Presentation of cervical cancer

To determine how patients with invasive cervical cancer present and whether presentation affects disease-free survival (DFS), a review of 81 patients treated for cervical cancer by the Division of Gynecologic Oncology and Pelvic Surgery at the Southern California Permanente Medical Group between January 1, 1986, and December 31, 1986, was performed. Fifty-six percent of patients presented with abnormal vaginal bleeding, twenty-eight percent presented with abnormal Papanicolaou (Pap) smears, nine percent presented with pain, four percent presented with vaginal discharge, and four percent presented with other symptoms. Follow-up was 24 to 41 months. Patients presenting with abnormal Pap smears had DFS of 96%. Those presenting with abnormal vaginal bleeding had DFS of 51% and those presenting with pain had DFS of 29%. Presentation strongly influences DFS (chi 2 = 16.8, P less than 0.001). Of women presenting with abnormal Pap smears, 87% were Stage I and 13% were Stage II. Of women presenting with other than abnormal Pap smears, 40% were Stage I, 34% were Stage II, and 26% were Stage III or IV. Presentation with abnormal Pap smear and stage are significantly related (chi 2 = 14.8, P less than 0.001). Of women presenting with abnormal Pap smears, 89% had cancers 0 to 2 cm, 5% had cancers 2.1 to 4 cm, and 5% had cancers greater than 4 cm in diameter. Of women presenting with other than abnormal Pap smears, 21% had cancers 0 to 2 cm, 26% had cancers 2.1 to 4 cm, and 53% had cancers greater than 4 cm in diameter. Presentation with abnormal Pap smear is significantly associated with tumor size (chi 2 = 25.4, P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

阴道上皮内瘤变20例临床分析

目的 探讨阴道上皮内瘤变(VAIN)的临床特征、治疗方法及预后.方法 收集中国医学科学院肿瘤医院1999年1月-2007年12月收治的20例VAIN患者的临床资料,对其进行回顾性分析.结果 20例患者均无明显临床症状和体征,多数患者(17例,85%)因阴道液基细胞学检查异常或诊断为宫颈癌后而行进一步检查(妇科检查、阴道镜检查及阴道镜下活检组织病理检查)时发现,少数患者(3例,15%)为宫颈癌术后随访时发现.85%(17例)的患者合并宫颈癌(12例)或宫颈上皮内瘤变(CIN,5例).90%的患者为VAIN Ⅲ.主要发生于阴道上段(17例,85%),且多呈多灶性分布(13例,65%).VAIN的治疗主要采用手术治疗(13例)和放疗(7例),治疗后的局部控制率达100%.3例(15%)复发患者均为VAIN Ⅲ,其中1例为放疗后复发,2例为手术后复发,分别经手术或放疗后病变仍可得到有效控制.结论 单纯性VAIN诊断阑难.常合并宫颈癌或CIN,病变多位于阴道上段且呈多灶性分布,手术和放疗均可有效控制VAIN,但治疗后应密切随访,以及早发现、诊断和治疗复发病变.     

Condyloma and cervical epithelial atypias in young women

One hundred and three adolescent women with cervical cytology suggestive of mild to moderate dysplasia were studied for the presence of condylomatous lesion. The analysis of smears revealed cells suggestive of condyloma in 81% of the cases. In histopathologic studies cervical lesions typical of condyloma were observed in 59 preparations. Of these 16 were papillary and 35 were flat condylomas, and in 8 cervices both papillary and flat condylomatous lesions were present. Colposcopic examination showed an atypical transformation zone in 57 cases. Papillary condylomas were present in 24 cervices in 7 cases combined with an atypical transformation zone. In addition to the cervical epithelial atypias there were 18 cases in which colposcopic and histologic examination of vagina revealed papillary warts, 13 of them combined with cervical condylomas. In four patients vaginal leucoplakia was seen and all were histologically flat condylomas. Thus, in 68 cases or in 66% of adolescent women having abnormal cervical cytology, histological investigation revealed condylomatous changes.     

