Benign glandular and squamous metaplastic-like cells seen in vaginal Pap smears of post hysterectomy patients: incidence and patient profile

We have observed benign glandular cells and squamous metaplastic-like cells in vaginal Pap smears of post hysterectomy patients (PHP). Vaginal Pap smears from 1,547 PHP were retrieved. In 2% of these smears (Group A) glandular cells were observed, with the majority of the smears revealing squamous metaplastic-like cells (47%). Mucinous endocervical columnar-like cells were seen in 9% of the cases, glandular cells not resembling endocervical cells in 13%, and a combination of the former two categories in 31%. Group A patients were compared with other PHP without these cells in their vaginal smears (Group B). Several clinical and surgical parameters were evaluated. A distinctive clinical profile was not identified for either group of patients (A or B). Of patients in group A 49.8% had a history of a previous gynecologic malignancy (Group B: 19%). Based on our study, we postulate that in the absence of a clinically identifiable source of these cells, the most likely source of origin is probably vaginal adenosis not associated with DES exposure in utero or a metaplastic phenomenon perhaps related to therapy. These cells do not seem to be related to imminent neoplasia or dysplasia.     

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.     

A cytohistologic study of atypical glandular cells detected in cervical smears during cervical screening tests in Iran

Atypical glandular cells (AGC) often cause diagnostic uncertainty in cervicovaginal smears. To determine the incidence of significant pathologies associated with AGC on Papanicolaou test, AGC smears were correlated with subsequent biopsy diagnoses. A retrospective review of archives of our cytology files for cervicovaginal smears diagnosed as AGC from April 1998 to March 2001 was performed. In 9390 cervicovaginal smears, AGC were reported in 76 (0.81%) cases, with histologic follow-up in 42 patients (55.3%). Twenty-two patients (52.4%) had preneoplastic or neoplastic, squamous, or glandular lesions on histologic examination. Among them were cervical intraepithelial neoplasia, basal cell abnormality of undetermined significance, cervical adenocarcinoma, endometrial hyperplasia or adenocarcinoma, vaginal adenocarcinoma, endocervical glandular dysplasia, metastatic breast carcinoma, and simple nonvillous trophoblastic tissue. Therefore, presence of AGC in cervical smears may exhibit a spectrum of findings, ranging from benign/reactive changes to squamous or glandular premalignancy or malignancy. A majority of these lesions are squamous dysplasia, and a significant number of patients had glandular malignancy. The results of the current study underline the importance of follow-up for patients with the diagnosis of AGC. To our knowledge, this is the first report in Iran showing the significance of AGC diagnosis.     

When applied to facial skin,does estrogen ointment have systemic effects?

Summary We examined cytological vaginal smears of 17 women before and after three months of dermal estrogen (1 g of 0.01% estradiol ointment or 0.3% estriol ointment once daily), applied to the face for dermatological indications. The mean age was 57.1±7.6 years (range from 46 to 66). Seven women had estrogenic smears (more than 10% superficial cells) before therapy. Nine women were treated with 0.01% estradiol ointment and 8 were treated with 0.3% estriol ointment. Both groups had gynecological examinations including cervical and vaginal smears before and after treatment and also monthly measurements of serum follicle-stimulating hormone, prolactin and estradiol levels. Serum hormone levels and the appearance of vaginal smears showed no significant change during treatment.     

Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy

One hundred twelve vaginal hysterectomies were performed during a period of 2 years, 8 months. During the first year and a half, fourteen procedures were performed on patients referred to our institution because of posthysterectomy vaginal prolapse. We present our results of abdominal and vaginal repairs for vaginal prolapse. Moreover, we present and emphasize a modified surgical technique for the prevention of posthysterectomy vaginal prolapse and enterocele during vaginal hysterectomy. In all 112 patients no posthysterectomy prolapse has occurred. It is concluded that these procedures are acceptable ones to prevent an infrequent, yet tragic consequence of hysterectomy.     

