Prognostic Capability of TNBC 3-Gene Score among Triple-Negative Breast Cancer Subtypes.

Background: Triple-negative breast cancer (TNBC) is a complex and molecularly heterogeneous entity, with the poorest outcome compared with other breast cancer subtypes. Previously, we developed a TNBC 3-gene score with a significant prognostic capability. This study aims to test the 3-gene score in the different TNBC subtypes. Methods: Data from 204 TNBC patients treated with neoadjuvant chemotherapy were retrieved from public datasets and pooled (GSE25066, GSE58812, and GSE16446). After removing batch effects, cases were classified into Lehman's TNBC subtypes and then the TNBC 3-gene score was used to evaluate the risk of distant recurrence in each subgroup. In addition, the association with tumor-infiltrating lymphocyte (TILs) levels was evaluated in a retrospective group of 72 TNBC cases. Results: The TNBC 3-gene score was able to discriminate patients with different risks within the pooled cohort (HR = 2.41 for high vs. low risk; 95%CI: 1.50−3.86). The score showed predictive capability in the immunomodulatory subtype (HR = 4.16; 95%CI: 1.63−10.60) and in the mesenchymal stem-like subtype (HR = 18.76; 95%CI: 1.68−208.97). In the basal-like 1, basal-like-2, and mesenchymal subtypes, the observed differential risk patterns showed no statistical significance. The score had poor predictive capability in the luminal androgen receptor subtype (p = 0.765). In addition, a low TNBC 3-gene score was related to a high level of TIL infiltration (p < 0.001). Conclusions: The TNBC 3-gene score is able to predict the risk of distant recurrence in TNBC patients, specifically in the immunomodulatory and mesenchymal stem-like subtype. Despite a small sample size in each subgroup, an improved prognostic capability was seen in TNBC subtypes with tumor-infiltrating components.

Arsenic, chromium, and other elements of concern in fish from remote boreal lakes and rivers: Drivers of variation and implications for subsistence consumption.

Eating fish provides numerous health benefits, but it is also a dominant pathway for human exposure to contaminants. Many studies have examined mercury (Hg) accumulation in fish, but fewer have considered other elements, such as arsenic (As) and chromium (Cr). Recently, freshwater fish from several pristine boreal systems across northern Ontario, Canada, have been reported with elevated concentrations of As and Cr for reasons that are not well understood. Our goal was to investigate the ecological and environmental influences over concentrations of As, Cr, and other elements in these fish to better understand what affects metal uptake and the risk to consumers. We measured 10 elements (including As, Cr, Hg) as well as carbon (δ13C), nitrogen (δ15N), and sulfur (δ34S) stable isotopes in 388 fish from 25 lake and river sites across this remote region. These data were used to determine the effect of: 1) trophic ecology; and 2) watershed geology on piscine elemental content. Overall, most element concentrations were low, often below provincial advisory benchmarks (ABs). However, traces of Hg, As, Cr, and selenium (Se) were detected in most fish. Based on their exceedance of their respective ABs, the most restrictive elements on fish consumption in these boreal systems were Hg > As > Cr. Arsenic and Se, but not Cr concentrations were related to fish size and trophic ecology (inferred from δ13C and δ15N), suggesting bioaccumulation of the former elements. Fish with enriched δ34S values, suggestive of anadromous behaviour, had marginally lower Hg but higher Se concentrations. Modeling results suggested a strong effect of site-specific factors, though we found weak trends between piscine elemental content and geological features (e.g., mafic intrusions), potentially due to the broad spatial scale of this study. Results from this study address gaps in our understanding of As and Cr bioaccumulation and will help to inform fish consumption guidelines.

Speciation of Phosphorus from Agricultural Muck Soils to Stream and Lake Sediments.

