Câncer de colo uterino na gestação / Cervical cancer in pregnancy

PONTOS-CHAVE • A incidência de câncer durante a gestação tem aumentado devido à tendência das mulheres em postergar a gravidez. O câncer de colo de útero é a terceira neoplasia mais comumente diagnosticada durante o período gestacional. • O rastreamento e o diagnóstico devem se dar como nas pacientes não gestantes; a citologia oncótica cervical é o exame obrigatório do pré-natal, e a colposcopia com biópsia pode ser realizada em qualquer período da gestação. • A gestação complicada pelo diagnóstico de um câncer deve sempre ser conduzida em centro de referência e por equipe multidisciplinar. • A interrupção da gestação em situações específicas, para tratamento-padrão, é respaldada por lei. • A quimioterapia neoadjuvante é uma alternativa segura de tratamento durante a gestação, para permitir alcançar a maturidade fetal. Apresenta altas taxas de resposta, sendo relatada progressão neoplásica durante a gestação em apenas 2,9% dos casos. O risco de malformações fetais decorrentes da quimioterapia é semelhante ao da população geral. Contudo, a quimioterapia está associada a restrição de crescimento intraútero, baixo peso ao nascer e mielotoxicidade neonatal. • Na ausência de progressão de doença, deve-se levar a gestação até o termo.

Conservative Treatment of Stage IA1 Cervical Carcinoma Without Lymphovascular Space Invasion: A 20-year Retrospective Study in Brazil / Tratamento conservador do câncer do colo do útero IA1 sem invasão linfovascular: estudo retrospectivo no Brasil

Abstract Purpose: To evaluate recurrence rates and risk factors among women with stage IA1 cervical cancer without lymph vascular space invasion managed conservatively. Methods: retrospective review of women with stage IA1 squamous cervical cancer who underwent cold knife cone or loop electrosurgical excision procedure, between 1994 and 2015, at a gynecologic oncology center in Southern Brazil. Age at diagnosis, pre-conization findings, conization method, margin status, residual disease, recurrence and survival rates were collected and analyzed. Results: 26 women diagnosed with stage IA1 squamous cervical cancer without lymphovascular space invasion underwent conservative management and had at least 12 months follow-up. The mean follow-up was 44.6 months. The mean age at diagnosis was 40.9 years. Median first intercourse occurred at age 16 years, 11.5% were nulliparous and 30.8% were current or past tobacco smokers. There was one Human immunodeficiency virus positive patient diagnosed with cervical intraepithelial neoplasia grade 2 at 30 months after surgery. However, there were no patients diagnosed with recurrent invasive cervical cancer and there were no deaths due to cervical cancer or other causes in the cohort. Conclusion: Excellent outcomes were noted in women with stage IA1 cervical cancer without lymphovascular space invasion and with negative margins who were managed conservatively, even in a developing country.

Resumo Objetivo: Avaliar recidiva e seus fatores de risco em mulheres com câncer do colo do útero estádio IA1 sem invasão do espaço linfovascular tratadas conservadoramente. Métodos: Estudo de coorte retrospectivo de pacientes com câncer do colo do útero IA1 escamoso submetidas a cone do colo do útero, entre 1994 e 2015, em um centro de ginecologia oncológica do sul do Brasil. Foram revisados e analisados idade no diagnóstico, achados pré-conização, método de conização, margens, doença residual, recorrência e sobrevida. Resultados: 26 mulheres diagnosticadas com câncer do colo do útero estádio escamoso sem invasão do espaço linfovascular foram submetidas a tratamento conservador, com seguimento mínimo de 12 meses. O tempo médio de seguimento foi 44,6 meses. A média de idade no diagnóstico foi 40,9 anos. A primeira relação sexual ocorreu aos 16 anos (mediana), 11,5% eram nulíparas e 30,8% eram tabagistas atuais ou passadas. Houve um caso de recidiva de neoplasia intraepitelial cervical grau 2 aos 30 meses em uma paciente com vírus da imunodeficiência humana. Não houve pacientes diagnosticados com câncer de colo do útero invasor recorrente, e não houve mortes por câncer do colo do útero ou outras causas. Conclusão: Os resultados observados após tratamento conservador em mulheres com câncer cervical escamoso IA1 sem invasão do espaço linfovascular com margens negativas foram excelentes, mesmo em um país em desenvolvimento.

When is There no Benefit in Performing a Biopsy in the Suspicion of Intraepithelial Lesions of the Cervix? / Quando não há benefício em realizar biópsia na suspeita de lesões intraepiteliais do colo uterino?

Abstract Objective To evaluate whether colposcopy-directed biopsy is necessary to increase the accuracy of diagnosing cervical intraepithelial lesions in relation to colposcopy. Methods We performed a retrospective, observational study by analyzing medical records obtained fromHospital de Clínicas do Paraná fromFebruary 2008 to February 2018. Patients with results of Pap tests, colposcopy, colposcopy-directed biopsy, and surgical procedures (high-frequency surgery or cold conization) were included. Data such as quadrants involved during colposcopy and age differences were also analyzed. Results A total of 299 women were included. Colposcopy was found to have an accuracy rate of 76.25% (95% confidence interval [CI], 71.4-81.1). Among the highest-grade lesions, the accuracy rate was 80.5% (95% CI, 75.7-85.3). The accuracy rates for biopsy were 79.6% (95% CI, 75-84.2) and 84.6% (95% CI, 80-89.1) for the highest-grade lesions. High-grade lesions were accurately confirmed in 76.9% and 85% of patients with 1 and 2 or more affected quadrants, respectively. For women younger than 40 years, the accuracy rates were 77.6% and 80.8% for colposcopy and biopsy, respectively. For women 40 years or older, the accuracy rates were 72.5% and 76.3% for colposcopy and biopsy, respectively. Conclusion There is no difference between the accuracy of colposcopy and that of biopsy in diagnosing cervical intraepithelial lesions in relation with the result of conization. The patients who received the greatest benefit when biopsy was not performed were those with high-grade lesions at colposcopy, a lesion involving 2 or more quadrants, and those younger than 40 years.

