Intracellular signalling via the AKT axis and downstream effectors is active and prognostically significant in cancer of unknown primary (CUP): a study of 100 CUP cases.

BACKGROUND: Hypothesising that cancer of unknown primary (CUP) may harbour unique characteristics, we present a translational study of the immunohistochemical expression and clinical correlation of key PTEN/AKT pathway molecules. PATIENTS AND METHODS: We collected 100 paraffin-embedded CUP tissue blocks. We studied using tissue microarrays the expression of PTEN, phospho-AKT, Cyclin D1, p21, phospho-RPS6. From the percentage of staining tumour cells and the literature, we selected cut-offs to classify the expression of each biomolecule. We correlated IHC expression with clinical data. RESULTS: PTEN, pAKT, and pRPS6 showed frequent expression. At univariate analysis, high IHC expression of pAKT and pRPS6 displayed statistically significant association with worse survival. Prognosis was worse upon concurrent high IHC expression of pMAPK and pAKT {median overall survival = 8 months [95% confidence interval (CI) 5.3-10.7] versus 17 months [95% CI 13.1-20.9]}. In multivariate analysis, high p21 was associated with better survival (risk ratio [RR] = 0.34 [95% CI 0.16-0.73], P = 0.005). High expression of pAKT (RR = 2.39 [95% CI 1.23-4.66], P = 0.01) or pRPS6 (RR = 2.76 [95% CI 1.31-5.84], P = 0.008) was associated with worse survival. CONCLUSIONS: p21 expression conferred favourable prognosis, while high pAKT or pRPS6 expression predicted worse prognosis. Concurrent MAPK and pAKT expression had a marked adverse impact on survival.

High-risk human papillomavirus DNA test and p16(INK4a) in the triage of LSIL: a prospective diagnostic study.

OBJECTIVE: The detection of high-grade cervical intraepithelial neoplasia (CIN) amongst patients with low-grade cytology (LSIL) is challenging. This study evaluated the role of high-risk HPV (HR-HPV) DNA test and p16(INK4a) immunostaining in identifying women with LSIL cytology at risk of harboring CIN2 or worse (CIN2+) and the role of p16(INK4a) in the triage of a population of HR-HPV positive LSIL. METHODS: We conducted a prospective study including women with LSIL cytology. Detection of HR-HPV was carried out by means of a polymerase chain reaction based assay. p16(INK4a) immunostaining was performed using the Dako CINtec cytology kit. All patients had colposcopically directed punch biopsies or large loop excision of the transformation zone of the cervix. The endpoint was detection of a biopsy-confirmed CIN2+. RESULTS: A series of 126 women with LSIL cytology were included. HR-HPV test had sensitivity 75% and specificity 64% for an endpoint of CIN2+. p16(INK4a) had significantly higher specificity of 89% (p=0.0000) but low sensitivity of 42%. The role of p16(INK4a) immunostaining in the triage of LSIL positive for HR-HPV was also evaluated. p16(INK4a) triage had 70% positive predictive value (PPV); however, this was not significantly higher than the PPV (56%) of HR-HPV test alone (p=0.4). CONCLUSIONS: The results indicate that HR-HPV or p16(INK4a) cannot be used as solitary markers for the assessment of LSIL. The addition of p16(INK4a) immunostaining led to an increase in HR-HPV specificity; however, the biomarker needs to be assessed further to establish its role as an adjunct test in the triage of LSIL.

A twisted kiss: in vitro and in vivo evidence of genetic variation and suppressed transcription of the metastasis-suppressor gene KiSS1 in early breast cancer.