The nature and management of agricultural soils can influence the forms of legacy P present in affected sediments; however, few studies have specifically characterized P in sediments affected by polder agriculture. In this study, the speciation of P as it flows from the muck soils of the Holland Marsh to the sediments of the West Holland River and Lake Simcoe, Ontario, Canada, was investigated. The distribution of P fractions and the characterization of organic P were analyzed by the sequential fractionation method and solution P nuclear magnetic resonance spectroscopy, respectively. Organic P was the predominant P form (∼58% of total P) in muck soils, whereas the redox-sensitive P fraction was predominant in surface stream sediments rich in organic matter (∼41-48% of total P), despite these sediments exhibiting near-neutral pH and high concentrations of both Ca and P. The proportion of relatively recalcitrant organic P forms was much greater in the muck soils than that exhibited by both stream and lake sediments. The decreasing proportion of recalcitrant organic P forms in sediments downstream from the Holland Marsh indicated the potential for faster organic P cycling. Our findings support the notion that diesters and pyrophosphate should be monitored, in addition to loosely bound inorganic P, due to their potential impact on water quality. The unique environment of the streams and lake area is considered to be particularly vulnerable to excessive fertilizer P use in adjacent croplands.

Repeated observation of immune gene sets enrichment in women with non-small cell lung cancer.

There are different biological and clinical patterns of lung cancer between genders indicating intrinsic differences leading to increased sensitivity to cigarette smoke-induced DNA damage, mutational patterns of KRAS and better clinical outcomes in women while differences between genders at gene-expression levels was not previously reported. Here we show an enrichment of immune genes in NSCLC in women compared to men. We found in a GSEA analysis (by biological processes annotated from Gene Ontology) of six public datasets a repeated observation of immune gene sets enrichment in women. "Immune system process", "immune response", "defense response", "cellular defense response" and "regulation of immune system process" were the gene sets most over-represented while APOBEC3G, APOBEC3F, LAT, CD1D and CCL5 represented the top-five core genes. Characterization of immune cell composition with the platform CIBERSORT showed no differences between genders; however, there were differences when tumor tissues were compared to normal tissues. Our results suggest different immune responses in NSCLC between genders that could be related with the different clinical outcome.

Automated segmentation and classification of cell nuclei in immunohistochemical breast cancer images with estrogen receptor marker.

Breast cancer is the most common malignant tumor in women worldwide. In recent years, there has been an increasing use of immunohistochemistry (the process of detecting the expression of certain proteins in cytological images) to obtain useful information for diagnosis. This paper presents an efficient algorithm that automatically detects breast cancer cell nuclei and divides them into two groups: those that express the ER marker and those that do not. First, the areas that belong to the carcinoma are automatically identified. Then, the algorithm evaluates features such as size and shape to correctly segment the nuclei in these fields. Finally, the Fuzzy C-Means algorithm is used to classify the detected nuclei. The method proposed was evaluated with a set of 10 images which contained 4093 cell nuclei. The algorithm correctly identified 93.1% of the nuclei, and sensitivity and specificity of the classification were 95.7% and 93.2% respectively.

Heterogeneidad intratumoral en cáncer de mama: reporte de dos casos y revisión de la literatura / Intratumoral heterogeneity in breast cancer: case report and literature review

El cáncer de mama (CM) es una enfermedad de gran complejidad. Presenta una gran variabilidad molecular, lo cual se puede observar cuando se comparan los tumores de distintos pacientes, dos regiones del mismo tumor, los ganglios regionales comprometidos versus el tumor primario y la metástasis a distancia versus la lesión primaria. Reportamos el caso de dos pacientes con CM con heterogeneidad en el fenotipo tumoral del tumor primario; el primer caso presentó dos tumores simultáneos de diferentes características dentro de la misma mama y el segundo caso mostró variación en el fenotipo del tumor luego del tratamiento neoadyuvante (TN). Así mismo, realizamos un análisis de la información publicada recientemente.

Breast Cancer (BC) is a complex disease. It shows notable molecular differences when we compare tumors from different patients, two intra-tumor distant regions, metastasis in regional lymph node versus primary lesion, and distant metastasis versus primary lesion. We report two cases of BC with tumor phenotype heterogeneity of the primary tumor. The first case developed two different simultaneous lesions inside the same breast and the second one developed a change in tumor phenotype after neoadjuvant treatment. Furthermore, we performed an evaluation of recently published information.

A genomic predictor of response and survival following taxane-anthracycline chemotherapy for invasive breast cancer.