Resumo Objetivo Avaliar se a biópsia colpodirigida é necessária para aumentar a acurácia diagnóstica nas lesões intraepiteliais de colo uterino em relaçãoà colposcopia. Métodos Estudo retrospectivo, observacional, incluindo pacientes submetidas a colposcopia, biópsia colpodirigida, e procedimento cirúrgico (cirurgia de alta frequência ou conização a frio), no período de fevereiro de 2008 a fevereiro de 2018, no Hospital de Clínicas da Universidade Federal do Paraná. Dados como número de quadrantes da lesão presentes na colposcopia, número de fragmentos retirados nas biópsias e diferenças por idade também foram analisados. Resultados Um total de 299 mulheres foram incluídas. Foi encontrada uma acurácia de 76,25% (intervalo de confiança [IC] 95% 71,4-81,1) entre a colposcopia e a conização, sendo 80,5% % (IC 95% 75.7-85.3) nas lesões de maior grau. A acurácia da biópsia foi de 79,6% (IC 95% 75-84,2), sendo 84,6% (IC 95% 80-89,1) nas lesões de maior grau. Pacientes com 1 quadrante acometido tiveram confirmação de 76,9% nas lesões de maior grau, enquanto as com 2 quadrantes acometidos apresentaram o mesmo resultado em 85% dos casos. A acurácia com a biópsia de 1 fragmento foi de 78% e com2 ou mais fragmentos 80%. Paramulheres com menos de 40 anos, a acurácia foi de 77,6% e 80,8% para colposcopia e biópsia, respectivamente. Para mulheres com 40 anos ou mais, a acurácia foi de 72,5% e 76,3% para colposcopia e biópsia, respectivamente. Conclusão Não há diferença entre a acurácia da colposcopia e a da biópsia colpodirigida no diagnóstico de lesões intraepiteliais cervicais em relação ao resultado da conização. As pacientes que tiveram o maior benefício quando a biópsia não foi realizada foram as que apresentaram lesão de alto grau na colposcopia e aquelas com menos de 40 anos, não existindo benefício emrealizar biópsia previamente a conização neste grupo de pacientes.

Neoplasia intraepitelial escamosa cervical de alto grau: abordagem ambulatorial / High-grade cervical intraepithelial neoplasia: outpatient approach

As neoplasias intraepiteliais cervicais correspondem a alterações identificadas por rastreamento citológico cervical e estudo histológico, pós-biópsia incisional guiada por colposcopia ou procedimento diagnóstico excisional. Podem ser tratadas com abordagens conservadoras e procedimentos excisionais. A vacinação anti-HPV e o tratamento excisional oportuno constituem, respectivamente, prevenção primária e secundária contra o câncer do colo uterino.(AU)

Cervical intraephitelial neoplasms correspond to changes identified by cervical citological screening and histological study, post-incisional biopsy guided by colposcopy or excisional diagnostic procedure. They can be treated with conservative approaches and excision procedures. Anti-HPV vaccination and timely excional treatment are primary and secondary prevention against cervical cancer, respectively.(AU)

Efectividad del cono LEEP en pacientes con lesiones intraepiteliales de alto grado en la Unidad de colposcopia del Servicio de Ginecología del Hospital de la Mujer / Effectiveness of the LEEP cone in patients with high-grade intraepithelial injuries in the colposcopy Unit of the Gynecology Service of La Mujer Hospital

OBJETIVO. Determinar la efectividad del CONO LEEP en pacientes con lesión intraepitelial de Alto Grado (LIE AG). MATERIAL Y MÉTODO. Estudio de tipo descriptivo, retrospectivo y transversal que incluyo a 68 pacientes quienes fueron sometidas a CONO LEEP por lesiones intraepiteliales de alto grado en el año 2014 en la unidad de colposcopia del Hospital de la Mujer. Se analizó la efectividad a través de la persistencia y/o recidiva de los controles posteriores en el año 2015. RESULTADOS. 33 pacientes realizaron control PAP posterior al CONO LEEP siendo el resultado citológico negativo para lesión intraepitelial más frecuente llegando a un porcentaje de 91% (30 pacientes). Se identificó que el 9% (3 pacientes) presento persistencia al tratamiento con CONO LEEP. CONCLUSIONES. El estudio determino la efectividad del procedimiento en las pacientes que acudieron a control citológico, se estimó en 91 %, lo cual demuestra que la conización es un método de ALTA EFECTIVIDAD con un 9% de persistencia encontrándose en los rangos esperados de persistencia de la NIC que es entre el 5 y el 17% de acuerdo a protocolos de Brasil, México y España.

OBJETIVE. To determine the effectiveness of the LEEP CONE in patients with High Grade Intraepithelial Lesion (HLL). MATERIAL AND METHOD. A descriptive, retrospective and crosssectional study that included 68 patients who underwent LEEP CONE for high-grade intraepithelial lesions in 2014 in the colposcopy unit of La Mujer Hospital. The effectiveness was analyzed through the persistence and / or recurrence of subsequent controls in 2015. RESULTS. 33 patients underwent PAP control after the LEEP CONE, the cytological result being negative for the most frequent intraepithelial lesion, reaching a percentage of 91% (30 patients). It was identified that 9% (3 patients) presented persistence to treatment with LEEP CONE. CONCLUSIONS. The study determined the effectiveness of the procedure in patients who attended cytological control, it was estimated at 91%, which shows that conization is a HIGH EFFECTIVENESS method with a 9% persistence, being in the expected ranges of persistence of the NIC which is between 5 and 17% according to the protocols of Brazil, Mexico and Spain.