UNLABELLED: KiSS-1 is ametastasis suppressor gene, its inactivation linked to advanced tumor stage and dismal prognosis. We studied its mutational status ,transcription and protein expression in human cancer cell lines and patients with early breast cancer.
Tumor tissue DNA and messenger RNA (mRNA) of KiSS1 exons III and IV from the human cancer cell lines Hela, Jurkat, A549, W138t, MCF-7 and from formalin-fixed resected breast adenocarcinomas from 50 women were analysed by means of PCR-SSCP, RT-PCR and sequencing. Tumor tissue was stained for KiSS1 protein expression by means of the streptavidin-biotin complex immunoperoxidase assay. Presence of KiSS1 mutation, mRNA levels and protein staining were examined for correlations with patient/tumor characteristics.
A transversion in exon IVa replacing cytosine with guanine was identified 242 base pairs from the translation start site (242C>G) in the cell lines MCF-7, A549 and in 5/50 tumors (10%), resulting in substitution of proline by arginine (P81R) and alteration of the protein tertiary structure. As the substitution was present in germ-line DNA in 3/5 breast cancer patients harbouring the polymorphism in their tumor, the incidence of tumour-specific somatic mutation was 4% among the 50 patiens with early breast cancer. Although the P81R substitution was associated with reduced KiSS1 protein immunoreactivity (56% in wild-type tumors versus 20% in KiSS1-variant tumours) and with axillary nodal involvement (55% in wild-type versus 80% in KiSS1-variant tumors), the correlations did not reach statistical significance. KiSS1 mRNA was detected in only 15/48 tumours (31%) and showed no correlation with mutation or protein expression. Twenty-six tumors stained for KiSS1 protein, in contrast to the universal strong staining seen in normal breast parenchyma and placental tissues. At amedian follow-up of 38 months, relapses occurred in 20% of women with non wild-type tumors versus 13% of women with wild-type KiSS1 tumors (p=0.7). Presence of KiSS1 mutation, mRNA levels and protein expression did not have prognostic significance for relapse-free survival.
In conclusion, altered nucleotide sequence and repression of transcription are two potential mechanisms of suppression of the anti-metastatic effects of KiSS1 in early breast cancer: Confirmation in larger cohorts and study of functional effects of the 242C>G exon IVa mutation are warranted. KEYWORDS: KiSS1, metastasis-suppressor gene, breast cancer, mutation, transcription.

Intestinal-type metaplasia in the original squamous epithelium of the cervix.

There have been a number of reports on cervical carcinomas, both invasive and intraepithelial (CIN III), indicating the presence of intracellular mucins in the absence of glandular differentiation. Yet, the expression of such cells in the normal/original squamous epithelium of the cervix remains unexplored. We investigated the presence of mucin-distended goblet cells at this site, after examining retrospectively normal cervices from 250 hysterectomy specimens. Goblet cells were detected in 3.2% (8/250) of the cervices examined using haematoxylin and eosin stained sections and confirmed by mucin histochemistry: alcian blue (AB) pH 2.5, periodic acid-Schiff reaction with and without diastase digestion (PAS-d, PAS) and the combined AB/PAS. Additional sections were stained with Diazo and Masson-Fontana for argentaffin granules and Grimelius for argyrophil cells, but were all negative and no other cell types were identified. It is believed that this incomplete type of intestinal metaplasia is an acquired change in the cervix, derived from multi-potential stem cells of Müllerian duct origin.

Targeting c-KIT, PDGFR in cancer of unknown primary: a screening study for molecular markers of benefit.

AIMS: In view of available targeted therapies, we investigated the presence of c-kit, PDGFR gene mutations and protein expression in cancer of unknown primary (CUP) in order to study their contribution in pathogenesis, their prognostic value and potential as therapeutic targets. METHODS: Mutations in hot spots c-kit exon 11 and PDGFR exons 12 and 18 were studied in paraffin-embedded tumour samples from 50 patients with CUP by means of PCR-based single-strand conformational polymorphism and protein expression by means of streptavidin-biotin immunoperoxidase assays. Molecular markers were screened for possible correlations with patient outcome. RESULTS: No shifted band was detected in any of the polyacrylamide gel electrophoreses, indicating absence of c-kit exon 11 and PDGFR exon 12, 18 mutations. Immunohistochemical analysis in 37 tumours revealed positive membranous CD117 expression in 30 samples (81%) of which five exhibited strong (+3), four moderate (+2) and 21 weak (+1) staining. PDGFRa protein staining was seen in 15 out of 30 (50%) cases, mostly weak (13) and rarely moderate (1) or strong (1). The expression of KIT or PDGFRa protein did not correlate with the clinical outcome of the patients in our cohort. CONCLUSIONS: In a moderate-sized CUP patient cohort, KIT or PDGFRa protein overexpression is rare, does not have gross prognostic significance for survival and is not associated with presence of activating mutations.

