Does Microinvasive Adenocarcinoma of Cervix Have Poorer Treatment Outcomes than Microinvasive Squamous Cell Carcinoma?

BACKGROUND: To compare the pathological findings and oncologic outcomes of stage IA cervical carcinoma patients, between adenocarcinoma and squamous cell carcinoma cases. MATERIALS AND METHODS: A total of 151 medical records of stage IA cervical carcinoma patients undergoing primary surgical treatment during 2006-2013 were reviewed. Information from pathological diagnosis and recurrence rates were compared with descriptive statistical analysis. The Kaplan-Meier method and Cox proportional hazards model were used for survival analysis. RESULTS: The median age was 48.9 years. There was no significant difference in rates of lymph node, parametrium, uterine, vaginal, or ovarian metastasis, when comparing adenocarcinoma with squamous cell carcinoma. Overall recurrence rates of adenocarcinoma (5.7%) and squamous cell carcinoma (2.6%) were not statistically significant different, even when stratified by stage. When comparing progression free survival with squamous cell carcinoma, adenocarcinoma had an HR of 0.448 (0.073-2.746), p=0.386. CONCLUSIONS: Microinvasive adenocarcinoma of cervix has similar rate of extracervical involvement and oncologic outcomes to squamous cell carcinoma.

Human cervix: an alternative substrate for detecting circulating pemphigus antibodies.

Monkey esophagus (ME) is a well-accepted substrate for diagnosing pemphigus vulgaris (PV) by indirect immunofluorescence (IIF). However, its availability is sometimes limited due to ethical concerns. This study aimed to investigate the usefulness of human cervix (HC) as a substrate in the diagnosis of PV by IIF. Initially, serum from 1 PV patient was incubated with tissues from 48 HCs. Median IIF titers on HCs that had different demographic and clinical characteristics were compared. Sera from 5 PV patients were then incubated with ME and 21 HCs. For each serum, the titer of IIF on HC that was not different from ME by more than two-fold dilutions was acceptable. Last, sera from 42 PV, 14 pemphigus foliaceous, and 62 non-pemphigus patients were used to evaluate sensitivity and specificity. The results demonstrate that differences in demographic data among HCs did not affect IIF titers. Titers obtained from ME and HC were comparable (81-100 % acceptable values). Sensitivity of HC for diagnosis of PV was better than for diagnosis of pemphigus foliaceus (90.5 and 71.4 %, respectively). Specificity for PV and PF was 96.2 %. We proposed that HC substrate can be used as an alternative substrate for diagnosis of PV by IIF.

Pathologic Risk Factors and Oncologic Outcomes in Early-stage Cervical Cancer Patients Treated by Radical Hysterectomy and Pelvic Lymphadenectomy at a Thai University Hospital: A 7 year Retrospective Review.

BACKGROUND: To evaluate the rate of pathologic high-risk factors, intermediate-risk factors, and treatment outcomes in early-stage cervical cancer patients undergoing radical hysterectomy and pelvic lymphadenectomy (RHPL). MATERIALS AND METHODS: Medical records of stage IA-IIA1 cervical cancer patients who underwent RHPL during the 2006 to 2012 time period and patient follow-up data until December 2013 were reviewed. RESULTS: Of 331 patients, 52 women (15.7%) had pathologic high-risk factors and 59 women (17.8%) had intermediate-risk factors without high-risk factors. All studied patients had an initial complete response. At median follow-up time of 40.9 months (range 1-103.3 months) and mean follow-up time of 43.3±25.3 months, 37 women had disease recurrence and 4 women had died of disease. The most common site of recurrence was the pelvis (64.8%). Five- year and 10-year disease free survival rates were 96.1% and 91.5%, respectively. Five-year and 10-year overall survival rates were 100% and 99.4%, respectively. Independent factors related to recurrence were pelvic node metastasis (odds ratio [OR], 2.670; 95%CI, 1.001-7.119), and >1/3 cervical stromal invasion (OR, 3.763; 95%CI, 1.483-9.549). CONCLUSIONS: The rates of pathologic high-risk and intermediate-risk factors should be considered and disclosed when counseling patients regarding primary treatment by RHPL. Oncologic outcomes of primary surgical treatment for early-stage cervical carcinoma were found to be excellent.

Long term outcomes of laser conization for high grade cervical intraepithelial neoplasia in Thai women.