Benefício da vacinação contra o HPV em pacientes submetidas a conização para remoção de lesão intra-epitelial cervical de alto grau / Benefit of HPV vaccination in patients undergoing conization to remove a high-grade cervical intraepithelial lesion

RESUMO Objetivo: Realizar uma breve revisão bibliográfica que mostre as mais recentes evidências científicas que permitam determinar se há benefícios em vacinar contra o HPV (Papilomavírus Humano) mulheres que já realizaram conização para tratamento de lesões pré- -malignas do colo do útero. Método: Foram revisados 5 artigos atualizados e específicos ao tópico, além de estudos em outras fontes bibliográficas. Resultados: Todos os artigos estudados revelaram forte fator protetivo da vacina em relação à recorrências de apresentação da patologia. Conclusão: Nossa revisão não indicou efeito terapêutico próprio da vacinação, mas indicou que há papel adjuvante ao tratamento cirúrgico, sendo uma associação em favor da proteção da mulher já tratada para a patologia relacionada ao HPV. PALAVRA-CHAVE: Conização, vacina, HPV, NIC, LEEP

ABSTRACT Objective: To carry out a brief literature review showing the latest scientific evidence to determine whether women who have already undergone conization for the treatment of pre-malignant lesions of the cervix are benefited from the vaccine against HPV (Human Papillomavirus). Method: Five updated and topic-specific articles were reviewed, as well as studies in other bibliographic sources. Results: All articles studied revealed a strong protective factor of the vaccine in relation to recurrent presentation of the pathology. Conclusion: Our review did not indicate a therapeutic effect of vaccination itself, but it indicated that there is an adjuvant role to surgical treatment, being a combination in favor of protecting women who have already been treated for HPVrelated pathology. KEYWORDS: Conization, vaccine, HPC, CIN, LEEP

Células glandulares atípicas: abordagem ginecológica / Atypical glandular cells: gynecological approach

As células glandulares atípicas representam 0,2% a 2,1% dos resultados dos testes de Papanicolaou. Mesmo com essa baixa prevalência, tem um significado importante no diagnóstico do câncer cervical e endometrial, tendo em vista que tais células e subcategorias, associadas à idade da paciente, podem prenunciar um número expressivo de doença intraepitelial, doença invasiva do endocérvix, endométrio e até neoplasias anexiais. E não se pode esquecer do importante número de resultados histológicos benignos, identificados no seguimento dessas pacientes, muitas vezes assintomáticas.(AU)

Atypical glandular cells represent 0,2% to 2,1% of Pap test results even with this low prevalence has an important significance in the diagnosis of cervical and endometrial cancer, considering that such cells and subcategories associated with the patient's age can predict a significant number of intraepithelial disease, invasive disease of the endometrium, endocervix and even adnexial neoplasms; no forgetting the important number of benign histological results, identified in the follow up of these patients, often asymptomatic.(AU)

Analysis of conization results in patients undergoing hysterectomy for uterine adenocarcinoma / Análise dos resultados de conização nos pacientes submetidos a histerectomia por adenocarcinoma uterino

Abstract Objective To observe if the histopathological result of a conization performed after cervical adenocarcinoma in situ diagnosis is compatible with the histopathological analysis of a subsequent hysterectomy. Methods The present descriptive and observational research consisted of the analysis of the medical records of 42 patients who were diagnosed with in situ adenocarcinoma postconization. The analysis consisted of whether there was compatibility between the histopathological reports of conization and hysterectomy and if there was an association between adenocarcinoma in situ and another neoplasia (squamous disease). Interpretation of any immunohistochemistry reports obtained was also performed. In addition, clinical and epidemiological data were also analyzed. Results A total of 42 conizations were performed, 33 (79%) were cold knife conizations and 9 (21%) were loop electrosurgical excision procedures (LEEPs). Of the patients analyzed, 5 (10%) chose not to undergo subsequent hysterectomy to preserve fertility or were < 25 years old. Out of the 37 patients with adenocarcinoma in situ who underwent subsequent hysterectomy, 6 (16%) presented with residual disease. This findingprovedincompatiblewiththe finding of the conizations, which had ruled out invasive cancer. Conclusion The prevalence of adenocarcinoma in situ increased in the past years. There is still a large part of the medical literature that advocates the use of conservative treatment for this disease, even though it is common knowledge that it is a multifocal disease. However, the majority of studies advocate that hysterectomy should remain the preferred treatment for women who have already completed their reproductive purpose.