Randomised comparison of growth hormone versus IGF-1 on early post-myocardial infarction ventricular remodelling in rats.

OBJECTIVE: Growth hormone and insulin-like growth factor-1 participate in post-myocardial infarction healing, but their relative importance is unclear. We compared the treatment effects of these agents on left ventricular remodelling. DESIGN: Wistar rats were randomised into a single dose of either growth hormone (0.5microg, n=29), or insulin-like growth factor-1 (0.5microg, n=27), delivered by direct intramyocardial punctures, and were compared with controls (n=30). Five minutes after treatment, myocardial infarction was generated by permanent ligation of the left coronary artery. Twenty-four hours post-ligation, serum levels of catecholamines were measured using radioimmunoassay and infarct size as well as infarct expansion index were calculated. The expression of genes related to extracellular matrix and angiogenesis was measured using polymerase chain reaction. RESULTS: Infarct expansion index was lower in growth hormone-treated rats (0.28+/-0.03, p=0.007) and in insulin-like growth factor-1-treated rats (0.35+/-0.03, p=0.044) compared to controls (0.51+/-0.06). Infarct size was significantly (p=0.0076) lower in growth hormone-treated rats (32.2+/-2.0%) and marginally (p=0.094) lower in insulin-like growth factor-1-treated rats (36.2+/-2.3%) compared to controls (42.0+/-2.7%). Survival rates were comparable in the three groups. Epinephrine was lower in the growth hormone group (2.8+/-0.2microg/l) compared to either controls (5.0+/-0.6microg/l, p=0.007), or to insulin-like growth factor-1-treated rats (6.3+/-0.6microg/l, p=0.0001). Collagen I and III expression in the infarct zone was higher in the growth hormone group compared to either the insulin-like growth factor-1 group or to controls. CONCLUSIONS: Both growth hormone and insulin-like-growth factor-1 decrease early infarct expansion, but growth hormone results in more favourable extracellular matrix remodelling and sympathetic activation.

Thrombospondin-1 expression in urothelial carcinoma: prognostic significance and association with p53 alterations, tumour angiogenesis and extracellular matrix components.

BACKGROUND: Thrombospondin-1 (TSP-1) is an extracellular matrix component glycoprotein, which is known to be a potent inhibitor of angiogenesis and may be important in cancer invasiveness. We examined the TSP-1 expression in correlation with conventional clinicopathological parameters to clarify its prognostic significance in bladder cancer. In addition, the possible correlation of TSP-1 expression with microvessel count, VEGF expression, p53 expression as well as with the expression of the extracellular matrix components was studied to explore its implication in vascularization and tumour stroma remodeling. METHODS: The immunohistochemical expression of TSP-1 in tumour cells and in the tumour stroma was studied in 148 formalin-fixed paraffin-embedded urothelial cell carcinoma tissue samples. RESULTS: TSP-1 was detected in perivascular tissue, at the epithelial-stromal junction, in the stroma and in tumour cells in the majority of the cases. In tumour cells, low TSP-1 expression was observed in 43% of the cases, moderate and high in 7%, while 50% showed absence of TSP expression. A higher TSP-1 immunoreactivity in well and moderately differentiated tumours compared to poorly differentiated was noted. PT1 tumours showed decreased TSP-1 expression in comparison to pTa and pT2-4 tumours. Increased tumour cell TSP-1 expression was related to increased microvessel density. In the tumour stroma, 37% of the cases showed small amount of TSP-1 expression, 7.5% moderate and high, while 55% of the cases showed absence of TSP-1 stromal immunoreactivity. Stromal TSP-1 expression was inversely correlated with tumour stage and tumour size. This expression was also positively correlated with microvessel density, VEGF expression and extracellular matrix components tenascin and fibronectin. Using univariate and multivariate analysis we didn't find any significant correlation of TSP-1 expression in superficial tumours in both tumour cells and tumour stroma in terns of the risk of recurrence and disease progression CONCLUSION: Our data suggest that both tumour and stromal TSP-1 expression may play a role in tumour aggressiveness and angiogenesis. In addition, the correlation of stromal TSP-1 expression with extracellular matrix components fibronectin and tenascin indicate its possible implication in tumour stroma remodeling.