CONTEXT: Prediction of high probability of survival from standard cancer treatments is fundamental for individualized cancer treatment strategies. OBJECTIVE: To develop a predictor of response and survival from chemotherapy for newly diagnosed invasive breast cancer. DESIGN, SETTING, AND PATIENTS: Prospective multicenter study conducted from June 2000 to March 2010 at the M. D. Anderson Cancer Center to develop and test genomic predictors for neoadjuvant chemotherapy. Patients were those with newly diagnosed ERBB2 (HER2 or HER2/neu)-negative breast cancer treated with chemotherapy containing sequential taxane and anthracycline-based regimens (then endocrine therapy if estrogen receptor [ER]-positive). Different predictive signatures for resistance and response to preoperative (neoadjuvant) chemotherapy (stratified according to ER status) were developed from gene expression microarrays of newly diagnosed breast cancer (310 patients). Breast cancer treatment sensitivity was then predicted using the combination of signatures for (1) sensitivity to endocrine therapy, (2) chemoresistance, and (3) chemosensitivity, with independent validation (198 patients) and comparison with other reported genomic predictors of chemotherapy response. MAIN OUTCOME MEASURES: Distant relapse-free survival (DRFS) if predicted treatment sensitive and absolute risk reduction ([ARR], difference in DRFS between 2 predicted groups) at median follow-up (3 years). RESULTS: Patients in the independent validation cohort (99% clinical stage II-III) who were predicted to be treatment sensitive (28%) had 56% (95% CI, 31%-78%) probability of excellent pathologic response and DRFS of 92% (95% CI, 85%-100%), with an ARR of 18% (95% CI, 6%-28%). Survival was predicted in ER-positive (30% predicted sensitive; DRFS, 97% [95% CI, 91%-100%]; ARR, 11% [95% CI, 0.1%-21%]) and ER-negative (26% predicted sensitive; DRFS, 83% [95% CI, 68%-100%]; ARR, 26% [95% CI, 4%-48%]) subsets and was significant in multivariate analysis. Other genomic predictors showed paradoxically worse survival for patients predicted to be responsive to chemotherapy. CONCLUSION: A genomic predictor combining ER status, predicted chemoresistance, predicted chemosensitivity, and predicted endocrine sensitivity identified patients with high probability of survival following taxane and anthracycline chemotherapy.

Breast cancer classification according to immunohistochemistry markers: subtypes and association with clinicopathologic variables in a peruvian hospital database.

BACKGROUND: Molecular classification is an excellent prognostic and predictive method in breast cancer (BC). In this study. we evaluated differences in clinicopathologic features and overall survival (OS) in four BC molecular subtypes: luminal A, luminal B, basal cell-like, and HER2/neu. PATIENTS AND METHODS: Immunohistochemical evaluation of estrogen receptor (ER), progesterone receptor (PgR), and HER2 was performed using a Peruvian hospital database of 1198 BC patients who were diagnosed between 2000 and 2002. Overall survival was calculated. RESULTS: Out of 1198 patients with invasive BC, 49.3% were luminal A; 13.2%, luminal B; 21.3%, basal-like; and 16.2%, HER2. The mean of age at diagnosis was 51.5 years for luminal A; 49.6 for luminal B; 49.5 for basal-like; and 49.4 for HER2. The HER2 subtype showed 63.7% positive lymph nodes, 42.3% stage III and 9.7% stage IV cases. Basal subtypes showed the highest prevalence of a poorly differentiated phenotype (70.3%). Average follow-up was 60 months. Five-year OS was significantly different between all 4 groups (P < .0001); luminal A had the highest OS, followed by luminal B, basal-like; and HER2. Results are compared with other population studies. CONCLUSION: This study shows significant differences between the distribution of molecular subtypes and clinicopathologic features. Immunohistochemistry is useful in the clinical management of BC patients.

Discovery of (pyridin-4-yl)-2H-tetrazole as a novel scaffold to identify highly selective matrix metalloproteinase-13 inhibitors for the treatment of osteoarthritis.

Potent, highly selective and orally-bioavailable MMP-13 inhibitors have been identified based upon a (pyridin-4-yl)-2H-tetrazole scaffold. Co-crystal structure analysis revealed that the inhibitors bind at the S(1)(') active site pocket and are not ligands for the catalytic zinc atom. Compound 29b demonstrated reduction of cartilage degradation biomarker (TIINE) levels associated with cartilage protection in a preclinical rat osteoarthritis model.

Epithelioid angiomyolipoma: a rare variant of renal angiomyolipoma.