Resumo Objetivo Observar se o resultado proveniente de uma conização realizada após o diagnóstico de adenocarcinoma cervical in situ é compatível com a análise histopatológica da histerectomia. Métodos A pesquisa foi descritiva e observacional e consistiu na análise de prontuário de 42 pacientes que tiveram o diagnóstico de adenocarcinoma in situ obtidas por conização. Foram analisados se havia compatibilidade entre os laudos de conização e histerectomia, margens do cone, se havia associação com outra patologia (doença escamosa) e interpretação de eventuais laudos histoquímicos obtidos. Além disso, também foram analisados dados clínico-epidemiológicos. Resultados Foram realizadas 42 conizações, sendo 33 (79%) por cone clássico e 9 (21%) por cirurgia de alta frequência. Das pacientes analisadas, 5 (10%) não foram submetidas a histerectomia por desejarem manter a fertilidade ou por terem idade < 25 anos. Das 37 pacientes com adenocarcinoma in situ no exame prévio realizado e que foram submetidas à histerectomia posteriormente, 6 (16%) apresentaram doença residual após o procedimento cirúrgico, apresentando laudos do anatomopatológico pós-histerectomia incompatíveis com o achado na conização que atestava margens livres. Conclusão A prevalência do adenocarcinoma in situ vemaumentando cada vez mais. Ainda há uma grande parte da literatura que defende o uso do tratamento conservador para esta doença, mesmo sabendo que ela é uma doença multifocal e que pode estar presente mesmo em situações nas quais o anatomopatológico evidencie margens livres. Tendo em vista essas características, a maioria preconiza que a histerectomia continua a ser o tratamento preferencial nas mulheres que já completaram o seu intuito reprodutivo.

Efficacy and safety of cryotherapy, cold cone or thermocoagulation compared to LEEP as a therapy for cervical intraepithelial neoplasia: Systematic review / Eficacia y seguridad de crioterapia, cono frio o termo-coagulación en comparación con LEEP como terapia para la neoplasia intraepitelial cervical: Revisión sistemática

ABSTRACT OBJECTIVES To determine the efficacy and safety of the use of cryotherapy, cold knife or thermocoagulation compared to Loop Electrosurgical Excision Procedure (LEEP) for the treatment of cervical intraepithelial neoplasia. METHODS Systematic review with meta-analysis of randomized controlled trials in women with cervical intraepithelial neoplasia undergoing treatment with cryotherapy, cold knife, or thermo-coagulation compared with LEEP, to estimate its efficacy and safety. The search was conducted on MEDLINE/PUBMED, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus, until September 2018. RESULTS The total of 72 studies were identified, of which only 8 studies met the inclusion criteria. The treatment of CIN with cold knife decreases the risk of residual disease compared with LEEP (RR, 0.54, 95%CI, 0.30-0.96, p = 0.04). The management of premalignant lesions with cryotherapy, compared with LEEP, increases the risk of disease recurrence by 86% (RR, 1.86, 95%CI, 1.16-2.97, p = 0.01), increases the risk of infections (RR, 1.17, 95%CI, 1.08-1.28, p < 0.001) and reduces the risk of minor bleeding by 51% (RR, 0.49, 95%CI) %, 0.40-0.59, p ≤ 0.001). CONCLUSIONS The treatment of premalignant lesions of cervical cancer with cold knife reduces the risk of residual disease. Nevertheless, cryotherapy reduces the risk of minor bleeding in the 24 hours after treatment and increases the risk of recurrence of disease and infections.

RESUMEN OBJETIVOS Evaluar la eficacia y seguridad del uso de crioterapia, cono frio o termo-coagulación en comparación con el procedimiento de escisión electroquirúrgica en asa (LEEP) para el manejo de neoplasias intraepiteliales cervicales. MÉTODOS Revisión sistemática de ensayos controlados aleatorizados en mujeres con neoplasia intraepitelial cervical en tratamiento con crioterapia, cono frio, o termo coagulación y LEEP, para estimar su eficacia y seguridad. La búsqueda se realizó en MEDLINE/PUBMED, Registro Cochrane Central de Ensayos Controlados (CENTRAL) y Scopus, hasta setiembre de 2018. RESULTADOS Se identificaron 72 estudios, ocho cumplieron los criterios de inclusión. Cono frio disminuyó el riesgo de enfermedad residual en comparación con LEEP (RR 0,54; IC del 95%, 0,30-0,96, p = 0,04). Crioterapia en comparación con LEEP incrementó el riesgo de recurrencia de enfermedad en un 86,0% (RR 1,86; IC del 95%, 1,16-2,97, p = 0,01) con un tiempo de seguimiento de seis a 24 meses, y de infecciones (RR, 1,17; IC del 95%, 1,08-1,28, p < 0,001); pero redujo el riesgo de sangrado menor en un 51,0% (RR 0,49; IC del 95%, 0,40-0,59, p ≤ 0,001). CONCLUSIONES Cono frio reduce el riesgo de enfermedad residual. Sin embargo, la crioterapia reduce el riesgo de sangrado menor en las 24 horas posteriores al tratamiento e incrementa el riesgo de recurrencia de enfermedad y de infecciones.

Pathologic discrepancies between colposcopy-directed biopsy and loop electrosurgical excision procedure of the uterine cervix in women with cytologic high-grade squamous intraepithelial lesions / 부인종양

OBJECTIVE: To investigate pathologic discrepancies between colposcopy-directed biopsy (CDB) of the cervix and loop electrosurgical excision procedure (LEEP) in women with cytologic high-grade squamous intraepithelial lesions (HSILs).METHODS: We retrospectively identified 297 patients who underwent both CDB and LEEP for HSILs in cervical cytology between 2015 and 2018, and compared their pathologic results. Considering the LEEP to be the gold standard, we evaluated the diagnostic performance of CDB for identifying cervical intraepithelial neoplasia (CIN) grades 2 and 3, adenocarcinoma in situ, and cancer (HSIL+). We also performed age subgroup analyses.RESULTS: Among the study population, 90.9% (270/297) had pathologic HSIL+ using the LEEP. The diagnostic performance of CDB for identifying HSIL+ was as follows: sensitivity, 87.8%; specificity, 59.3%; balanced accuracy, 73.6%; positive predictive value, 95.6%; and negative predictive value, 32.7%. Thirty-three false negative cases of CDB included CIN2,3 (n=29) and cervical cancer (n=4). The pathologic HSIL+ rate in patients with HSIL− by CDB was 67.3% (33/49). CDB exhibited a significant difference in the diagnosis of HSIL+ compared to LEEP in all patients (p<0.001). In age subgroup analyses, age groups <35 years and 35–50 years showed good agreement with the entire data set (p=0.496 and p=0.406, respectively), while age group ≥50 years did not (p=0.036).CONCLUSION: A significant pathologic discrepancy was observed between CDB and LEEP results in women with cytologic HSILs. The diagnostic inaccuracy of CDB increased in those ≥50 years of age.