Early, intracoronary growth hormone administration attenuates ventricular remodeling in a porcine model of myocardial infarction.

OBJECTIVE: Ventricular remodeling is a common corollary of myocardial infarction. We hypothesized that this process may be attenuated by growth hormone, administered as a single high-dose, selectively in the infarct zone, early postmyocardial infarction. DESIGN: In 35 pigs (29+/-4 kg), myocardial infarction was generated by inflation of an over-the-wire angioplasty balloon in the circumflex artery for 60 min and 5 further pigs were sham-operated. Ten minutes after reperfusion, the pigs were randomized (2:1) to either growth hormone (1 IU/kg) (n=23) or normal saline (n=12), delivered via the balloon catheter. All survivors were treated with captopril and were sacrificed 4 weeks after myocardial infarction. RESULTS: Compared to controls, growth hormone-treated animals displayed lower heart weight (4.1+/-0.5 g/kg body weight, versus 3.4+/-0.4 g/kg, respectively, p=0.003) and dimensions (left ventricular short axis diameter 46+/-7 mm versus 37+/-6 mm, p=0.01; right ventricular short axis diameter 38+/-7 mm versus 30+/-5 mm p=0.001). Growth hormone increased wall thickness in the infarct (6.0+/-1.8 in controls versus 9.9+/-3.7 in treated animals, p=0.004) and non-infarct zones (10.6+/-1.8 in controls versus 15.5+/-3.8 in treated animals, p=0.0006) and produced higher (p<0.05) microvascular density in both zones. CONCLUSION: Intracoronary administration of growth hormone attenuates left and right ventricular remodeling by inducing hypertrophy and by enhancing angiogenesis.

The role of fine-needle aspiration biopsy in the management of patients with thyroid nodules.

Fine-needle aspiration biopsy (FNAB) of the thyroid gland is the most cost-effective examination in the evaluation of thyroid nodules. The aim of this study was to present our experience from all patients who underwent thyroid FNA in the University Hospital of Ioannina, Greece, in the period 1993-2003, and its value in the diagnostic management of patients with thyroid nodules. FNA was performed in 900 patients of whom 753 were females and 147 males. The cases were classified according to diagnosis into five groups: benign/negative 628, primary carcinoma 28, metastatic carcinoma 5, suspicious/indeterminate 60 and non-diagnostic 179. Cytological findings were compared with histopathological findings and the statistical analysis in our data yielded the following results: sensitivity 92.1%, specificity 93.2%. These results are in accordance with the already published data in the international literature. In cases of differential diagnosis between adenomatoid hyperplasia and follicular neoplasia, four cases were diagnosed as hot nodules. In the benign group, three cases were diagnosed as nodular hyperplasia with cystic degeneration on FNA, but, after surgical treatment, histologically were diagnosed as papillary carcinomas. In the group of suspicious/indeterminate, two cases were diagnosed as suspicious for follicular neoplasia on FNA and, after surgical treatment, were diagnosed histopathologically as medullary carcinomas. In conclusion, we suggest that routine measurement of serum calcitonin is useful and mandatory in the detection of medullary carcinoma among patients with nodular thyroid diseases. Taking into consideration the clinical data can minimize false-positive and false-negative rates. We conclude that FNA is an effective screening test in the evaluation of the necessity for surgical treatment in patients with thyroid nodules.

Prognostic significance of thymidine phosphorylase in superficial bladder carcinoma.

