Evaluation of CO(2) laser excision or vaporization for the treatment of vulvar intraepithelial neoplasia.

OBJECTIVE: Our objective was to evaluate the results of laser surgery in patients with vulvar intraepithelial neoplasia (VIN). METHODS: From January 1990 to December 1996, 52 patients with histologically proven VIN were treated with CO(2) laser vaporization or laser excision. The analysis included anamnestic characteristics, clinical aspects, types of treatment, correlation of the preoperative biopsy with the excised pathologic specimen, and follow-up results. RESULTS: Fourteen women underwent laser vaporization, and 38, laser excision. Of the patients submitted to vaporization, 11 were cured in one session (75%), 1 required two procedures, and 2 other patients, who underwent more treatments, eventually developed invasive squamous cell cancer 5 and 7 years from the initial treatment. The cure rate for laser excision was better, as a single session of treatment was curative in 33 of 38 patients (87%). In 3 cases the pathology report on the excised specimen showed an unrecognized invasive lesion (12%) and the women underwent radical surgery. The 2 remaining patients, both affected by multifocal disease, experienced recurrences and were treated with laser excision 2 and 3 years after the primary treatment, respectively. Symptom relief was obtained in all patients studied with both laser vaporization and excision. CONCLUSIONS: Excisional laser surgery is an effective treatment for patients with VIN. In addition, CO(2) laser excision allows evaluation of the operative specimen and detection of occult early invasion with good preservation of vulvar morphology; laser vaporization, while retaining good cosmetic results, is less effective in VIN treatment and does not allow evaluation of the surgical specimen.

Risk factors for high-grade cervical intraepithelial neoplasia in patients with mild cytological dyskaryosis: human papillomavirus testing versus multivariate tree analysis of demographic data.

The objective of this study was to compare the use of molecular hybridization by hybrid capture methodology for human papillomavirus (HPV) with the use of demographic and lifestyle variables as intermediate triage in patients with cytological mild dyskaryosis. The study was designed as a prospective study using regression tree analysis of demographic data in consecutive patients who were subjected to colposcopic evaluation at the colposcopy clinic at the First Department of Obstetrics and Gynaecology, University of Milan (Milan, Italy). A total of 177 women were subjected to colposcopy because of a single routine Pap smear showing mild dyskaryosis. A structured interview, sampling for HPV testing for the detection of viral DNA by hybrid capture methodology, and colposcopic evaluation with cervical biopsies were performed for each subject. The accuracies of molecular hybridization for HPV and of the classification model based on the demographic and lifestyle variables in predicting patients with histologically high-grade cervical intraepithelial lesions were measured. The classification model based on the demographic and lifestyle variables showed comparable results with molecular hybridization for HPV (specificity, 0.75 versus 0.73; sensitivity, 0.61 versus 0.67, respectively). The use of demographic and lifestyle variables appears to be a simple and economic possibility for triaging patients with mild dyskaryotic smears in a screening program.

Cervicography and HPV DNA testing as triage criteria for patients with abnormal pap smear.

Cervicography and HPV DNA testing have been proposed as intermediate triage techniques for the management of patients with Pap smear showing minor-grade atypia. The aims of the present study of 221 patients with positive Pap smear (ages 16-65) were (1) to evaluate the association of cervicography and HPV DNA test with the probability of biopsy and final histology diagnosis of CIN2 or worse, (2) to identify the combinations of results on cervicography and HPV DNA test associated with the absence of such lesions, and (3) to estimate the cost of a potential triage protocol for patients with HPV-CIN1 smear. The probability of biopsy showed a univariate association with the severity of the smear result and the cervicography classification but not the HPV DNA test. In the multivariate analysis, only the cervicography result was a significant predictor of biopsy. The final histology diagnosis showed a univariate association with each of the three tests and a multivariate association with the degree of cytology positivity and the cervicography result. Among patients with HPV-CIN1 smears, only a negative cervicography (with any HPV DNA test result) was always associated with the absence of severe histologic lesions. This pattern accounted only for 7% of such patients. The additional costs of a potential triage protocol based on cervicography were estimated to exceed the savings resulting from the reduced colposcopy rate.

Operator variability in disease detection and grading by colposcopy in patients with mild dysplastic smears.

BACKGROUND: To determine interoperator variability in the colposcopic evaluation of patients with mild dysplastic smears, retrospective comparison of colposcopy and biopsy results in 856 patients examined by 11 colposcopists in the Outpatient Colposcopy Clinic of "L. Mangiagalli" Institute, Milano, was performed. METHODS: The patients underwent a complete colposcopic assessment and target biopsy on suspect areas if a screening smear showed mild dysplasia. Colposcopic findings and disease detection rate for each operator were compared. RESULTS: There was no significant (P > 0.05) difference in the recording of abnormal colposcopic findings. Significant differences were found, however, in abnormal transformation zone grading (P < 0.001), biopsy rate (P < 0.05), and squamocolumnar junction visualization (P < 0.005). There was no significant difference in overall disease detection (P > 0.5) but there was a statistically significant, inverse relation (r = -0.6, P < 0.01) between the high grade (cervical intraepithelial neoplasia grades 2 and 3) and low grade (human papillomavirus/cervical intraepithelial neoplasia grade 1) detection rate for each operator. CONCLUSIONS: High grade disease detection in patients with mild dysplastic smears is influenced the subjectivity of the colposcopic examination. This should be considered when planning optimal management for patients with mild dysplasia.

Topical testosterone in the treatment of vulvar lichen sclerosus.

OBJECTIVES: Comparison between 2% testosterone propionate and petrolatum ointment in the treatment of vulvar lichen sclerosus in a randomized, double-blind, controlled clinical study. METHODS: Fifty-eight consecutive patients with histologically confirmed vulvar lichen sclerosus were enrolled. They underwent a 1-year period of topical treatment with either medication, with clinical evaluations of symptoms and gross appearance at 2-month intervals, followed by histological evaluation at the end of the treatment period. Statistical analysis was performed according to the chi-squared test and the Student-Newman-Keuls test. RESULTS: A substantial improvement in symptoms was achieved in 20 (66.6%) patients in the testosterone group and in 21 (75%) patients in the placebo group. No statistical differences were observed between the two groups. Gross changes were observed in a few cases and no case demonstrated histologic modifications. CONCLUSIONS: Petrolatum ointment is as effective as 2% testosterone in the treatment of vulvar lichen sclerosus.