Resultados de la conización por radiocirugía en pacientesatendidas en consulta de patología de cuello uterino / Results of Conization by Radiosurgery in patients treated in a Cervical Pathology Clinic

Introducción: La radiocirugía tiene como objetivo proporcionar una herramienta de diagnóstico y tratamiento. Objetivos: Describir los resultados de la conización por radiocirugía en pacientes atendidas en la consulta de patología de cuello uterino de la institución. Métodos: Se realizó una investigación descriptiva de corte transversal en el Hospital General Docente Mártires del 9 de Abril de Sagua la Grande, Villa Clara, Cuba. La población de estudio estuvo conformada por la totalidad de 256 pacientes atendidas en la consulta de patología de cuello uterino que fueron sometidas a conización por radiocirugía, entre enero 2013 y diciembre 2015. Para la recogida de la información se empleó la revisión de documentos y se confeccionó un modelo de recogida de datos. Resultados: El diagnóstico preoperatorio que aportó mayor cantidad de casos fue el NIC III (displasia severa) (78 casos; 30,5 por ciento). Conclusiones: Las lesiones premalignas en el presente estudio comenzaron a aparecer con marcada incidencia a partir de los 20 años y hasta los 49, sobresaliendo el grupo de 30 - 39 años. El aumento en el número de parejas sexuales, así como el comienzo temprano de las relaciones sexuales incrementan el riesgo de padecer lesiones intraepiteliales en el cuello del útero. A partir de los cinco años de iniciada las relaciones sexuales comienzan a aparecer las lesiones intraepiteliales cervicales, el diagnóstico preoperatorio que aportó mayor cantidad de casos fue el NIC III (displasia severa). En los diagnósticos histológicos por sacabocado y cono existió correspondencia en todos los casos(AU)

Introduction: Radiosurgery aims to provide a diagnostic and treatment tool. Objectives: To describe the results of conization by radiosurgery in patients treated in the cervical pathology clinic of the institution. Methods: A descriptive cross-sectional investigation was carried out at Mártires del 9 de abril General Teaching Hospital, in Sagua la Grande, Villa Clara, Cuba. The study population consisted of 256 patients attended in the cervical pathology clinic who underwent conization by radiosurgery, from January 2013 to December 2015. For the collection of the information, the document review was used and a data collection form was made. Results: The preoperative diagnosis that contributed the greatest number of cases was IAS III (severe dysplasia) (78 cases; 30.5 percent). Conclusions: The premalignant lesions in the present study began to appear with a marked incidence from the age of 20 and up to 49, with the group of 30-39 years standing out. The increase in the number of sexual partners, as well as the early sexual intercourse increase the risk of suffering intraepithelial lesions in the cervix. After five years of beginning sexual intercourse, cervical intraepithelial lesions begin to appear, the preoperative diagnosis that contributed the greatest number of cases was IAS III (severe dysplasia). In histological diagnoses by punch and cone correspondence existed in all cases(AU)

A randomized trial comparing limited-excision conisation to Large Loop Excision of the Transformation Zone (LLETZ) in cervical dysplasia patients / 부인종양

OBJECTIVE: To show noninferiority of a limited-excision (resection of the dysplastic lesion only) vs. classical Large Loop Excision of the Transformation Zone (LLETZ). METHODS: In this prospective, randomized, multicenter trial, women with human papillomavirus (HPV) positive cervical intraepithelial neoplasia grade 3 were randomized into two groups (1:1). Primary outcome was the rate of negative HPV tests after 6 months, secondary outcomes included cone size, complete resection rates as well as cytological and histological results after 6 and 12 months. A sample size of 1,000 was calculated to show noninferiority of the limited-excision compared to the LLETZ group using a noninferiority margin of 5%. Enrollment was stopped after 100 patients due to slow accrual. RESULTS: Patients in the limited-excision group did not show a lower number of negative HPV tests (78% [LLETZ]−80% [limited-excision]=−2%; 90% confidence interval=−15%, 12%). The limited-excision resulted in a substantially lower cone size (LLETZ: 1.97 mL vs. limited-excision: 1.02 mL; p < 0.001) but higher numbers of involved margins (LLETZ: 8% vs. limited-excision: 20%). Although postoperative cytological results slightly differed, histological results were similar in both groups. One limited-excision patient received immediate re-conisation, whereas one patient in each group was scheduled for re-conisation after 6 months. CONCLUSION: The limited-excision could represent a promising option to reduce the surgical extent of conisations while maintaining oncological safety. The trial was not sufficiently powered to reach statistical significance due to early termination. Nevertheless, the study provides important insights in the feasibility of a limited-excision and could serve as a pilot study for future trials. TRIAL REGISTRATION: German Clinical Trials Register Identifier: DRKS00006169

Artificial Neural Network Analysis of Spontaneous Preterm Labor and Birth and Its Major Determinants

BACKGROUND: Little research based on the artificial neural network (ANN) is done on preterm birth (spontaneous preterm labor and birth) and its major determinants. This study uses an ANN for analyzing preterm birth and its major determinants.