Cytologic examination to detect clear cell adenocarcinoma of the vagina or cervix

OBJECTIVE: The aim of this study was to determine the sensitivity of cytopathologic examination for the detection of vaginal or cervical clear cell adenocarcinoma (CCA). METHODS: Systematic collection in the Dutch automated nationwide pathology archive of all cytology and histology data of women with CCA, born in The Netherlands after 1947 was performed. All cytologic examinations within 2 years prior to histological diagnosis of CCA were included. RESULTS: Ninety patients with CCA have been registered. Forty-nine of these patients had cytologic examinations prior to histology. Eighty-five percent of cervical CCAs were preceded by a positive cervical smear. One hundred percent of vaginal CCAs were preceded by a positive vaginal smear. Cervical smears are relatively insensitive to detect vaginal CCA. Vaginal smears were often omitted. Only 2 apparently false-negative smears were found. The mean numbers of smears in diethylstilbestrol (DES)-exposed and nonexposed women were minimally different: 1.0 and 0.8, respectively. This suggests an only modest impact of the awareness of DES as a risk factor. FIGO tumor stage I was preceded more frequently by cytology than the higher tumor stages. CONCLUSION: The majority of CCA cases can be detected at an early stage by yearly clinical and cytological examinations, which must comprise cervical as well as vaginal sampling. Since CCA may also occur in postmenopausal women, for the purpose of secondary prevention of CCA regular cytologic examinations of DES-exposed women must be continued after menopause.     

Urinary cytology in female genital cancer

Stimulated by a report that 89 per cent of patients with cancer of the uterine cervix showed malignant cells in the urine sediment, the present study was undertaken to evaluate urinary cytology as a means of early cancer detection. In 350 patients both vaginal smears and urinary sediments were examined; of 69 cases of genital cancer, 67 revealed significant findings on vaginal smear as compared to 29 in urine specimens. The urine cytology was of little diagnostic value in noninvasive cervical carcinomas—only one case was reported positive and one as doubtful from the 13 cases in this class. Eighteen of 38 invasive cervical carcinomas revealed malignant cells in the urine specimens. For other tumors also the urine cytology was found to be of limited value. The procedure may be of use as a supplement to and not as a substitute for more direct cytologic examination.     

Colposcopy

Colposcopy has gained widespread acceptance in the United States only in the last ten years and today is considered standard practice for evaluating women with abnormal Pap smears. Colposcopy use has provided a less radical means of diagnosis and developed new ways of treating premalignant diseases of the cervix. Other uses of colposcopy include evaluation of cervical, vaginal, and vulvar lesions; monitoring gravidas with preinvasive disease of the cervix; and screening of DES-exposed women. In addition, colposcopy is used in conjunction with CO2 laser in selective treatment of patients with cervical intraepithelial neoplasia.     

Primary malignant melanoma of the uterine cervix: case report and review of the literature.

This is a case report and review of the literature on primary melanoma of the cervix. There have been only 26 published cases of primary cervical melanoma and most are poorly documented and doubtful. The patients' ages ranged from 26 to 78 years old with a mean age of 55 +/- 13 years. The main presenting symptom was vaginal bleeding (83.0%). The majority of the patients, 88%, presented in stage I or II. Treatment varied from a simple excision of a cervical mass to a radical hysterectomy with lymph node dissection and adjuvant radiation or chemotherapy. Our patient presented with vaginal bleeding and was diagnosed as having stage IIa cervical melanoma. She underwent a radical hysterectomy, partial vaginectomy, and pelvic and paraaortic lymph node dissection. She received adjuvant radiation therapy and her survival was 29 months. The prognosis of primary cervical melanoma is usually poor and unpredictable. We recommend a radical hysterectomy and vaginectomy, if necessary, to obtain negative surgical margins of at least 2 cm. We advocate lymphadenectomy only for grossly positive nodes.     