OBJECTIVE: We investigated the expression of thymidine phosphorylase (TP) in bladder carcinomas and assessed its prognostic significance in superficial bladder cancer samples. PATIENTS AND METHODS: We studied 142 primary bladder cancer samples immunohistochemically for nuclear thymidine phosphorylase (TPN), cytoplasmic (TPC) and stromal (TPSTR) expression. We correlated them with standard clinicopathological features (grade, stage, concurrent in situ, multiplicity, primary or recurrent status), as well with recurrence and progression. We examined also the relationship between TP and tumor microvessel density. RESULTS: The level of all types of TP correlated well with stage, while grade correlated well only with TPSTR and the presence of carcinoma in situ only with TPN. Patients with low levels of TPN had a longer tumor free interval, during a 38.6 months mean follow up time. Regarding the association between TP count and microvessel density we found the strongest association with TPSTR (p=0.003), a borderline statistical significance with TPC (p=0.049) and no relationship with TPN (p=0.072). CONCLUSIONS: We suggest that the assessment of TPN might be useful for predicting recurrence in superficial bladder cancer. We propose also that TP may stimulate angiogenesis.

The value of neuroendocrine markers in non-small cell lung cancer: a comparative immunohistopathologic study.

In order to estimate the value of immunohistochemical identification of neuroendocrine (NE) differentiation markers in non-small cell lung carcinomas (NSCLCs), we investigated the expression of five neuroendocrine and neural differentiation-related antigens in 51 NSCLCs. Additionally, 20 epithelial lung tumors with NE differentiation [15 carcinoids and five small cell lung carcinomas (SCLCs)] and 61 epithelial tumors of various other origin (breast, prostate, colon and head-neck carcinomas) were studied. An indirect two-stage immunoperoxidase method was performed in formalin-fixed and paraffin-embedded tissue specimens, by using commercially available monoclonal antibodies. These antibodies are directed against neuron-specific enolase (NSE), chromogranin-A and Leu-7 which are general markers of NE differentiation, bombesin, which is a specific NE secretory product and neurofilament triplet protein (NFTP), an intermediate filament protein of neuronal differentiation. All five markers demonstrated a positive immunoreactivity in NSCLCs, equally distributed to all three histologic subtypes, ranging from 16 to 47% of the cases (NSE 47%, bombesin 21.5%, Leu-7 21.5%, chromogranin-A 18% and NFTP 16%). Most of the carcinoids and SCLCs expressed multiple or all NE markers. The other four epithelial tumors showed a positive immunoreactivity for bombesin, Leu-7 and NFTP, ranging from 11 to 40% of the cases. Chromogranin-A was not expressed in any of these tumors, whereas NSE was demonstrated only in 17% of breast carcinomas. The following remarks can be drawn from this study: (1) some NSCLCs showed immunophenotypic NE differentiation; (2) among all the markers used, NSE was the most sensitive (sensitivity, 100%) and chromogranin-A the most specific (specificity, 100%); and (3) NSE and chromogranin-A appear to be the most valuable and useful indicators of probable neuroendocrine differentiation in lung epithelial tumors.

Thermal tissue damage following laser and large loop conization of the cervix.

OBJECTIVE: To compare thermal injury zones produced with laser and diathermy loop conization. METHODS: Excisional cervical specimens (cones and cervices) were obtained from 40 consecutive women who underwent abdominal hysterectomy. The subjects were assigned to have either laser or diathermy loop conization (20 in each group). The duration of each procedure was recorded. Histopathologic measurements of thermal injury zones were performed in all specimens. RESULTS: The techniques produced cone specimens of similar depth. The mean depth of thermal injury produced with laser conization in cone specimens (mean +/- standard deviation 0.49 +/- 0.16 mm) and cervical craters (0.58 +/- 0.24 mm) was significantly greater (P < .001) than the corresponding depth in cone specimens (0.22 +/- 0.09 mm) and cervical craters (0.27 +/- 0.11 mm) obtained by diathermy loop excision. The mean time of the two procedures was also significantly different (P < .001); laser conization 11 +/- 4.5 minutes and loop conization 2 +/- 1.2 minutes. CONCLUSION: For routine conization, loop diathermy causes less thermal damage to the specimen and is a faster procedure than laser.