OBJECTIVE: We present a case of primary renal epithelioid angiomyolipoma, its association with tuberous sclerosis and review the literature. METHODS: We present the case of a 12 year-old male with past medical history of tuberous sclerosis, characterized by developmental delay, tonic and clonic seizures, and cutaneous abnormalities. He presented with macroscopic hematuria and abdominal pain. CT scan of the abdomen showed the presence of a left renal tumor. He underwent left radical nephrectomy. Pathologic study of the specimen showed primary renal epithelioid angiomyolipoma, corroborated by immunohistochemistry staining. Review of the literature was performed for this rare variant and its malignant potential. RESULTS: The presence of this epithelial variant is rare and must be taken into account because of its malignant potential and, thus, with different prognosis and follow up, compared to classical angiomyolipoma. CONCLUSIONS: Renal angiomyolipoma is an uncommon benign tumor, representing a challenge for clinical and pathological diagnosis. Despite the big size they can reach, as well as bilaterality, multiplicity of lesions and/or lymphatic regional involvement, its malignant potential has not been established. Nevertheless, the epithelioid variant has been described recently, a rare entity with aggressive behavior, difficult histological characterization and poor prognosis.

Angiomiolipoma epiteloide: una variante del angiomiolipoma renal / Epithelioid angiomyolipoma: a rare variant of renal angiomyolipoma

OBJETIVO: Presentar un caso de angiomiolipoma (AML) variante epitelioide, primario renal, su asociación con Esclerosis Tuberosa (ET) y revisión de la literatura.MÉTODOS: Presentamos el caso de un paciente varón de 12 años con antecedente de retardo en el desarrollo psicomotor, crisis epilépticas tónico clónicas y estigmas cutáneos, todo esto compatible con ET. Debuta con hematuria macroscópica y dolor abdominal, encontrándose en la tomografía tumor que compromete dos tercios superiores del riñón izquierdo. Fue sometido a nefrectomía radical izquierda. La anatomía patológica, corroborada con estudios de inmunohistoquímica informó la presencia de AML, variante epiteliode.Se reviso la bibliográfica existente sobre esta variante poco común y su comportamiento maligno.RESULTADOS: La presencia de la variante epitelial es poco frecuente pero debe tenerse en cuenta por su comportamiento maligno y por lo tanto diferente pronóstico y seguimiento comparado al AML clásico.CONCLUSIONES: El AML renal es un tumor benigno, poco común, que representa un reto para el diagnóstico clínico e histopatológico. A pesar del gran tamaño que puede alcanzar, la bilateralidad, la multiplicidad de las lesiones y/o el compromiso linfático regional, no se ha demostrado su potencial maligno. Sin embargo, en los últimos años se ha descrito la variante epitelioide, entidad rara de comportamiento agresivo, difícil caracterización histológica y pobre pronóstico(AU)

OBJECTIVE: We present a case of primary renal epithelioid angiomyolipoma, its association with tuberous sclerosis and review the literature.METHODS: We present the case of a 12 year-old male with past medical history of tuberous sclerosis, characterized by developmental delay, tonic and clonic seizures, and cutaneous abnormalities. He presented with macroscopic hematuria and abdominal pain. CT scan of the abdomen showed the presence of a left renal tumor. He underwent left radical nephrectomy. Pathologic study of the specimen showed primary renal epithelioid angiomyolipoma, corroborated by immunohistochemistry staining. Review of the literature was performed for this rare variant and its malignant potential.RESULTS: The presence of this epithelial variant is rare and must be taken into account because of its malignant potential and, thus, with different prognosis and follow up, compared to classical angiomyolipoma.CONCLUSIONS: Renal angiomyolipoma is an uncommon benign tumor, representing a challenge for clinical and pathological diagnosis. Despite the big size they can reach, as well as bilaterality, multiplicity of lesions and/or lymphatic regional involvement, its malignant potential has not been established. Nevertheless, the epithelioid variant has been described recently, a rare entity with aggressive behavior, difficult histological characterization and poor prognosis(AU)

Nuclear factor-kappaB mediated inhibition of cytokine production by imidazoline scaffolds.

The mammalian nuclear transcription factor NF-kappaB is responsible for the transcription of multiple cytokines, including the pro-inflammatory cytokines tumor necrosis factor alpha (TNF-alpha) and interleukin 6 (IL-6). Elevated levels of pro-inflammatory cytokines play an important role in the pathogenesis of inflammatory disorders such as rheumatoid arthritis (RA). Inhibition of the pro-inflammatory transcription factor NF-kappaB has therefore been identified as a possible therapeutic treatment for RA. We describe herein the synthesis and biological activity of a series of imidazoline-based scaffolds as potent inhibitors of NF-kappaB mediated gene transcription in cell culture as well as inhibitors of TNF-alpha and IL-6 production in interleukin 1 beta (IL-1beta) stimulated human blood.

