally effective, but differ in associated morbidity and complications. Most often, stage Ib1 cervical cancer is treated by radical hysterectomy with pelvic lymphadenectomy. Laparoscopically assisted radical vaginal hysterectomy has shown similar efficacy and recurrence rates. Radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy may be an option in small cervical cancer where preservation of fertility is desired. There is lot of conflicting published work regarding the treatment of bulky stage Ib-IIa cervical cancer. While some centers are performing primary surgery as for Ib1 disease followed by tailored postoperative radiation with or without chemotherapy, the others are in favor of primary chemo-radiation therapy. Neoadjuvant chemotherapy followed by radical surgery has emerged as a possible alternative, which may improve a survival in patients with stage Ib2 disease. Concomitant chemoradiation is becoming a new standard in treatment of advanced disease, because it has been clearly shown to improve disease-free, progression-free and overall survival. Management of recurrent disease depends on previous treatment, site and extent of recurrence, disease-free interval and patient's performance status. CONCLUSIONS: Treatment decisions should be individualized and based on multiple factors including the stage of the disease, age, medical condition of the patient, tumor-related factors and treatment preferences, to yield the best cure with minimum complications.

Treatment of cervical intraepithelial neoplasia reverses CD4/CD8 lymphocyte abnormalities in peripheral venous blood.

Immunosuppressed patients have an increased prevalence of cervical intraepithelial neoplasia (CIN) and apparently normal subjects with CIN have evidence of immunosuppression. The immunosuppression may antedate the cervical lesion or be a result of the CIN. One index of an impaired immune response is a reduced ratio of CD4/CD8 peripheral blood lymphocytes. This study sought to confirm that patients with CIN had a reduced CD4/CD8 ratio and to determine whether local treatment of the cervical lesion affected the abnormality. Patients with CIN had a lower mean CD4/CD8 ratio than controls (1.19 vs. 1.83, P < 0.01) and more of the patients with CIN had a ratio less than 1.0 [14/38 (37%) vs. 1/30 (3%), P < 0.01]. After laser treatment of CIN, the mean CD4/CD8 ratio was higher than before treatment (1.76 vs. 1.19, P < 0.01). Paired pre- and post-treatment values in 11 patients confirmed this improvement (mean CD4/CD8: 1.14 vs. 2.08, P < 0.01). These findings confirm an association between CIN and a reduced CD4/CD8 ratio. The effect on lymphocytes of treating CIN suggests that the altered ratio is a result of the disease rather than a pre-existing etiologic factor.

A comparison of cytology and cervicography in cervical screening.

The sensitivity and specificity of cervical cytology and of cervicography in the detection of CIN and invasive cancer of the cervix were determined in a screening programme of an asymptomatic population of 418 women. Because all of the subjects were examined colposcopically and biopsies were taken from any suspicious areas, the presence or absence of disease was determined by the histology of directed cervical biopsies independently of the screening methods being tested. Cervicography correctly identified 24 of the 27 women with CIN or invasive cancer, whereas cytology detected only 14 (sensitivity of 0.89 vs. 0.52; P < 0.01). Cervicography detected CIN in 11 women with negative smears, six having CIN III. Only one case of CIN I was detected by cytology when cervicography was negative. Two cases of CIN II were not detected by either method. Inclusion in the analysis of the results from 23 women with technically defective cervigrams reduced the size of the difference in sensitivity, but it remained significant (0.74 vs. 0.48; P < 0.05). Cervicography was only slightly less specific than cytology (0.92 vs. 0.94; NS). Cervicography appears to be more effective than cytology in screening for cervical premalignancy but may be more demanding of those who perform the test.

[Duodenal polyps of gastric origin]. / Polipi duodenuma zeludacne geneze.

Recently, thanks to the collected knowledge and increased diagnostic abilities we more often meet the diseases that have been considered very seldom. Beside that, we form the new assumptions that must be proved. Today, more often we meet gastric mucosa in duodenum. That according to some researchers, introduces a real possibility for appearance of the polyps, ulcers or cancer on gastric substratum. In the subject patient the two polyps of the gastric origin were found in a duodenum. That could support the assumption that ectopic gastric mucosa presents one of the real possibilities for appearance of polyps, ulcers and cancer.