Human papillomavirus testing and the outcome of treatment for cervical intraepithelial neoplasia.

OBJECTIVE: To investigate whether human papillomavirus (HPV) testing could be used in the follow-up after large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia (CIN). METHODS: We performed a retrospective study of 41 women who developed subsequent CIN after LLETZ (group A) and 82 women without CIN for a minimum of 5 years after LLETZ (group B). The first post-treatment cervical smear was retrieved and examined for high-risk HPV deoxyribonucleic acid. The sensitivity, specificity, positive and negative likelihood ratio of HPV testing, first post-treatment Papanicolaou test, and excision margins for the detection of treatment failure were calculated. Multiple logistic regression analysis was also done. RESULTS: The HPV test was positive in 38 of 41 women in group A and 13 of 82 in group B (P <.001). An abnormal cytologic result in the first post-treatment smear was found in 20 of 41 in group A and 11 of 82 in group B (P <.001). Sixteen women in group A and 18 in group B had involved margins (P =.046). Values for the sensitivity, specificity, and positive and negative likelihood ratios of the HPV test were 93%, 84%, 5.8, 0.08; for the Papanicolaou test they were 49%, 87%, 3.9, 0.586; and for margin status they were 39%, 78%, 1.8, 0.782, respectively. Positive HPV test presents significantly high odds ratio for treatment failure (P <.001), independent of cytology and margin status. CONCLUSION: Women who postoperatively have positive HPV testing are at higher risk of treatment failure. This could be performed at the first post-treatment visit and further follow-up could be adjusted accordingly.

Clonal analysis by PCR and RFLP in breast cancer and precancerous lesions. Preliminary data.

In order to investigate the clonality in various benign, precancerous and malignant breast lesions, we analyzed small DNA samples from paraffin sections of various breast lesions by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) of the X-chromosome-linked phosphoglycerokinase (PGK) gene. DNA from the lesion as well as from the adjacent normal tissue were analyzed in each case. Two restriction endonucleases. Hpa-II, a methylation sensitive restriction enzyme and Bst XI, a restriction endonuclease, which recognizes this polymorphic site on the PGK gene, were used. Of 19 cases, one case of in situ ductal Ca (DCIS), two cases of invasive ductal Ca and one case of multifocal ductal Ca were shown to be monoclonal. Two cases of intraductal papillomas were found to be polyclonal. One case of atypical ductal hyperplasia showed no conclusive findings. Additionally DNA was not yielded from 3 cases and other 7 cases were not informative, derived from females homozygotes. Further study of a larger number of cases is in progress.

Immunohistochemical expression of Bcl-2 protein in breast lesions: correlation with Bax, p53, Rb, C-erbB-2, EGFR and proliferation indices.

Expression of bcl-2 protein was investigated and correlated with Bax, p53 and Rb proteins, c-erbB-2, EGFR and the proliferation indices PCNA, Ki-67 and MIB1 as well as with the conventional clinicopathological parameters in 95 cases for breast cancer tissue and 20 cases of benign hyperplastic lesions. Bcl-2 and Bax proteins immunoreactivity was detected in normal, hyperplastic and neoplastic breast epithelium. Expression of the bcl-2 protein was detected in 40% of carcinomas (> 10% positive neoplastic cells) and 85.2% of the benign hyperplastic lesions. Bax protein expression was detected in 8.1% of the carcinomas and 5.3% in the hyperplastic group. Rb and p53 proteins were detected in 75.5% and 45.5% of carcinomas. No relationship was observed between bcl-2 expression and patient's age, tumour size, tumour type and grade, lymph node status, Rb protein expression and proliferation indices. However, a strong positive relationship was detected between bcl-2 and Bax (p = 0.008), estrogen (ER) (p = 0.007) and progesterone receptors' (PgR) status (p = 0.0003). An inverse correlation with p53 protein (p = 0.004) was detected. Furthermore, a strong correlation was also observed between pRb and p53 (p = 0.001). The results indicate that in breast cancer bcl-2 protein expression may be under hormonal control. Since the expression is bcl-2 protein was inversely correlated with p53 protein expression, we suggest that bcl-2 may be related with favourable outcome in breast cancer.