Sequential radiation changes in cytology of vaginal smears in carcinoma of cervix uteri during radiotherapy

The study deals with acute/immediate radiation changes in 2020 sequential vaginal smears in 101 patients of carcinoma of the cervix uteri, 97 were of squamous cell carcinoma and 4 of adenocarcinoma. The smears were collected after 12-14 days, 15-24 days and 25 days to 6 weeks following radiotherapy. The pretreatment vaginal smears were collected and examined for percentage of cancer cells. Subsequent smears were studied for radiation changes in benign and malignant cells, such as cell size, vacuolation of cytoplasm, multinucleation and nuclear changes, etc. A gradual and linear decline in cancer cells was observed until the end of therapy; 41.6% of patients had less than 10% cancer cells within 12-14 days of therapy, 63.4% of patients between 15 and 24 days and 74.6% after 25 days to 6 weeks following radiation. Eighty three percent of the patients attained zero level at the end of therapy.     

Sacrospinous ligament fixation for eversion of the vagina

During the period from January 1, 1974, through June 30, 1987, 100 patients were treated with a sacrospinous ligament suspension of the vaginal apex at the University of Michigan Medical Center. Fifty-seven patients had a posthysterectomy complete vaginal prolapse; 38 patients, an incomplete vaginal prolapse; and five, a posthysterectomy enterocele. Fifty-one patients had had an abdominal hysterectomy and 49 a vaginal hysterectomy previously. Almost half of the patients had had at least one attempt at surgical correction of the prolapse and three patients had had four previous procedures. The immediate postoperative complications were not unexpected. Febrile morbidity responding to appropriate therapy was the most common complication. There was no surgical mortality. Seventy-one of the 78 patients were operated on greater than or equal to 1 year ago and were the subjects of the review. Sixty-four of the patients (90%) had complete symptomatic relief after operation. Ten of these patients had some asymptomatic laxity of the vaginal walls and nine others had satisfactory support but vaginal stenosis or symptoms of stress urinary incontinence after operation. Four patients developed cystoceles and three others had recurrent vaginal prolapse. The vaginal approach to the treatment of eversion of the vagina has many advantages, as reported. The surgical goals described were attained; therefore, use of the sacrospinous ligament fixation procedure as a therapeutic procedure only is defended. The surgical technique is described. Finally, the sacrospinous ligament fixation of vaginal vault prolapse should assume high priority in our therapeutic regimen.     

Carcinomas of the female genital tract occurring after pelvic irradiation: a report of 15 cases.

The concept of postradiation sarcoma is widely appreciated, however carcinomas arising in previously irradiated fields, the putative "postradiation carcinoma," are less well understood. Fifteen patients who developed gynecological malignancies after pelvic radiation therapy were studied. Five of these patients had HPV-related tumors both pre- and post- irradiation. Ten were irradiated for cervical cancer, one for endometrial carcinoma, one for vulvar carcinoma, one for colon cancer and 2 for benign conditions. The mean and median latent periods from the initiation of radiation therapy to the development of the second malignancy were 22.8 and 19 years, respectively (22.4 and 19.5 years, respectively, for non-HPV-related cancers; 24 and 18 years for HPV-related cancers). The "postradiation" malignancies included 2 ovarian carcinomas, 5 vaginal carcinomas (3 invasive, 2 in situ), 4 endometrial carcinomas, one cervical carcinoma, one vulvar carcinoma, one distal urethral carcinoma, and one pelvic carcinoma of unclear primary site. Gynecological carcinomas may occur many years after pelvic irradiation. Although the evidence for a causative role is circumstantial, these tumors appear to have a similar latent period as postradiation sarcomas.     

Total laparoscopic radical parametrectomy

Although the surgical approach to early invasive cervical carcinoma may result in a better functional quality of life, the majority of patients with occult cervical cancer posthysterectomy still are treated with radiation therapy. Obviously, a radical operation still is considered a technically difficult task. Recently, laparoscopic-assisted vaginal radical parametrectomy (LAVRP) has been reported as an alternative treatment for this situation. In laparoscopic-assisted vaginal radical hysterectomy (LARVH), parts of the procedure are performed vaginally. We modified LAVRP in treating cervical cancer as through the laparoscope completely total laparoscopic radical parametrectomy (TLRP). The major advantage of TLRP for occult cervical cancer is that the entire surgery is performed under direct observation. It may reduce the possibility of visceral organ injury during vaginal procedures and could minimize the vaginal bleeding from vaginal dissection. Our preliminary experiences suggest that TLRP is feasible for carefully selected candidates.     

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.     