Hemoperitoneum: a complication of loop electrosurgical excision procedure

Loop electrosurgical excision procedure (LEEP) is commonly performed for the management of cervical intraepithelial neoplasia. Although LEEP is considered to be a relatively simple procedure, several unexpected complications have been reported in the literature. Herein, we report a case of hemoperitoneum caused by uterine perforation following LEEP. Blood collection in pelvic cavity and two small defects of the uterus were confirmed by diagnostic laparoscopy. The defects were sutured and the patient recovered well after the operation.

Tipificación viral en el seguimiento de conización: rol pronóstico de la persistencia del HPV post cono con asa / Viral typing in conization monitoring: prognostic role of HPV persistence post cone with loop

RESUMEN Fundamento: La persistencia del virus papiloma posterior a la conización del cuello uterino, se ha considerado un factor de riesgo para la persistencia de lesiones intra epiteliales (LIE) causadas por virus papiloma. Para determinar la asociación entre persistencia de lesión cervical y la presencia del virus papiloma posterior a la conización del cuello uterino, se realizó un estudio observacional prospectivo en un grupo de 123 pacientes portadoras de lesiones intraepiteliales de alto grado (LIEAG) tratadas con conización. Material y métodos: Se siguieron a 123 pacientes portadoras de LIEAG, ingresadas a la Unidad de Patología Cervical entre Abril de 2013 y Abril de 2014, las que fueron seguidas por 2 años hasta Abril de 2016. Se realizó genotipificación antes, y entre 4 a 6 meses posterior a la conización. Los datos se tabularon considerando la edad, paridad, tipo de virus, persistencia de LIE, reconización o requerimiento de histerectomía posterior. Resultados: La mediana de la edad fue de 37 años, el 91% fueron multíparas, y solo el 9% fueron nulíparas. El 56% ingresó por NIE III y el 44% por NIE II. Los virus más frecuentes fueron el 16, 31,58, 52 y 56. La persistencia de virus papiloma se constató en el 37% de las pacientes conizadas. La persistencia de LIE se observó en el 27% de las pacientes que fueron positivas para virus papiloma posterior a la conización, en comparación a sólo el 5% en las que fueron negativas. Del total de pacientes positivas para virus papiloma posterior a la conización, 12 de ellas presentaron persistencia de lesión confirmadas histológicamente por biopsia cervical, 8 pacientes requirieron recono por LIE de alto grado, 2 pacientes fueron a histerectomía y en 2 casos se realizó seguimiento estricto por NIE I. Cuando la tipificación post cono fue negativa solamente 3 pacientes requirieron conización y en sólo una se realizó seguimiento estricto por NIE I. Conclusión: La persistencia del virus papiloma posterior a la conización se asocia a mayor persistencia de LIEAG, mayor frecuencia de reconización o histerectomía posterior.

ABSTRACT Backgroud: The persistence of papilloma virus after conization of the cervix has been considered a risk factor for the persistence of cervical intra epithelial lesion (CIN) caused by papilloma virus. Aim: In order to determine the association between cervical lesion persistence and the presence of papilloma virus after conization, a prospective observational study was performed in a group of 123 patients with intraepithelial lesions treated with conization. Material and methods: We followed 123 patients with high grade CIN who were admitted to the Cervical Pathology Unit, between April 2013 and April 2014; they were followed for 2 years until April 2016. Viral genotyping was done before, and among the 4 to 6 months after the LEEP. Data were tabulated considering age, parity, type of virus, persistence of CIN, reconization or requirement of posterior hysterectomy. Results: The median age was 37 years, 91% were multiparous, and only 9% were nulliparous. 56% had NIE III and 44% NIE II. The most frequent viruses were 16, 31, 58, 52 and 56. The persistence of papillomavirus was present in 37% of patients. The persistence of CIN was observed in 27% of patients who were positive for papilloma virus after conization, compared to only 5% in those who were negative. Of the total number of patients positive for papilloma virus, in 12 of them had intra epitelial lesions were confirmed by cervical biopsy, 8 patients required recone for high grade CIN, 2 patients underwent hysterectomy, and 2 patients underwent follows up strictly by CIN I. When post cone typing was negative only 3 patients required conization and only one was followed strictly by CIN I.

Conduta pós-conização em casos de margem comprometida / Post conization conduct in cases of compromised margins

O comprometimento de margens pós-conização é uma situação que se apresenta ao médico, que aborda as neoplasias intraepiteliais do colo, com relativa frequência. Deve ser conduzida de forma individualizada, obedecendo algumas características da paciente e outras particularidades da própria doença, não se esquecendo que uma abordagem especificamente dirigida, com bom relacionamento médico-paciente, deverá ter prioridade.(AU)

The compromised margins post conization is a situation what one presents to a doctor, who approaches the neoplasias intra epiteliais of the cervix, with relative frequency; must be driven in the individualized form, obeying some characteristics of the patient and other peculiarities of the disease itself; not forgetting that an specific direct approach must be priority, with a good patient-medical relationship.(AU)

Terapéutica del cáncer de cuello uterino, una revisión de la literatura / Cervical cancer therapeutics: a literature review / Terapêutica do câncer de colo do útero, uma revisão de literatura

