Kinetics of DNA load predict HPV 16 viral clearance.

INTRODUCTION: While high HPV 16 viral load measured at a single time point is associated with cervical disease outcomes, few studies have assessed changes in HPV 16 viral load on viral clearance. OBJECTIVE: To measure the association between changes in HPV 16 viral load and viral clearance in a cohort of Thai women infected with HPV 16. STUDY DESIGN: Fifty women (n=50) between the ages of 18-35 years enrolled in a prospective cohort study were followed up every three months for two years. Women positive for HPV 16 DNA by multiplex TaqMan assay at two or more study visits were selected for viral load quantitation using a type-specific TaqMan based real-time PCR assay. The strength of the association of change in viral load between two visits and viral clearance at the subsequent visit was assessed using a GEE model for binary outcomes. RESULTS: At study entry, HPV 16 viral load did not vary by infection outcome. A >2 log decline in viral load across two study visits was found to be strongly associated with viral clearance (AOR: 5.5, 95% CI: 1.4-21.3). HPV 16 viral load measured at a single time point was not associated with viral clearance. CONCLUSIONS: These results demonstrate that repeated measurement of HPV 16 viral load may be a useful predictor in determining the outcome of early endpoints of viral infection.

Twelve years experience with radical hysterectomy and pelvic lymphadenectomy in early stage cervical cancer.

The objective of this study was to evaluate the outcome, prognostic factors and complications of early stage cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy (RHPL). The medical records of cervical cancer patients undergoing RHPL at Chiang Mai University Hospital over 12 years, between January 1995 and December 2006 were reviewed. There were 1,253 patients in the study period. The mean age was 44 years of age. Of these, 26.9% had prior diagnostic conisation. The maximum tumour size was 8 cm. The most common histology was squamous cell carcinoma (67%) followed by adenocarcinoma (23%). The distribution of FIGO staging was: stage IA 8.7%; stage IB 15.8%; stage IB1 61%; stage IB2 6.2%; and stage IIA 8.5%. Pelvic nodes, parametrial and vaginal margin involvement were detected in 15.9%, 10.7% and 3.8% of the patients, respectively. A total of 66.5% of patients underwent RHPL without adjuvant treatment; 12.1% received neoadjuvant chemotherapy. The estimated 10-year recurrence-free survival rate was 90%. Stage IB2/IIA, non-squamous cell carcinoma, nodal involvement and positive vaginal margins were independent, significant, poor prognostic factors. The most common long-term complication was lymphoedema. It was concluded that early stage cervical cancer patients treated with RHPL have long-term favourable outcome with minimal morbidity. Stage IB2 and IIA, non-squamous cell carcinoma, nodal and vaginal involvement were independent adverse prognostic factors.

Malignant perivascular epithelioid cell tumour of the round ligament mimics leiomyoma on computed tomography.

We report a case of a 45-year-old woman who had a palpable mass in the left lower quadrant of the abdomen. Computed tomography (CT) showed a circumscribed mass in the left round ligament of the uterus. The mass had heterogeneous density and enhancement accompanied by mottled calcification, which was initially identified as a leiomyoma. A histopathological examination revealed a malignant perivascular epithelioid cell tumour (PEComa), which is a rare soft tissue tumour. This case demonstrates that the appearance of malignant PEComa on the CT can mimic leiomyoma, which is the most common tumour of the round ligament. To the best of our knowledge, this is the first report of a CT appearance of this round ligament tumour. The radiological features and differential diagnosis are discussed.

Women in a region with high incidence of cervical cancer warrant immediate colposcopy for low-grade squamous intraepithelial lesion on cervical cytology.

The objective of this study was to determine the prevalence of high-grade histologic diagnoses in women who had low-grade squamous intraepithelial lesion (LSIL) on Pap smear in an area with high incidence of cervical cancer. We conducted a retrospective study of 220 women with LSIL cytology undergoing colposcopic examination in Chiang Mai University Hospital between January 1999 and July 2004. The histologic diagnoses, obtained from colposcopically directed biopsy or electrical loop excision after initial colposcopy, showed that 80 (36.4%) women had histologically confirmed high-grade lesions and 11 (5%) women had microinvasive (9) and frankly invasive (2) carcinomas. Overall, 41.5% of women with LSIL on Pap smear had significant underlying lesions, requiring appropriate treatment. In conclusion, in the region with high incidence of cervical cancer, women with LSIL cytology are at increased risk of having underlying high-grade lesions and invasive cancer. Immediate referral for colposcopy is warranted.

Outcomes of loop electrosurgical excision procedure for cervical neoplasia in human immunodeficiency virus-infected women.