Lower genital tract rhabdomyosarcoma: case series and literature review

OBJECTIVE: Rhabdomyosarcoma (RMS) of the lower genital tract is a rare tumor. It tends to occur in childhood in the vagina and in rare cases, RMS can originate in the uterine cervix, with a peak incidence in the 2nd decade. METHODS: A hospital-based tumor registry was searched to find all patients with female genital tract RMS, which were treated between 1999 and 2004. The medical records of all patients were reviewed. A single pathologist reviewed all pathologic specimens. RESULTS: Among the 1,528 patients with genital tract malignancies, six RMS were found: three vaginas, three cervixes. All patients presented with vaginal bleeding. Mean age of patients was 16(13-30). The lesions in vagina were clinically staged as stage I (2), stage II (1) and in cervix were stage I (2) and stage III(1). All of the patients were treated with surgery and adjuvant chemotherapy. One patient with cervical RMS was treated with adjuvant chemo radiation. Two patients with cervical RMS died from the large size and extent of the disease 9 and 11 months after diagnosis, but all patients with vaginal RMS remain alive after a mean follow-up of 38 months. CONCLUSION: Most patients present with vaginal bleeding and a palpable cervical or vaginal mass. While the optimal management of these tumors is uncertain, primary therapy with wide local excision and chemotherapy can result in prolonged survival and cure in patients with early stage RMS. Vaginal lesions have a better prognosis than cervical lesions. In patients with un-embrional RMS, large size of lesion, cervical origin and extent of disease, survival rates was decreased.     

The significance of atypical glandular cells on routine cervical cytologic testing in a community-based population

OBJECTIVES: We sought to determine the follow-up rate of women with glandular atypia on routine Papanicolaou smears in a community-based population and to describe the associated pathologic findings. STUDY DESIGN: Over a 12-month period, all patients with Papanicolaou smears with atypical glandular cells of undetermined significance were reviewed for demographic and clinical characteristics and followed up for a period of 12 to 24 months. RESULTS: Of the 48,890 Papanicolaou smears examined, 141 (0.29%) were diagnosed with atypical glandular cells of undetermined significance. Of these, 22 (17.6%) had no record of any subsequent investigation, and only 64 (51.2%) were monitored with both colposcopy and biopsy. Of the 64 biopsy specimens, 39 (60.9%) were positive for disease. Twenty-six (66.7%) were of squamous origin, with the most advanced lesion being cervical intraepithelial neoplasia 3. An additional patient had a combined cervical intraepithelial neoplasia and adenocarcinoma in situ lesion. Four (10.3%) additional patients had glandular cervical lesions, 2 benign polyps and 2 adenocarcinoma in situ lesions. Seven (17.9%) patients had endometrial lesions (benign polyps, 2 patients; complex atypical endometrial hyperplasia, 1 patient; and endometrial carcinoma, 4 patients). One patient had ovarian cystadenocarcinoma. Postmenopausal women were 5 times more likely to have a glandular lesion. Women with abnormal vaginal bleeding were also more likely to have a glandular lesion. These same patient groups were also more likely to have endometrial disease. CONCLUSION: The incidence of atypical glandular cells of undetermined significance on Papanicolaou smears in this community-based population was 0.29%, which is consistent with estimates from institution-based populations. Nearly 50% of women studied were not followed up with tissue biopsy. Of those with a tissue biopsy, 61% had positive findings, including 5 with cancer. Although postmenopausal status and abnormal vaginal bleeding were associated with endometrial or glandular disease, studies of larger patient populations should be conducted to examine potential risk factors for these conditions.     

CO2 laser vaporization in the treatment of cervical human papillomavirus infection in women with abnormal Papanicolaou smears.

In a randomized study, we have evaluated the treatment of cervical human papillomavirus (HPV) lesions by CO2 laser vaporization. Fifty patients with abnormal Papanicolaou smears and histological evidence of cervical HPV infection associated or not with cervical intraepithelial neoplasia (CIN) grade I were randomized to either a treatment or a control group. The cervical swabs were obtained every 3 months in both groups and examined for HPV type 16 DNA by the polymerase chain reaction. After a follow-up period of 12 months no significant differences were found between the laser treatment and the control groups in relation to the disappearance of the abnormal Papanicolaou smear. Two patients in the treatment group and 3 in the control group had a conization because of development of CIN I or aggravation of the concomitant CIN found at the initial visit. The percentage of women who demonstrated HPV in their cervical smears at 12 months' follow-up was identical in the two groups, supporting the hypothesis that HPV is a persistent infection during which the virus is widespread in the vaginal epithelium.     