[Correlation of sonographic and patho-anatomic findings in myomatous changes in the uterus]. / Korelacija sonografskog i pato-anatomskog nalaza miomatozno promenjene materice.

In spite of the fact that ultrasound is an accessory diagnostic measure in gynaecology, added to clinical examination, it can help in a more accurate diagnosis and better preparation for surgery. The comparison of data obtained by ultrasonic and macroscopic measurements of uterine leiomyoma in 130 patients did not reveal a statistically significant difference between the two methods. The mean size of all measured leiomyomas was 61.47 mm in longitudinal diameter, 53.00 mm in anteroposterior and 53.95 mm in transversal. Measured by ultrasound the mean dimensions of the same diameters were 62.29 mm, 56.91 mm and 55.11 mm respectively. Differences in the mean values of all measured diameters obtained in some cases can be explained by subjective elements in the use of ultrasound, the examiners experience and postoperative reduction of the removed organ volume, as well as by technical factors which may influence the ultrasonic image. Thus, the accuracy of ultrasonic measurement completes the knowledge about the size of the pelvic mass; it is helpful in preparation for surgery, and decreases the possibility of unexpected situations during the surgery.

[T lymphocytes, non-malignant and premalignant changes in the planocellular epithelium of the uterine cervix]. / T limfociti, nemaligne i premaligne promene plocastoslojevitog epitela grlica materice.

T lymphocytes play an important role in the immune response to both neoplasia and viral infection. Normally, about 60% of T lymphocytes in the peripheral blood are T4 (helper) lymphocytes, while 20-30% are T8(suppressor) lymphocytes. When this ratio is inverted, most significant changes occur. The aim of the study was to examine the T4/T8 lymphocyte ratio in the peripheral blood of patients with nonmalignant and premalignant changes of the cervical epithelium and to compare it with that in patients without any cytological or colposcopical cervical abnormality. The results show a significant decrease of the T4/T8 lymphocyte ratio in the peripheral blood of patients with leukokeratosis (1.55) and especially of those with cervical intraepithelial neoplasia (1.19), compared with the results of the control group (2.31). These findings, as well as the knowledge of the importance of immune response in the control of the onset of malignancy, that the determination of T4/T8 lymphocyte ratio might be helpful in the prediction of the degree of premalignant cervical chance and indicate patient's follow-up.

[Smoking and nonmalignant changes in the uterine cervix]. / Pusenje i nemaligne promene grlica materice.

The evidence of the association between smoking and cervical dysplasias has been established by several reports. It has been suggested that smoking might depress the immune mechanism and allow a sexually transmitted infective agent to result in an abnormal cellular development, leading to the onset of dysplasia. It, was also established that some chemical products of smoking could be selectively deposited in gynaecological tissues. The aim of this study was to examine the frequency of smoking habits in patients with non-malignant cervical changes and to compare it to the one in patients without cytological or colposcopical cervical abnormalities. The study group consisted of 63 patients with historically confirmed non-malignant cervical changes: 6 patients with cervicitis, 12 with leukokeratosis of the cervical epithelium, 13 with mild dysplasia, 21 with moderate dysplasia and 11 patients with sever dysplasia. 68 patients were without cervical changes and made the control group. The percentage of smokers among the patients with cervical changes (53.97%) statistically significantly differs from the results of the control group (32.35%). This percentage is increasing with the severity of cervical change. Testing for a dose-response relationship reveals no difference between the light and heavy smokers. An increased risk for development of cervical changes with increasing duration of smoking could not be established. The results are in agreement with the opinions that smoking is associated with an increased risk for development of cervical dysplasia which is considered to be a precursor lesion of cancer of the cervix. Although it could not be established by our analysis, it is thought that this risk increases with the increased frequency and longer duration of smoking.

T lymphocytes in non-malignant, pre-malignant and malignant changes of the cervix.