Quinazolinones and pyrido[3,4-d]pyrimidin-4-ones as orally active and specific matrix metalloproteinase-13 inhibitors for the treatment of osteoarthritis.

Quinazolinones 8 and pyrido[3,4-d]pyrimidin-4-ones 9 as orally active and specific matrix metalloproteinase-13 inhibitors were discovered for the treatment of osteoarthritis. Starting from a high-through-put screening (HTS) hit thizolopyrimidin-dione 7, we obtained two chemotypes, 8 and 9, using computer-aided drug design (CADD) and methodical structure-activity relationship (SAR) studies. They occupy the unique S 1'-specificity pocket and do not bind to the Zn(2+) ion. Some pyrido[3,4-d]pyrimidin-4-ones, such as 10a, possess favorable absorption, distribution, metabolism, and elimination (ADME) and safety profiles. 10a effectively prevents cartilage damage in rabbit animal models of osteoarthritis without inducing musculoskeletal side effects when given at extremely high doses to rats.

Discovery and characterization of a novel inhibitor of matrix metalloprotease-13 that reduces cartilage damage in vivo without joint fibroplasia side effects.

Matrix metalloproteinase-13 (MMP13) is a Zn(2+)-dependent protease that catalyzes the cleavage of type II collagen, the main structural protein in articular cartilage. Excess MMP13 activity causes cartilage degradation in osteoarthritis, making this protease an attractive therapeutic target. However, clinically tested MMP inhibitors have been associated with a painful, joint-stiffening musculoskeletal side effect that may be due to their lack of selectivity. In our efforts to develop a disease-modifying osteoarthritis drug, we have discovered MMP13 inhibitors that differ greatly from previous MMP inhibitors; they do not bind to the catalytic zinc ion, they are noncompetitive with respect to substrate binding, and they show extreme selectivity for inhibiting MMP13. By structure-based drug design, we generated an orally active MMP13 inhibitor that effectively reduces cartilage damage in vivo and does not induce joint fibroplasias in a rat model of musculoskeletal syndrome side effects. Thus, highly selective inhibition of MMP13 in patients may overcome the major safety and efficacy challenges that have limited previously tested non-selective MMP inhibitors. MMP13 inhibitors such as the ones described here will help further define the role of this protease in arthritis and other diseases and may soon lead to drugs that safely halt cartilage damage in patients.

Melanoma maligno de la región mamaria en el Instituto de Enfermedades Neoplásicas: 50 años / Malignant melanoma of the mammary region in the Institute of Diseases Neoplasicas: 50 years

Introducción: En nuestro medio y a nivel nacional no existe ningún trabajo acerca de melanoma maligno de localización mamaria, por lo cual se desconoce lo relacionado con muchos aspectos clínicos y terapéuticos de esta enfermedad, hemos considerado entonces analizar el tema, evaluando en forma retrospectiva su historia natural, características, el resultado del tratamiento y los factores de pronóstico para aquellos pacientes que en el Instituto de Enfermedades Neoplásicas tienen el diagnóstico de ésta entidad. Métodos: En un estudio clínico retrospectivo, se revisaron las historias clínicas de 24 pacientes con diagnóstico de melanoma maligno de la región mamaria que fueron atendidas en el Instituto de Enfermedades Neoplásicas, Lima- Perú, entre 1952-2002. Resultados: La edad de los pacientes varió de 1 a 85, alcanzando una mediana de 51 años. No hubo diferencia en la distribución de los pacientes en cuanto al sexo ni al lado de la mama afectada. La mediana de tiempo de enfermedad al diagnóstico fue 1 año. El tamaño del tumor varió de 1 cm a 18 cm alcanzando una mediana de 2.8 cm. El síntoma principal fue generalmente nevus congénito en 46 por ciento siendo el dolor un síntoma infrecuente. El estadío clínico I fue el más frecuente con el 38 por ciento de los casos en cambio el nivel de Breslow fue generalmente mayor de 4mm. Un tercio de los pacientes tuvieron el tipo histológico de extensión superficial seguido del tipo nodular. La cirugía es la base del tratamiento y ésta se ha modificado con el paso del tiempo a técnicas más conservadoras utilizadas en nuestra institución a partir del año 2000.