ⅠA1期子宫颈癌早期诊断与治疗路径分析

目的探讨ⅠA1期子宫颈癌早期诊断和治疗的临床路径。方法对2003年1月至2012年12月诊断及治疗的71例ⅠA1期子宫颈癌患者的临床资料进行回顾性分析。结果在同期581例子宫颈癌患者中,ⅠA1期子宫颈癌患者71例,占12.2%,患者平均年龄（45.0±10.4）岁。在71例ⅠA1期子宫颈癌患者中,70例（98.6%）患者病理类型为鳞状细胞癌;29例（40.8%）患者有异常阴道出血或排液;67例（94.9%）患者有不同程度的宫颈细胞学异常,65例（91.1%）患者高危型人乳头瘤病毒（HR-HPV）阳性;32例（45.1%）患者阴道镜下多点活检病理提示早期浸润癌,62例（87.8%）患者子宫颈锥切术后病理诊断。结论子宫颈癌ⅠA1期患者的早期发现主要通过子宫颈癌筛查,对于筛查异常者及时行阴道镜及病理检查,高度可疑子宫颈癌前病变及浸润癌者建议及时行子宫颈锥切术。     

Analysis of Atypical Squamous (Glandular) Cells of Undetermined Significance Smears by Neural Network–Directed Review

Objective: The objective of this study was to evaluate the value of neural network–directed review of smears determined to contain atypical squamous (glandular) cells of undetermined significance to identify those cases most likely to be associated with cervical intraepithelial neoplasia.Methods: One hundred sixty smears reported as atypical squamous (glandular) cells of undetermined significance on patients having colposcopy and directed biopsy within 1 year of the smear were identified. The smears were subjected to a neural network–directed review and classified according to findings on this review. The latter findings were related to those obtained on cervical biopsy.Results: One hundred sixty smears originally reported as atypical squamous (glandular) cells of undetermined significance were subjected to neural network–directed review. The smears were upgraded in 20.6% of cases. Ninety-one patients were found to have normal biopsies, and 69 had biopsies reported as abnormal. Of the smears in patients with abnormal biopsies, 37.7% were upgraded, whereas only 7.7% of smears from those with normal biopsies were upgraded (P < .001). Nine patients were found to have cervical intraepithelial neoplasia–3 on biopsy. Six of the nine smears (66.7%) taken on these patients were upgraded.Conclusion: Neural network-directed analysis of smears conventionally diagnosed as atypical squamous (glandular) cells of undetermined significance will reveal findings suggesting a squamous intraepithelial lesion in a significant number of cases. This approach requires further study because it is a relatively cost-effective means of triaging patients with a cytologic diagnosis of atypical squamous (glandular) cells of undetermined significance.     

colposcopy

Colposcopy has gained widespread acceptance in the United States only in the last ten years and today is considered standard practice for evaluating women with abnormal Pap smears. Colposcopy use has provided a less radical means of diagnosis and developed new ways of treating premalignant diseases of the cervix. Other uses of colposcopy include evaluation of cervical, vaginal, and vulvar lesions; monitoring gravidas with preinvasive disease of the cervix; and screening of DES-exposed women. In addition, colposcopy is used in conjunction with Con laser in selective treatment of patients with cervical intraepithelial neoplasia.     

放疗对早期子宫颈癌患者移位卵巢功能的影响

目的探讨放疗对早期(Ⅰ~Ⅱa期)宫颈癌患者移位卵巢功能的影响。方法对早期宫颈癌患者62例行广泛性全子宫切除加盆腔淋巴结切除加双侧卵巢结肠旁沟侧方移位术,术后随访患者有无绝经期症状,并测定血清中卵泡刺激素和雌二醇水平以判定卵巢功能。62例患者中, 30例未予任何放疗(G0组); 17例患者仅术前接受了A点剂量为15Gy的腔内后装治疗(G1组); 15例术后予以45~50Gy盆腔外照射(G2组),其中14例术前已接受了放疗(方法同G1组)。结果G0、G1和G2组患者卵巢功能衰竭的发生率分别为20% (6 /30)、35% (6 /17)和64% (9 /14),分别两两比较,差异均有统计学意义(P<0 01); 3组术后发生卵巢功能衰竭的患者中,其平均衰竭时间分别为15 7、12 0和9 2个月,分别两两比较,差异均有统计学意义(P<0 05)。2例(3% )发生了移位卵巢囊肿,未发现卵巢转移。结论早期宫颈癌患者术前或术后放疗均能明显引起卵巢功能衰竭,甚至卵巢移位手术本身也会影响卵巢的功能。     