Transvaginal uterine ultrasonography compared with endometrial biopsy for the detection of endometrial disease in perimenopausal women with uterine bleeding.

BACKGROUND: Almost 70% of all gynecological consultations in perimenopausal women are related to irregular uterine bleeding. In this prospective study, we compared endometrial assessment by transvaginal ultrasonography (TVS) in perimenopausal women with irregular uterine bleeding to histological assessment and tested whether the TVS was effective as a diagnostic tool for the detection of endometrial pathology in these women. MATERIALS AND METHODS: Eighty consecutive perimenopausal women complaining of irregular uterine bleeding participated in the study. The women were evaluated by transvaginal scans, performed immediately before endometrial biopsy. The ultrasonographic results were compared with the histological diagnosis obtained from the endometrial biopsy. RESULTS: Sixty-seven out of 80 women (83.7%) had normal histological findings, whereas 13 (16.3%) had abnormal findings. No endometrial cancer was diagnosed in this cohort of women. In the 67 women with a histological diagnosis of normal endometrium, mean+/-SD endometrial thickness was 10.5+/-4.0 mm (range 4.0-18.5 mm), whereas the corresponding value in the 13 women with abnormal findings was 18.7+/-3.8 mm (range 13.5-22.5 mm). If a 13 mm cut-off limit was used for endometrial thickness, which would include all abnormal cases, the sensitivity, specificity and positive predictive values were 100%, 71.64% and 40.62%, respectively. CONCLUSION: TVS can identify women with perimenopausal bleeding in which the likelihood of endometrial pathology is high and in which tissue sampling should be performed. Thus, TVS can be a primary method of selecting women with perimenopausal bleeding who must be further investigated with more invasive methods such as endometrial biopsy.

Screening transvaginal uterine ultrasonography for identifying endometrial pathology in postmenopausal women.

BACKGROUND: During the last decade, transvaginal ultrasonography (TVS) has become a widely-used technique for the evaluation of endometrial histology. The purposes of this study were to compare transvaginal sonographic evaluation of the endometrium with histology obtained by endometrial biopsy in asymptomatic postmenopausal women and to determine whether screening transvaginal sonography might be useful in the evaluation of postmenopausal women. MATERIALS AND METHODS: The study included 59 unselected asymptomatic postmenopausal women who attended the outpatient clinic for annual cervical cytology at Ioannina University Hospital Greece. The women were evaluated by transvaginal scans, performed immediately before endometrial biopsy. RESULTS: In the 43 women with a histopathological diagnosis of normal endometrium/inadequate for assessment/atrophy, the mean endometrial thickness was 5.1 +/- 3.3 mm (range 0.8-13.8 mm) whereas the corresponding value in the 16 women with abnormal findings was 17.6 +/- 4.3 mm (range 9.4-24.6 mm) (p<0.001). If a 9 mm cut-off limit was used for endometrial thickness, the sensitivity, specificity and positive predictive value were 100%, 90.69% and 80%, respectively. CONCLUSION: TVS is a sensitive test for determining endometrial disease in asymptomatic postmenopausal women. However, well-designed studies should be conducted, completed, analysed and validated before a mass-screening program using TVS is implemented.

Large loop excision of the transformation zone for treating cervical intraepithelial neoplasia: a 12-year experience.