Apendicitis complicada como enfermedad intercurrente en pacientes con cáncer gástrico avanzado / Complicated acute appendicitis as intercurrent disease in patient with advanced gastric cancer

Reportamos el caso de un paciente varón de 64 años atendido por abdomen agudo que es intervenido quirúrgicamente con el diagnóstico presuntivo de peritonitis por apendicitis complicada. El paciente estaba así mismo, cursando con deposiciones oscuras desde aproximadamente 2 semanas antes de su ingreso y melena franca los 3 días previos a su ingreso. Concomitantemente presentó dolor epigástrico severo, e intenso dolor en fosa iliaca derecha en las últimas horas. El hallazgo endoscópico determinó cáncer gástrico avanzado Borrmann II y el informe anatomopatológico respectivo, adenocarcinoma infiltrante tipo intestinal medianamente diferenciado. El informe operatorio fue peritonitis por apendicitis perforada en su base con coprolitos libres y carcinomatosis intra-abdominal, el informe anatomopatológico respectivo fue apéndice cecal con ulceración de mucosa, necrosis y perforación de pared muscular en su base; respecto a las muestras de epiplon y mesenterio tomadas en el intraoperatorio señala; tejido adiposo infiltrado por adenocarcinoma tubular medianamente diferenciado, compatible con cáncer gástrico primario.

Diagnóstico citológico colposcópico e histológico de la infección del cuello uterino por PVH / Colposcopic cytologic diagnosis and histologic of the infection of the PVH cervix uteri

La infección genital por papilomavirus humano (PVH), desempeña un rol importante en la génesis de lesiones pre-neoplásicas y del cáncer invasivo de cuello uterino. El estudio citomorfológico para el diagnóstico de infección del cuello uterino por papilomavirus humano (PVH), se viene utilizando en forma creciente en los últimos años, sin embargo, en nuestro medio, su valor diagnóstico no ha sido confirmado todavía por métodos más sensibles. El presente trabajo correlaciona la citología, colposcopía e histología con el estudio molecular del ADN viral, por el método de la reacción en cadena de la polimerasa (PCR). Siete tipos virales fueron estudiados: 6, 11, 31, 33, 35, 16 y 18. Se estudiaron 150 mujeres con dos o más criterios citomorfológicos de infección por PVH. La detección del ADN por PCR fue 34.6 por ciento (52 mujeres). En 5 casos la tipificación fue negativa a los 7 tipos considerados. Los tipos de PVH de alto riesgo, 16 y/ó 18 se hallaron en 59.5 por ciento, los de bajo riesgo, 6 y/ó 11 en 59.5 por ciento y los PVH de mediano riesgo en 21.2 por ciento. El 44.6 por ciento de los casos tuvieron infección múltiple. La edad promedio fue 32 años, 42 casos (80.7 por ciento) correspondieron a la 3ra. y 4ta. décadas. La presencia simultánea de los signos clásicos, coilocitosis y disqueratosis tuvo mayor valor predictivo positivo por PCR, 45.4 por ciento (10/22). La positividad del ADN en las mujeres con imagen colposcópica anormal (ICA) fue 37.7 por ciento. El epitelio acetoblanco no brillante, ajustado con la superficie no plana y los criterios citológicos de disqueratosis y 3 signos no clásicos fueron los hallados más frecuentes sugestivos de infección por PVH, OR:6.6, IC:95 por ciento (1.36-50.6) p=0.03. La correlación del diagnóstico histológico de infección del PVH con el ADN+ en las mujeres con ICA fue 40.7 por ciento (31/76) y en las mujeres sin ICA 22.2 por ciento (2/9). En mujeres con ICA y microbiología positiva y negativa, la positividad del ADN fue de 36.3 por ciento y 42.8 por ciento, respectivamente. De 41 mujeres con ICA y con microbiología positiva a Cándida y/o Chlamydia 13 (31.7 por ciento) fueron ADNPVH. Las infecciones a gérmenes Gram positivo y Gram negativos (aerobios y anerobios), Chlamydia, Cándida y Trichomonas, no modificaron el valor predictivo positivo citológico, colposcópico e histológico.