Role of radiotherapy in the management of cervical carcinoma

Different therapy schemes related with the stage of tumours are reported, after general considerations on the topic. We have evaluated various criteria for the choice of methods, pointing out the complications of therapy. Lithium-carbonate action during radiation therapy has been studied, valuing the positive effect on leukopoiesis and the consequent better clinical conditions of the patients in course of treatment. In this study we report our experience with regard to 21 patients affected by cervical neoplasia, histologically diagnosed. The stages of neoplasia in the 21 patients were so distributed: 10 at stage I B, 8 at stage II A, 3 at stage II B. Treatment consisted of three therapeutical techniques: 1) application of radium in the cervical canal and in the vaginal fornices; 2) surgical procedure; 3) application of radium against the vaginal vault. In agreement with other author's results, the histological exam of the surgical specimen confirmed in different cases the complete absence of neoplastic aspects following the pre-operative radiotherapy. Although our experience is limited, we hold that radio-surgical "sandwich" treatment of cervical carcinoma may represent an excellent therapy in young women and in patients with associated systemic diseases. The follow-up of the 21 patients has excluded up to this day any neoplasia. In this program pre-operative intracavitary radiotherapy is a primary step allowing, in the majority of the cases, the reduction of surgical radicality. In so doing, effective therapeutical results associated with a better quality of life are obtained.     

Pelvic radiation necrosis and osteomyelitis following chemoradiation for advanced stage vulvar and cervical carcinoma

BACKGROUND: The treatment regimen indicated for most advanced stage vulvar, vaginal, and cervical cancer usually involves adjuvant chemoradiation therapy. Although the risk of complications is low, there have been reported cases of radiation necrosis and osteomyelitis following treatment for vulvar, vaginal, and cervical cancer. CASES: We present a vulvar cancer patient and a cervical cancer patient, both of whom were treated with radical surgery and postoperative chemoradiation. Following therapy, they were afflicted with pelvic radiation necrosis and osteomyelitis. The patients underwent surgery to resect the necrotic bone tissue and long-term antibiotic therapy to treat their osteomyelitis. They have since recovered and are followed closely by their gynecologic oncology and infectious disease physicians. CONCLUSION: The radiotherapy utilized to treat advanced stage gynecologic cancer can cause intestinal, vaginal, and urologic complications from micro-vascular damage to the organs. Pelvic bone osteonecrosis is a rare but disabling complication of pelvic radiation. Fortunately, with aggressive therapy, these patients may do well clinically.     

Abnormal Papanicolaou smears after earlier smears with atypical squamous cells

From November 1984 to January 1986, 138 women were seen in our cervical clinic with atypical squamous cells in a referring cervical Papanicolaou smear. We obtained a second smear and performed a careful pelvic examination, microscopic examination of the vaginal secretions and endocervical culture for the gonococcus. The time interval between the smear showing atypical squamous cells and the one performed in our clinic ranged from 1 to 12 months. The Papanicolaou smear from 59 (50%) of the 117 women who had it repeated within four months returned abnormal as compared to 5 (24%) of the 21 repeated after four months (P = .04). Of 41 women with persistent atypical squamous cells, 10 (24%) had a clinically detectable vaginal infection, while only 3 (4%) of the 74 women with a normal repeat smear had an infection (P less than .01). These findings suggest an association between cervical cytology showing atypical squamous cells and vaginal infections. Nevertheless, this cytologic diagnosis should not be dismissed lightly since a high percentage of women with atypical squamous cells on cytology are found to have dysplasia on colposcopically directed biopsies. The most appropriate method of evaluating these patients has yet to be determined. If the clinician elects to follow these patients with serial Papanicolaou smears, the ideal interval between smears needs to be defined. Our data suggest that an interval of four to six months would be the most efficient.     

Clinical evaluation of follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears.