AIM: To report long term outcomes of laser conization for high grade cervical intraepithelial neoplasia (CIN) in Thai women. MATERIALS AND METHODS: A retrospective cohort study was conducted in patients undergoing laser conization due to abnormal cervical cytology suggesting neoplasia during 1989 to 1994 and having follow-up data until December 2010. Conization was performed under colposcopy using a 0.5-mm CO2 laser beam with power density of 18,000-20,000 watts/cm2, and the surgical base was vaporized using a low power defocused beam. The follow-up protocol included cervical cytology and colposcopy. Long term outcome measures were failure rate (persistence and recurrence), post-conization status of transformation zone, and obstetric outcomes. RESULTS: Of 104 patients undergoing conization, 71 had therapeutic conization for high grade CIN and were followed up for a median time of 115 (range 12-260) months. There was one case of persistent and one of recurrent disease comprising a failure rate of 2.8%. The post treatment transformation zone was well visualized in 68.3% of 63 patients with an intact uterus. Sixteen patients achieved 25 pregnancies; none had second trimester miscarriage. The obstetric outcomes were unremarkable. CONCLUSIONS: Laser conization under colposcopic visualization for the treatment of high grade CIN in Thai women has a low failure rate of 2.8%. The post-conization transformation zone could not be evaluated completely in approximately 30% of cases; therefore the follow-up protocol should include both cytology and colposcopy. Obstetric outcomes are not adversely affected by this therapeutic procedure.

Agreement between colposcopic diagnosis and cervical pathology: Siriraj hospital experience.

AIM: To evaluate the agreement between colposcopic diagnosis and cervical pathology a retrospective chart review was performed. MATERIALS AND METHODS: This study included 437 patients who underwent colposcopy and cervical biopsy or conization at Siriraj Hospital from October 2010 - December 2012. The patient clinical characteristics, cervical cytology results, colposcopic diagnoses, cervical pathology results were recorded and correlations between variables were analyzed. RESULTS: Agreement of colposcopic diagnosis and cervical pathology was matched in 253 patients (57.9%). The strength of agreement with weighted Kappa statistic was 0.494 (p<0.001). Colposcopic diagnoses more often overestimated (31.1%) than underestimated (11%) the cervical pathology. Agreement of colposcopic diagnosis and cervical pathology within 1 grade was found in 411 patients (94.1%). Positive predictive value (PPV) of high grade colposcopy or more was 75.5%, whereas the negative predictive value (NPV) of insignificant and low grade colposcopy was 83.8%. False positives of high grade colposcopy or more were 21%. False negatives of insignificant or low grade colposcopy were 19.1%. CONCLUSIONS: Strength of agreement between colposcopic diagnosis and cervical pathology was found to be only moderate. A biopsy at colposcopy should be performed at a gold standard level to detect high grade lesions.

Long-term outcomes of a loop electrosurgical excision procedure for cervical intraepithelial neoplasia in a high incidence country.

AIM: To evaluate the operative, oncologic and obstetric outcomes of the loop electrosurgical excision procedure (LEEP) in cases with cervical neoplasia. MATERIALS AND METHODS: A retrospective cohort study was conducted on patients who were suspected of cervical neoplasia and therefore undergoing LEEP at Siriraj Hospital, Mahidol University, Thailand, during 1995-2000. Outcome measures included operative complications in 407 LEEP patients and long-term outcomes in the 248 patients with cervical intraepithelial neoplasia (CIN) who were treated with only LEEP. RESULTS: There were 407 patients undergoing LEEP; their mean age was 39.7±10.5 years. The histopathology of LEEP specimens revealed that 89 patients (21.9%) had lesions ≤CIN I, 295 patients (72.5%) had CIN II or III, and 23 patients (5.6%) had invasive lesions. Operative complications were found in 15 patients and included bleeding (n=9), and infection (n=7). After diagnostic LEEP, 133 patients underwent hysterectomy as the definite treatment for cervical neoplasia. Of 248 CIN patients who had LEEP only, seven (2.8%) had suffered recurrence after a median of 16 (range 6-93) months; one had CIN I, one had CIN II, and five had CIN III. All of these recurrent patients achieved remission on surgical treatment with re-LEEP (n=6) or simple hysterectomy (n=1). A significant factor affecting recurrent disease was the LEEP margin involved with the lesion (p=0.05). Kaplan-Meier analysis showed 5-year and 10-year disease-free survival (DFS) estimates of 99.9%. Twelve patients became pregnant a total of 14 times, resulting in 12 term deliveries and two miscarriages - one of which was due to an incompetent cervix. CONCLUSIONS: LEEP for patients with cervical neoplasia delivers favorable surgical, oncologic and obstetric outcomes.

Performance of Siriraj liquid-based cytology: a single center report concerning over 100,000 samples.

BACKGROUND: To evaluate the performance of Siriraj liquid-based cytology (LBC) for cervical neoplasia screening after increasing use of this technology. MATERIALS AND METHODS: Cytological reports of 103,057 Siriraj-LBC specimens obtained in 2007-2009 were compared with those of 23,676 specimens obtained in 2006. RESULTS: Comparing with the year 2006, the 2007-2009 patients were slightly older (43.4 ± 12.yr vs 42.7 ± 12.2 yr, p <0.001), and their specimens had much lower proportion of unsatisfactory slides (OR=0.06, 95%CI 0.04-0.09) with comparable detection rates (3.96% vs 3.70%, p=0.052) but different proportions of various cytological abnormalities (p<0.001). The 2007-2009 Siriraj-LBC had a negative predictive value (NPV) for cervical intraepithelial neoplasia 2+ (CIN2+) of 97.6% and an overall positive predictive value (PPV) of 43.9%. The PPV for CIN2+ varied with types of abnormal cytology, from 13.7% to 93.8% in atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), atypical squamous cells cannot exclude HSIL (ASC-H), high-grade squamous intraepithelial lesion (HSIL), atypical glandular cells (AGC), to squamous cell carcinoma (SCC), respectively. The PPVs for CIN2+ in ASCUS and LSIL were comparable, but the PPV for CIN1 was higher for LSIL than for ASCUS (41.63% vs 16.32%). CONCLUSIONS: Siriraj-LBC has demonstrated a stable detection rate and NPV for CIN2+ of >95% since the first year of use. The comparable PPVs for CIN2+ of ASCUS and LSIL suggests that these two conditions may undergo similar management; other cytological abnormalities need immediate evaluation.