Introducción. El cáncer de cuello uterino es la segunda causa de muerte más frecuente mundialmente; por ello, existen terapias tanto invasivas como poco invasivas que buscan impactar la supervivencia de la enfermedad. Entre los diferentes métodos de tratamiento se encuentran la radioterapia externa, la braquiterapia, la quimioterapia, la conización, la traquelectomía y la histerectomía radical. Objetivo. Revisar las características de cada uno de los métodos de tratamiento disponibles para el manejo del cáncer de cuello uterino. Metodología. Se realizó una búsqueda, en las bases de datos PUBMED y LILACS, de artículos publicados entre los años 2013 y 2016 que tuvieran como tema central el cáncer de cuello uterino y su tratamiento; luego de aplicar criterios de inclusión y exclusión, se seleccionaron 41 artículos para la revisión. Resultados. Para el manejo del cáncer de cérvix se plantean, como métodos poco invasivos: la conización, con supervivencia a cinco años de 95.1% en cáncer microinvasor; la radioterapia de haz externo, con supervivencia total de 92.2% a cinco años; la quimioterapia, con supervivencia similar a la radioterapia, pero con disminución de la necesidad de cirugía; y la braquiterapia combinada con quimioterapia, que logró respuesta en 64% de pacientes con cáncer estadio IA, IIA y IB. En relación con métodos más invasivos, se encuentran la traquelectomía en cáncer temprano sin compromiso local o a distancia, alcanza supervivencia del 95%, con tasas de embarazo de 50% posteriores al tratamiento y la histerectomía radical, con supervivencia total de 100% a cinco años en cáncer estadio IA2 y IB1, requiriendo algunas veces combinación con otros métodos. Para las técnicas quirúrgicas se han desarrollado nuevos abordajes y variantes. Conclusiones. Los tratamientos en cáncer de cérvix han mostrado resultados alentadores en cuanto a supervivencia, además, la conización y traquelectomía permiten preservar la fertilidad. La quimioterapia, la radioterapia de haz externo y la braquiterapia logran buen control del cáncer de cérvix en estadios tempranos y se pueden usar como coadyuvantes de los métodos quirúrgicos. Sin embargo, la histerectomía radical es el estándar esencial para manejo del cáncer de cérvix, con buenos resultados en supervivencia; sus variantes, además, han logrado disminuir las complicaciones. [Suárez-Cadena FC. Terapéutica del cáncer de cuello uterino, una revisión de la literatura. MedUNAB. 2018;21(1):100-114.doi: 10.29375/01237047.2583].

Introduction. Worldwide, cervical cancer is the second most frequent cause of death, and because of its existence, there are several kinds of therapies that range between invasive to non-invasive ones. The purpose of these procedures is to impact disease survival within the human body. Thus, among those treatment methods used for cervical cancer treatment, we can find the following: external beam radiotherapy, brachytherapy, chemotherapy, cervical conization, trachelectomy, and radical hysterectomy. Objective. To review the characteristics of each one of the available methods for treating cervical cancer. Methodology. Published articles between 2013 and 2016 were collected using the databases PUBMED and LILACS. These articles had as a central topic cervical cancer and its treatment. After applying certain inclusion and exclusion criteria within the research, 41 articles were selected to be reviewed. Results. As non-invasive treatment methods for cervical cancer, the following are proposed: cervical conization method, which has a 5-year survival rate of 95.1% when treating micro-invasive cancer; external beam radiotherapy method, which has an overall 5-year survival rate of 92.2%; chemotherapy method, whose survival rate is similar to external beam radiotherapy method's one, but with a slight diminishing of surgery risk; and finally brachytherapy method, which combined with chemotherapy method achieves 64% of response among patients in cancer stages IA, IIA and IB. On the other hand, more invasive treatment methods are presented as follows: trachelectomy method when treating early cancer stages (with no local involvement or distant spreading) reaches a survival rate of 95% and a post-treatment pregnancy rate of 50%, and radical hysterectomy method has a 5-year survival rate of 100% among patients in cancer stage IA2 and IB1, in spite in some occasions this method requires to be combined with other treatment techniques. New therapeutic approaches and variations have been developed for surgical techniques. Conclusions.Cervical Cancer treatments have shown promising results regarding survival rate and in some procedures, such as conization and trachelectomy, preservation of fertility rate. Methods such as chemotherapy, external beam radiotherapy, and brachytherapy have a great control of cervical cancer in early stages, and they can also be used as adjuvant therapies for surgical interventions. Nonetheless, radical hysterectomy is the standard and essential medical procedure for managing cervical cancer. This method has shown good results regarding survival rates and its variants have helped to diminish associated complications. [Suárez-Cadena FC.Cervical cancer therapeutics: a literature review. MedUNAB. 2018;21(1):100-114.doi: 10.29375/01237047.2583]