OBJECTIVES: The aim of this study was to evaluate the efficacy of the follow-up methods and results of atypical glandular cells of undetermined significance (AGUS) detected on cervicovaginal Pap smears. METHODS: From May 1991 to December 1996, we have performed 407, 451 cervicovaginal Pap smears, of which 326 patients were identified as AGUS. Of the 326 patients, 268 patients were followed by repeat Pap smears, colposcopy, cone biopsy, or endometrial curettage. RESULTS: The incidence of AGUS on Pap smears is approximately 0.08%. The mean age of the patients was 43 years (range 22-79 years). The most common complaint was abnormal vaginal bleeding. The gross findings of the cervix were normal to mild erosion. The following past histories of patients could affect the AGUS results on Pap smear: 30 had cone biopsy, 21 had Pap smears on pregnancy and within 8 weeks after delivery or evacuation, 3 were on hormonal replacement therapy, 2 had intrauterine devices for contraception, and 5 were undergoing follow-up after treatment of cervical cancer. The benign lesions detected during follow-up periods were 6 microglandular hyperplasia of the cervix, 5 atypical squamous metaplasia of the cervix, 2 cervical endometriosis, 2 tubal metaplasia, 10 cervical myoma, 11 cervical polyps, 9 endometrial polyps, 3 uterine myoma, 1 pelvic endometriosis, 1 ovarian endometriosis, and 4 uterine adenomyosis. The premalignant or malignant lesions of the cervix were 4 low-grade squamous intraepithelial lesions, 24 high-grade squamous intraepithelial lesions, 8 glandular atypia/dysplasia, 5 adenocarcinoma in situ, 3 microinvasive adenocarcinoma, and 4 invasive adenocarcinoma. The neoplastic lesions of the uterus were 6 endometrial hyperplasia, 11 endometrial adenocarcinoma, 1 malignant mixed Müllerian tumor, and 1 metastatic endometrial adenocarcinoma. Sixty-seven (25%) of 268 patients followed up were identified as having clinically significant lesions of the cervix or uterus. The detection rates of abnormal lesions were 3.1% with repeated Pap smears (3/98), 28.4% with colposcopic-directed biopsy (31/109), 63.6% with cone biopsy (35/55), and 29.7% with endometrial curettage (19/64). CONCLUSION: AGUS on Pap smears showed various benign and malignant lesions of the cervix or uterus. The clinicians must communicate with the pathologists regarding the patient's clinical information as well as the origin of the atypical glandular cells in Pap smears. We recommend that patients with AGUS on Pap smear should undergo immediate intensive diagnostic studies, including colposcopic-directed biopsy with endocervical curettage or cone biopsy, to detect cervical lesions and endometrial curettage to detect endometrial lesions.     

Radiation-induced benign glandular cells in posthysterectomy smears: a cytomorphologic and clinical analysis

In this retrospective study, we aimed to investigate the frequency and cytomorphologic characteristics of benign glandular cells (BGCs) in hysterectomized individuals. We also discussed the possible effect of radiation therapy on these cells. We reviewed our cytopathology archive material through a 5.5-year period and found 1460 posthysterectomy vaginal smears. Of these, 508 smears were from patients who had undergone hysterectomy for a gynecological malignancy. Review of this vaginal cytology material revealed 17 posthysterectomy patients whose smears contained BGCs. We obtained detailed clinical information in 16 of these. In addition to routine Papanicolaou staining, mucicarmine stain was also used to demonstrate cytoplasmic mucin in some cases. All the patients had a history of gynecological malignancy and had radiation therapy. Glandular cells appeared singly or in rows and honeycomb groups and did not show cytologic atypia. We concluded that radiation might give rise to a metaplastic process in which basal cells of squamous epithelium of the vagina transform into glandular cells. Most probably this process is independent of radiation dosage and period and is irreversible. We also propose that the possibility of encountering glandular cells in posthysterectomy smears is higher than expected, if the mucin stains have been used for the microscopic examination.     

Evaluation of Serial Cervical Cytology in the Assessment of Preinvasive Cervical Neoplasia

Examination was made of the cervical cytology in 107 patients who underwent cone biopsy with a subsequent diagnosis of severe dysplasia or carcinoma in situ (105) or microinvasive carcinoma (2). Multiple smears had been performed for each patient over a period of time. From the total number of smears a 'false-negative' cervical cytology rate of 10.3 per cent was found. The time interval from the initial abnormal smear until definitive surgical treatment was carried out was calculated. The cervical smear prior to cone biopsy was found to correlate with the histological diagnosis in only 46.7 per cent. The implications of performing repeated cervical cytology are discussed and a firm recommendation is made that patients with abnormal cervical smear be promptly referred to definitive treatment.