Estrogen-progestogen induced hematocolpometra following allogeneic stem cell transplant

OBJECTIVES: Gynecological manifestation of chronic graft-versus-host disease (cGVHD) has been invariably described in association with its extensive form. We have also observed it in a patient with the limited cGVHD form. DESIGN: We here describe our experience of gynecological complications in a population of 30 women who were followed up in a single center 12-120 months after allogeneic stem cell transplant (allo-SCT) due to hematological malignancies. All of them manifested premature ovarian failure because of the received treatments. RESULTS: Three out of 14 women who were affected by cGVHD developed hematocolpometra after estrogen + progestogen therapy (EPT) introduction, due to uterine and vaginal dystrophy and synecchiae. Extensive cGVHD, including dermal and mucosal localization, was present in two women while the third had only liver involvement. None of our patients had received radiation therapy or had a posttransplant history of infection. Local application of estrogens consistently improved the gynecological complication. However, vaginal synecchiae tended to relapse when local treatment was interrupted, despite no other apparent evidence of active cGVHD. CONCLUSIONS: All women with cGVHD should undergo gynecological examination before introducing EPT, to avoid unpleasant complication as hematocolpometra. Vaginal and cervical synecchiae should be treated with prolonged local treatments, and temporary use of continuous EPT regimens may be preferable in these women. Moreover, close monitoring by pelvic exam and ultrasonography is advisable during the initial cycles to detect any complication caused by possible intrauterine adhesions undetected during the previous gynecological examination.     

Early development of vaginal shortening during radiation therapy for endometrial or cervical cancer

Abstract. Katz A, Njuguna E, Rakowsky E, Sulkes A, Sulkes J, Fenig E. Early development of vaginal shortening during radiation therapy for endometrial or cervical cancer.
Vaginal necrosis can occur following radiation therapy for gynecological malignancies. The distal vaginal mucosa has a poorer radiation tolerance than the mucosa in the upper region. We examined the extent of vaginal shortening in patients treated by intravaginal brachytherapy with or without pelvic irradiation. Maximal extension of the vaginal cylinder above the pubis was measured for each insertion. We found that the difference in mean values between insertions (2.3 vs. 1.7 cm) was highly statistically significant ( P < 0.0001). Our study shows that vaginal shortening can occur during the course of intracavity and external irradiation. These alterations in vaginal anatomy can have important consequences on doses received by the distal vaginal mucosa.     

Prevention of infectious morbidity after elective abdominal hysterectomy

Objective

Our aim was to investigate whether posthysterectomy infectious morbidity could be reduced by intravaginal therapy before operations.

Materials and methods

Women expected to undergo elective total abdominal hysterectomy were included. Vaginal flora was evaluated by preoperative Gram-stained vaginal smears up to Nugent’s criteria. Study group were administered vaginal combination therapy including 500?mg metronidazole and 100?mg miconazole nitrate two times a day for 7?days. Control group were not given any preoperative vaginal therapy. Postoperative infectious morbidity was evaluated and compared.

Results

Ninety-five women in the study group and 97 women in the control group completed the study protocol. Women with abnormal flora had significantly more wound and vaginal cuff infections than the women with normal flora in the control group. Urinary infections were significantly higher in the study group (38.9 vs. 23.7?%) and vaginal cuff infections were significantly higher in the untreated control group (2.1 vs. 8.2?%).

Conclusions

We concluded that postoperative vaginal cuff infections can be decreased by treating abnormal vaginal flora before elective abdominal hysterectomies.     

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.     

Atypical glandular cells of undetermined significance in cervical cytologic findings

OBJECTIVE: Our purpose was to increase our understanding of the clinical significance of atypical glandular cells of undetermined origin. STUDY DESIGN: All cytologic Papanicolaou smears were reviewed and classified within the context of the Bethesda classification system. Charts of all patients with a diagnosis of atypical glandular cells of undetermined origin were reviewed for previous medical history, diagnostic study, histologic diagnosis, and prior Papanicolaou smear abnormalities. RESULTS: The incidence of atypical glandular cells of undetermined origin in 76,018 Papanicolaou smears was 0.196%. We reviewed 133 patient medical records with cytologic diagnoses. Eighty of these patients have had appropriate follow-up. Thirty-six (45%) of these were found to have significant histologic abnormalities, including 6 patients with cervical intraepithelial neoplasia, grades 2 and 3, and 4 invasive cancers. CONCLUSION: The frequency of underlying serious histologic changes is much greater in atypical glandular cells than in atypical squamous cells of undetermined significance. On the basis of our results, we believe that all patients with atypical glandular cells should undergo intensive evaluation including colposcopy, cervical biopsy, and endocervical curettage. When diagnosis cannot be clearly established, patient should undergo endometrial biopsy.     