Introdução. O câncer de colo do útero é a segunda causa de morte mais frequente no mundo e por isso, existem terapias invasivas e minimamente invasivas que buscam impactar na sobrevivência da doença. As principais opções de tratamento para o câncer de colo do útero são: a radioterapia externa, a braquiterapia, a quimioterapia, a conização, a traquelectomia e a histerectomia radical. Objetivo. Revisar as características de cada um dos métodos disponíveis para o tratamento do câncer de colo do útero. Métodos. Pesquisa feita nas bases de dados PUBMED e LILACS, de artigos publicados entre 2013 e 2016 com o assunto principal: tratamento do câncer de colo do útero e tratamiento. Foram selecionados 41 artigos para revisão, após a aplicação dos critérios de inclusão e exclusão. Resultados. Para o tratamento do câncer de colo de útero, os seguintes métodos são considerados minimamente invasivos: a conização, com sobrevida em cinco anos equivalente a 95,1% no câncer microinvasor; a radioterapia externa, com sobrevida total de 92,2% em cinco años; a quimioterapia, com sobrevida semelhante à radioterapia, mas com diminuição da necessidade de cirurgia; e a braquiterapia combinada com quimioterapia, que obteve resposta em 64% dos pacientes com estádio IA, IIA e IB. Em relação aos métodos mais invasivos, a traquelectomia no câncer precoce sem comprometimento 102local, ou à distância, atinge 95% de sobrevida, com 50% de taxas de gestação após o tratamento e histerectomia radical, com sobrevida total de 100% a cinco anos no estádio IA2 e IB1, requerendo às vezes combinação com outros métodos. Para técnicas cirúrgicas, novas abordagens e variantes foram desenvolvidas. Conclusões. Os tratamentos de câncer de colo do útero mostraram resultados encorajadores em termos de sobrevida, além disso, a conização e traquelectomia permitem preservar a fertilidade. A quimioterapia, a radioterapia externa e a braquiterapia conseguem um bom controle do câncer de colo do útero em estádios iniciais e podem ser usadas como coadjuvantes dos métodos cirúrgicos. Entretanto, a histerectomia radical é o padrão essencial para o tratamento de câncer de colo do útero, com bons resultados na sobrevida; suas variantes, além disso, conseguiram reduzir as complicações. [Suárez-Cadena FC.Terapêutica do câncer de colo do útero, uma revisão de literatura. MedUNAB. 2018;21(1):100-114.doi: 10.29375/01237047.2583].

Predicting factors for resumption of spontaneous voiding following nerve-sparing radical hysterectomy / 부인종양

OBJECTIVE: To determine factors affecting voiding recovery on the day of Foley catheter removal (postoperative day 7, POD7) after nerve-sparing radical hysterectomy (NSRH) for early-stage cervical cancer. METHODS: Early-stage cervical cancer patients, who underwent type C1 radical hysterectomy between January 2006 and June 2016 were included. Clinical and pathological data were reviewed. Association between inability to attain adequate voiding function on POD7 and potential predicting factors were evaluated in univariate and multivariate analysis. RESULTS: Of 755 patients, 383 (50.7%) resumed adequate voiding function on POD7 while 372 (49.3%) did not. Tumor size was larger in patients whose voiding function was inadequate (2.5 vs. 2.0 cm, p=0.001). Lengths of resected parametria and adjacent vagina were more extensive in patients with inadequate voiding function (p 4 cm (p 4 cm, postoperative urinary tract infection, and primary surgeon were significantly associated with inability to attain adequate voiding function on POD7. CONCLUSION: Extent of disease represented by tumor size, urinary tract infection as well as individual surgeon's technique independently predict resumption of adequate voiding function on POD7 following NSRH.

Is the ovarian preservation safe in young women with stages IB–IIA villoglandular adenocarcinoma of the uterine cervix? / 부인종양

OBJECTIVE: Because villoglandular adenocarcinoma (VGA) of the uterine cervix has favorable features and outcomes, patients receive less radical surgery and young women preserve their ovaries. We aimed to evaluate the clinicopathological features and outcomes of VGA and to see if the ovarian preservation is safe in young women with VGA. METHODS: We retrospectively reviewed medical records and identified patients with VGA, who had been treated and followed from January 2004 to December 2015. RESULTS: This study consisted of 17 patients with VGA, including 9 premenopausal women. International Federation of Gynecology and Obstetrics (FIGO) stage IB1 disease was found in 12 patients (70.6%), IA1 in 2, IA2 in 1, IB2 in 1, and IIA1 in 1. Of the 12 women diagnosed with stage IB1 disease, a young woman received only conization and she has not showed a recurrence. During a median follow-up of 58 months (range: 12–116), 4 patients, who had undergone radical surgery for stage IB1 disease, had a recurrence and one of them died due to disease progression. Among patients with stages IB–IIA disease, 2 premenopausal women did not receive simultaneous oophorectomy or chemoradiation therapy. Both of them had a recurrent tumor at adnexa. CONCLUSION: This study revealed favorable features and outcomes of VGA. However, the appropriate treatment for young women with early-stage VGA must be cautiously selected. Ovarian preservation might not be safe when young women with stages IB–IIA VGA undergo surgical procedures.

The use of conization to identify and treat severe lesions among prediagnosed CIN1 and 2 patients in Japan / 부인종양

OBJECTIVE: To evaluate the clinical efficiency of identifying patients with suspicious severe lesions by conization among prediagnosed cervical intraepithelial neoplasia (CIN) 1 and 2 patients in Japan. METHODS: The data in a Japanese nation-wide registry for cervical cancer (2009 and 2011) was collected to analyze the clinical efficacy of pre- and postdiagnosis for 13,215 Japanese women who underwent treatment by conization. Their preoperative and postoperative histologic findings and clinical outcomes were evaluated using standard statistical procedures including clinical and demographic characteristics. RESULTS: Almost half of 1,536 women who were treated by conization after the prediagnosis of CIN1 and 2 because the lesions showed no evidence of natural regression actually contained CIN1–2 (45.0%), CIN3 (47%), or invasive cancer (2.7%) in their cervical tissue. They underwent conization either for therapeutic (treatment) (78.5%) or diagnostic (21.5%) reasons. Invasive disease was diagnosed postoperatively more often in diagnostic cases (6.1%) than in therapeutic cases (2.8%). All the patients survived their diagnostic and therapeutic conization after approximately 30 months of follow up. CONCLUSION: Our study shows that the continuous observation of the prediagnosed CIN1 and 2 cases by the combination of cytology, colposcopy and histology in Japan has worked successfully to identify severe lesions by using conization as well in the process.