The objective of this study was to evaluate the treatment outcomes and complications in human immunodeficiency virus (HIV)-infected women undergoing loop electrosurgical excision procedure (LEEP) for cervical neoplasia. The medical record of 60 evaluable HIV-infected women who had abnormal Papanicolaou (Pap) smear and underwent LEEP following colposcopy at Chiang Mai University Hospital between May 1998 and June 2004 was reviewed. Thirty-one (51.7%) had associated genital infection at screening. Twenty-five (41.7%) had opportunistic infection, but only 18 (30.0%) were treated with antiretroviral therapy. The most common abnormal Pap smear was high-grade squamous intraepithelial lesion (46.7%), followed by low-grade squamous intraepithelial lesion (40.0%). Forty (66.7%) women had clear surgical margins after LEEP. Only one (1.7%) woman had severe intraoperative hemorrhage. Early and late postoperative hemorrhage were noted in three (5%) women of each period. Localized infection of the cervix was detected in seven (11.7%) women. Two (3.3%) women developed cervical stenosis at 6 months after LEEP. There was no significant difference in overall complications between HIV-infected women and the control group (P= 0.24). Among 60 HIV-infected women, no statistical difference in the rate of margins involvement (P= 1.00) and complications (P= 0.85) could be demonstrated between HIV-infected women who received antiretroviral therapy and those who did not. Disease-free rate at 6 and 12 months were 97.1% and 88%, respectively. These data demonstrated that LEEP appears to be safe and effective in HIV-infected women.

The risk of residual neoplasia in women with microinvasive squamous cervical carcinoma and positive cone margins.

The objective was to evaluate the prevalence and factors affecting residual disease in women with cervical microinvasive carcinoma (MIC) with positive cone margins for high-grade lesions and invasive carcinoma. We reviewed histopathology slides of 129 women with MIC who had high-grade lesions or invasive carcinoma at cone margins. These patients underwent hysterectomy following cone biopsy between January 1994 and June 2004. Of the 129 patients, 77 (59.7%) had residual disease in the hysterectomy specimens, in which 57 (44.2%) had residual high-grade lesions. Twenty patients (15.5%) had residual invasive carcinoma: 18 were microinvasive and 2 were invasive. Factors significantly affecting the risk of residual disease included positive postconization endocervical curettage (P= 0.001), positive cone margins for invasive carcinoma (P= 0.003), and depth of stromal invasion >1 mm (P= 0.014). Cox proportional hazards analysis revealed positive cone margins for invasive carcinoma as significant predictor of residual invasive disease (hazard ratio, 3.22; 95% CI 1.21-8.60, P= 0.019) In summary, patients with MIC and positive cone margins for high-grade lesions or invasive carcinoma are at high risk of residual neoplasia. Repeat cone biopsy should be performed to determine exactly the severity of lesion before planning treatment.

Outcomes of abandoned radical hysterectomy in patients with stages IB-IIA cervical cancer found to have positive nodes during the operation.

The objective of this study was to evaluate the outcomes of stages IB-IIA cervical cancer patients whose radical hysterectomy (RH) was abandoned for positive pelvic nodes detected during the operation compared with those found to have positive nodes after the operation. Among 242 patients with planned RH and pelvic lymphadenectomy (RHPL) for stages IB-IIA cervical cancer, 23 (9.5%) had grossly positive nodes. RH was abandoned, and complete pelvic lymphadenectomy was performed. Of these 23 patients, 22 received adjuvant chemoradiation, and the remaining 1 received adjuvant radiation. Four patients with positive para-aortic nodes were additionally treated with extended-field irradiation. When compared with 35 patients whose positive nodes were detected after the operation, there were significant differences regarding number of positive nodes and number of patients receiving extended-field irradiation. Complications in both groups were not significantly different, but the 2-year disease-free survival was significantly lower in the abandoned RH group compared with that of the RHPL group (58.5% versus 93.5%, P= 0.01). In conclusion, the survival of stages IB-IIA cervical cancer patients whose RH was abandoned for grossly positive pelvic nodes was significantly worse than that of patients whose node metastasis was identified after the operation. This is because the abandoned RH group had worse prognostic factors.

Reasons for improper simple hysterectomy in patients with invasive cervical cancer in the northern region of Thailand.

OBJECTIVE: To determine the reasons for improper simple hysterectomy in the presence of invasive cervical cancer. METHODS: The medical records of 70 patients who had undergone simple hysterectomy in the presence of invasive cervical cancer and were referred to Chiang Mai University Hospital between January 1991 and December 1998 were reviewed. RESULTS: Approximately half of the patients presented with abnormal vaginal bleeding. Failure to perform a Papanicolaou smear before the operation accounted for 35.4%. Normal pelvic examination in which no gross invasive tumor was observed accounted for 59%. The most common indications for inappropriate operation was cervical dysplasia. The reasons for inappropriate simple hysterectomy included lack of preoperative cervical cytology (22.8%), incomplete evaluation of cervical dysplasia or microinvasion on biopsy (21.4%), false-negative cervical cytology (18.6%), failure to perform an endocervical curettage following conization (8.6%), emergency hysterectomy (8.6%), failure to perform indicated conization (5.6%), errors in colposcopic examination (4.3%), incomplete evaluation of an abnormal cervical cytology (1.4%), failure to perform endocervical currettage following loop conization (1.4%), failure to review slide (1.4%), failure to check the pathology report (1.4%), failure to biopsy a gross cervical lesion, and skipped lesion in upper part of the endocervix (1.4%). One case of invasive disease was missed for unknown reason. CONCLUSION: Most cases of inappropriate hysterectomy resulted from deviation from guideline for cervical cancer detection. Preoperative Papanicolaou smear and strict adherence to the well-established diagnostic protocol for patients with an abnormal smear are advised to prevent such occurrence.