Performance and cost analysis of Siriraj liquid-based cytology: a direct-to-vial study.

OBJECTIVE: To compare the cytological diagnoses, specimen adequacy, and cost of the Siriraj liquid-based cytology (LBC) with those of the conventional smear technique. STUDY DESIGN: An observational study with historical comparison was conducted in a tertiary university hospital. Cytological reports of 23,676 Siriraj-LBC specimens obtained in 2006 were compared with those of 25,510 conventional smears obtained in 2004. RESULTS: Overall prevalence of abnormal cervical cytology detected by conventional smear was 1.76% and by Siriraj-LBC was 3.70%. Compared with the conventional method, the Siriraj-LBC yielded a significantly higher overall detection rate of abnormal cervical cytology, with a 110.23% increase in the detection rate (P<0.001), mainly due to the increase in diagnosis of squamous intraepithelial lesions (SIL), both low and high grade, together with atypical squamous cells of undetermined significance, "atypical squamous cells cannot exclude HSIL", and malignancies, but not atypical glandular cells. The Siriraj-LBC had a smaller proportion of unsatisfactory slides (4.94% vs. 18.60%, P<0.001) and a higher negative predictive value (96.33% vs. 92.74%, P=0.001), but no difference in positive predictive value (83.03% vs. 86.83%, P=0.285). The cost of Siriraj-LBC was approximately 67% higher than that of the conventional cytology used in Siriraj Hospital and 50-70% lower than that of the commercially available LBC techniques in Thailand. CONCLUSION: The Siriraj-LBC increases the detection rate of abnormal cytology, improves specimen adequacy, and enhances the negative predictive value without compromising the positive predictive value. For centers where conventional Pap smear does not perform well, the introduction of a low cost Siriraj-LBC might help to improve performance and it may be an economical alternative to the commercially available liquid-based cytology.

Meigs' Syndrome with Elevated Serum CA125: Case Report and Review of the Literature.

An elevated serum CA125 level in association with a pelvic mass, pleural effusion, and massive ascites usually signifies a dismal prognosis in a postmenopausal woman. However, surgery and histopathological examination are required for the correct diagnosis and treatment, since an elevated CA125 level can be falsely positive for ovarian malignancy. We present a case of Meigs' syndrome due to right ovarian fibroma with elevated CA125 level in a postmenopausal woman.

Comparison between Siriraj liquid-based and conventional cytology for detection of abnormal cervicovaginal smears: a split-sample study.

This study aimed to evaluate the correlation and agreement between Siriraj liquid-based cervical cytology (Siriraj -LBC) and conventional cytology. A total of 479 women who attended the Department of Obstetric and Gynaecology Siriraj Hospital for cervical cancer screening were enrolled. For each woman collection of cervical cells was performed using VCE technique. After smearing cells on a glass slide for conventional cytology, both broken ends of wooden spatula and cotton swabs were then placed into a plastic vial containing a specific preservative solution for Siriraj-LBC. All specimens were prepared and interpreted by experienced cytotechnologists at the Gynecologic Cytology Unit. Interpretations of the results from one technique were made without knowledge of those from the other technique. The results from both techniques were compared for agreement and correlation. Colposcopy or histology was used as the gold standard. The overall detection rate of abnormal cervicovaginal cells was higher by Siriraj-LBC than by conventional cytology (11.1% vs. 1.67%, P <0.001). These two techniques had high diagnostic agreement of 89.77%, and minimal to fair correlation with a Kappa of 0.128 (P<0.001) and a Spearman rho correlation coefficient of 0.394 (P <0.001). There were 49 cases whose Siriraj-LBC revealed higher cytologic grading than did the conventional cytology; there were no cases of the opposite result. The gold standard was available in 45 cases with abnormal cytology by Siriraj-LBC, revealing a positive predictive value (PPV) of 71.1% for Siriraj-LBC and 97.8% for conventional cytology, and a negative predictive value (NPV) of 42.2% for the conventional cytology. In conclusion, The results from Siriraj-LBC and conventional cytology have high diagnostic agreement and minimal to fair correlation. The Siriraj-LBC increases detection rate of abnormal cervicovaginal cells with probable decrease in false negatives but increase in false positives from the baseline values by conventional cytology. Therefore the screening performance of Siriraj-LBC is not inferior to the conventional cytology and this approach may be used as an alternative screening method for cervical cancer.