Prognostic value of persistent cancer cells in vaginal smears of patients with cervical carcinoma treated by radiotherapy

In an attempt to improve the therapeutic scheme in cervical carcinoma a clinical research program involving 100 patients with stages 1 and 2 of cervical carcinoma was started. All patients underwent radiation treatment only. In the series 32 patients were state 1 and 68 stage 2. About 1/2 had undifferentiated squamous epithelioma and the others moderately differentiated epthelioma. Radiotherapy consisted of intracavity radium of 5000 mg-hr. and an external telecobalt irradiation up to 4000 rad tumor dose through 4 portals. During and after radiotherapy patients were followed by clinical examiniations and vaginal smears. Months after beginning of treatment another cervical punch biopsy was done. The 3 year recovery rate was 97% of stage 1 but only 75% of stage 2 patients. Recovery seemed better in well differentiated epithelioma and in cases treated first with external radiation. There were 13 deaths from recurrent disease within 5 to 35 months after begining of treatment. Punch biopsies performed 4 months after beginning of treatment revealed carcinomatous tissue in the cervical area of only 2 of these 13 patients. In all 87 survivors, abnormal cells disappeared from vaginal smears by 7 weeks. In the 13 fatal cases, abnormal cells persisted for 7 weeks or beyond. In 5 of the 13 fatal cases, tumor cells in the vaginal smears persisted throughout the remainder of the patients' lives. Other follow-up methods seemed inefficient cases. Well defined vaginal cytology seemed of most prognostic value. The radioresistent group could be submitted to complementary surgical treatment to improve the prognosis.     

The role of vaginal apex excision in the management of persistent posthysterectomy dyspareunia

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of vaginal apex excision in the treatment of patients with posthysterectomy dyspareunia. STUDY DESIGN: This was a case series with an independent third-party survey of patients with posthysterectomy dyspareunia managed at the University of Utah Pelvic Pain Clinic. Thirteen patients were first treated with local injections of anesthetics into localized vaginal pain foci. Further evaluation included formal psychometric testing and a diagnostic spinal block. Nine patients underwent surgical excision of the vaginal apex. An independent interviewer who did not know the patients assessed the effects of this procedure on dyspareunia and coital frequency at a mean of 36.4 +/- 3.7 months after the operation. RESULTS: The mean coital verbal analog pain score (1-10 scale) decreased from 9.22 +/- 0.27 before excision of the vaginal apex to 3.11 +/- 0.84 after the operation (P <.001), and coital frequency improved from 5.22 +/- 2.02 episodes per month before surgery to 11.11 +/- 1.82 episodes per month after surgery (P =.02). Of the 9 patients, 5 essentially had the dyspareunia cured. Dyspareunia was decreased and coital frequency was markedly increased in all but 1 of the other 4 cases. CONCLUSION: Excision of the vaginal apex is an effective treatment for carefully selected patients with posthysterectomy dyspareunia.     

The diagnosis of genital malignancy by vaginal smears

Six thousand, seven hundred fifty-three smears on 1,709 patients have been studied. The smears were obtained, stained, and classified by the methods of Papanicolaou and Traut. One hundred fourteen patients with genital malignancy were diagnosed by smears out of a group of 124 diagnosed by pathology; a percentage error of 8.1.False positive diagnoses were made in 34 of 1,585 patients; a percentage error of 2.1.Nine patients have been presented who illustrate the diagnosis of genital carcinoma by the vaginal smear method. These include squamous celled carcinoma of the cervix, 5; squamous celled carcinoma of the vulva, 1; sarcoma of the uterus, 1; and chorionepithelioma, 1. Those patients having squamous celled carcinoma of the cervix show that the diagnosis of malignancy sometimes may be made earlier by smears than by the biopsy method.Primary adenocarcinoma of the oviduct was revealed in the vaginal smears of one patient.One patient with adenocarcinoma of the endometrium in which smears were negative even when they were obtained from the tumor surface is reported to show a weakness of the smear method.Salient features, good and bad, of the vaginal smear method in the diagnosis of genital cancer have been presented.It is thought that this procedure will become routine in the complete physical examination of women, but that treatment for malignancy should not be instituted prior to pathologic tissue confirmation.