BACKGROUND: Although the existing evidence suggests that there is no obviously superior conservative method for treating cervical intraepithelial neoplasia (CIN), one of the most widely used is the large loop excision of the transformation zone (LLETZ). MATERIALS AND METHODS: A total of 897 women who were treated with LLETZ at our colposcopy clinic from 1989 to 2000 were retrospectively studied. RESULTS: Forty women did not have significant cervical pathology (4.5% over-treatment rate). Clear margins of excision were obtained in 748 (88.5%) of the 845 cases of CIN or microinvasive cancers. Treatment failure rates were 4.7% for clear margins and 26.8% for involved or uncertain. CONCLUSION: LLETZ is a fast and reliable method of treating CIN and microinvasive carcinoma. Generalized cauterization of the resulting crater should be avoided and satellite HPV lesions ablated. Involved margins have a higher treatmentfailure rate, therefore a larger excision is recommended as cervical craters regenerate. Treatment in pregnant women can be delayed until postpartum provided they have adequate surveillance during pregnancy.

Screening transvaginal uterine ultrasonography for identifying endometrial pathology in postmenopausal women.

BACKGROUND: During the last decade, transvaginal ultrasonography (TVS) has become a widely-used technique for the evaluation of endometrial histology. The purposes of this study were to compare transvaginal sonographic evaluation of the endometrium with histology obtained by endometrial biopsy in asymptomatic postmenopausal women and to determine whether screening transvaginal sonography might be useful in the evaluation of postmenopausal women. MATERIALS AND METHODS: The study included 59 unselected asymptomatic postmenopausal women who attended the outpatients' clinic for annual cervical cytology at Ioannina University Hospital, Greece. The women were evaluated by transvaginal scans, performed immediately before endometrial biopsy. RESULTS: In the 43 women with a histopathological diagnosis of normal endometrium/inadequate for assessment/atrophy, the mean endometrial thickness was 5.1 +/- 3.3 mm (range 0.8-13.8 mm) whereas the corresponding value in the 16 women with abnormal findings was 17.6 +/- 4.3 mm (range 9.4-24.6 mm) (p<0.001). If a 9-mm cut-off limit was used for endometrial thickness, the sensitivity, specificity and positive predictive value were 100%, 90.69% and 80%, respectively. CONCLUSION: TVS is a sensitive test for determining endometrial disease in asymptomatic postmenopausal women. However, well-designed studies should be conducted, completed, analysed and validated before a mass-screening program using TVS is implemented.

Spontaneous evolution of human papillomavirus infection in the uterine cervix.

BACKGROUND: Little is known about the natural history and the malignant potential of low-grade cervical intraepithelial neoplasia associated with human papillomavirus (HPV) infection. Cervical cancer remains the second most frequent cause of death in women across the world. Epidemiologic and molecular studies have shown that human papillomavirus (HPV) is associated with cervical carcinogenesis. In this prospective study we examined the behavior of low-grade cervical intraepithelial lesions associated with HPV infection over a 6-year period. MATERIAL AND METHODS: During 1992, women with Papanicolaou smears reporting koilocytotic atypia (HPV effect) with or without grade 1 cervical intraepithelial neoplasia (HPV +/- CINI, low grade squamous intraepithelial lesions, LgSIL), along with colposcopic impression of LgSIL were included to the study. Between 1992 and 1998 all women underwent repeat Papanicolaou smears, colposcopic evaluation and HPV DNA testing every six months. HPV typing of cervical scrapes was done by PCR. RESULTS: A total of 330 women completed at least 6 years of follow up. Among women with high-risk HPV types (16/18), the presence of dysplasia (grade 1 cervical intraepithelial neoplasia) was significantly correlated with the progression of the lesion; 29% of cases with HPV + CINI (15 out of 75) progressed to more severe lesions versus only 9% of cases with HPV infection (18 out of 225), P < 0.001, chi-square test. The incidence of histologically confirmed progressive lesions was significantly greater in women with mild dysplasia (18 out of 75, 24%) compared to women without dysplasia (13 out of 255, 5%), P < 0.001, chi-square test. CONCLUSIONS: In our study HPV typing was not predictive of the evolution of low-grade intraepithelial lesions associated with HPV infection. Standard cytologic screening and colposcopy are the most effective means of monitoring low-grade lesions.