T lymphocytes play an important role in the immune response to both neoplasia and viral infection. Normally about 60% of T lymphocytes in the peripheral blood are T4 lymphocytes, while 20-30% are T8 ones. The T4/T8 ratio is usually 2:1. When this ratio is inverted the most significant changes occur. The aim of our study was to examine the T4/T8 lymphocyte ratio in the peripheral blood of patients with histologically confirmed non-malignant and premalignant changes of the cervix and to compare it both with the ratio in patients with squamocellular carcinoma of the cervix and those without any cytological or colposcopical cervical abnormality. The study group consisted of 118 patients, 17 of them had leukokeratosis of the cervical epithelium, 20 had cervical intraepithelial neoplasia (CIN) and 42 patients had cervical cancer, 39 patients had normal cervical findings and comprised the control group. Peripheral blood lymphocytes were examined by indirect immunoperoxidase technique, using OKT 4 and OKT 8 monoclonal antibodies. The average T4/T8 lymphocyte ratio in the peripheral blood of patients with leukokeratosis was 1.55, and in those with CIN 1.19. In patients with cancer the ratio was 1.34. The differences was not statistically significant. The control group had an average T4/T8 ratio of 2.31 which was significantly different compared to the results of the other groups. The value of these and similar results obtained by other authors is still uncertain. The alteration of T lymphocyte subsets may occur in the peripheral blood of patients with viral infections and some viruses are considered important in the etiology of CIN.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary ovarian cancer]. / Primarni rak jajnika.

Out of 108 patients treated for primary ovarian cancer from 1984 to 1986, 76% suggested adnexal changes, while malignancy was suspected only in 35% of them. The first symptoms appeared in 51.8% of patients up to three months before the establishment of the diagnosis. In the two thirds of them the disease was in the III or IV stage. Histologically, epithelial tumours were most frequent (86.1%), mostly (51.6%) moderately differentiated. Surgery ranged from hysterectomy with adnexectomy and omentectomy (58.3%) to explorative laparotomy with biopsy. Later intervention included chemotherapy in 62%, chemotherapy and radiotherapy in 15.7%, and radiotherapy alone in 14.8% of patients. Too short a time has elapsed since the treatment started to predict a 5-year survival, but the 2-year survival for all patients amounts to 38.9%.

[Cervicography--a useful method for the early detection of changes in the uterine cervix]. / Cervikografija--pomocna metoda u ranom otkrivanju promena grlica materice.

Cervicographic findings were analysed in 156 patients of whom 71 had previously been found to have cervical changes (group I) and 85 were regularly examined within the periodic systematic examination programme (group II). In group I there were 15.5% negative cervicographic findings, 80.3% suspect, and 4.2% technically inadequate. Out of suspect findings, carcinoma in situ or invasive carcinoma were detected in 54.4%, of which 9.7% were cytologically false negative. In group II, in 69.4% of cases, some colposcopic changes (non-malignant) were observed, while in 3 out of 26 colposcopically normal findings, there were some changes in the cervicogram.

Epidemiology of cancer of the female genital organs in Yugoslavia.

The descriptive epidemiological method was applied. In the preparation of the data, basic statistical procedures were used. Data were obtained from Slovenian Cancer Registry and Yugoslav Statistics Institute, and studied over the period from 1971 to 1985. In terms of rate of occurrence, malignant neoplasms of the female genital organs rank first in all cases of cancer, with 20.94%. Uterine cervix and corpus and ovary, are always in the ten leading primary cancer sites. Malignant neoplasms of the female genital organs comprise about 2% of all causes of death in females and just over 15% of all deaths from cancer. Cervical cancer has an average incidence rate of 18.56, while mortality rate is 4.67 per 100,000 women. Both incidence and mortality decreased throughout the investigated period. Other malignant neoplasms of the uterus appear in 15.45 cases per 100,000 and this rate shows a slightly increasing trend. However, the mortality rate is 3.77 and this shows a distinct decrease, in all parts of the country. The average incidence rate for cancer of the ovary is 12.61, decreasing slowly. Malignant neoplasms of the ovary have the mortality rate of 3.94, which has been constantly rising. Malignant neoplasms of the other genital organs have the average incidence rate of 3.15 and mortality rate of 0.95. These rates remain stable over the period from 1971 to 1985.