Vaginal reconstructive surgery for severe pelvic organ prolapses: A ‘uterine-sparing’ technique using polypropylene prostheses

Objective

The Ulmsten's “Integral Theory” for pelvic floor dysfunctions is based on the need to reinforce fascias and ligaments with prostheses to obtain a reconstitution of the pelvic floor's anatomy. In September 2004 we developed a “uterine-sparing” surgical technique to correct such pathologies and in this paper we present results obtained. Primary outcome was to evaluate the technique's efficacy, secondary outcomes the resolution of stress urinary incontinence, postoperative pain (VAS scale), safety and complications.

Study design

This prospective study included patients affected by stage 3 and 4 uterine-vaginal prolapse who wished to conserve their uterus. Those with (1) minor degrees of severity, (2) unfit for surgery, (3) with a clear indication to hysterectomy (i.e. endometrial cancer), (4) with an elevated operative risk (American Society of Anaesthesiologists—ASA score III and IV), (5) previous vaginal surgeries and (6) with moderate/severe defecation problems were excluded. The technique consisted in a sacrospinous colposuspension with polypropylene mesh. The pelvic status was classified according to the international Pelvic Organ Prolapse staging system (POP-Q). Postoperative pain was scored with the VAS Scale. All patients were given the King's Health questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Wexner questionnaire.

Results

From September 2004 to November 2006 we treated 80 patients. Polypropylene prostheses (Gynemesh-Soft PS, 10 cm × 15 cm – GyneMesh, Gynecare Ethicon – Somerville, NJ, USA) were used to reconstruct the pubo-cervix or the recto-vaginal fascia. We performed an anterior-central vaginal reconstruction in 35 (43.8%) patients, central-posterior in 25 (31%) and total reconstruction in 20 (25%). The median follow-up was 21 months (range 18–26). The severe pelvic prolapse, evaluated with the POP-Q System, was completely treated in all the patients and no recurrences were observed. The urodynamic examination showed a complete resolution of the stress urinary incontinence in 10 patients (83%). Sexual activities improved in all patients. We recorded three vaginal erosions and one patient complained of a postoperative dyspareunia.

Conclusions

This pilot study suggests that our technique is safe and effective and can efficiently repair the pelvic organs prolapse, without undergoing hysterectomy and with a low rate of vaginal erosions.     

宫颈癌及高级别宫颈上皮内瘤变子宫切除术后阴道上皮内瘤变88例临床分析

目的:探讨宫颈癌及高级别宫颈上皮内瘤变(CINⅡ及以上,简称CINⅡ+)子宫切除术后阴道上皮内瘤变(VaIN)的临床特点、诊断及治疗。方法:回顾性分析收治的宫颈癌及CINⅡ+术后门诊规律随访时经阴道镜下活检发现的88例VaIN患者(VaINⅠ55例,VaINⅡ23例,VaINⅢ10例)的临床病理资料。结果:(1)88例患者中82例(93.18%)无明显临床症状。发生VaINⅠ的中位年龄(47.23岁)低于VaINⅡ+(50.75岁),差异有统计学意义(P0.05)。(2)CINⅡ+和宫颈癌术后发生VaIN的平均时间为22.01±4.13月,CINⅡ+及宫颈癌术后2年内发现VaIN的比率(65.90%)高于2年及以上(34.10%),差异有统计学意义(P0.05)。(3)TCT、HPV及两者联合筛查VaIN的敏感性分别为44.57%、69.31%、87.50%,差异有统计学意义(P0.05)。(4)HPV感染:61例HPV感染的VaIN患者中,高危型HPV感染58例(95.08%)。发生VaIN时HPV感染亚型与既往CINⅡ+或宫颈癌时HPV感染亚型相同的VaINⅡ+所占比例(56.00%)多于VaINⅠ(17.78%),差异有统计学意义(P0.05)。(5)共失访8例(9.09%)。50例VaINⅠ患者均未治疗,随访24例(48.00%)患者转为正常,23例(46.00%)患者为持续VaINⅠ状态,3例(6.00%)进展为VaINⅡ。未行治疗的VaINⅡ患者7例,规律随访6例,无一例进展;经手术治疗的VaINⅡ+患者24例,无一例进展为阴道癌。1例持续的阴道或外阴上皮的中重度不典型增生,共行4次手术治疗。结论:VaIN多无临床症状,易漏诊;随年龄的增加,VaIN的级别较高。CINⅡ+及宫颈癌术后2年内应密切监控VaIN的发生。HPV和TCT联合筛查能提高对VaIN的诊断。检测特定类型的HPV感染对于识别VaIN风险有一定重要性。VaINⅠ采用观察治疗可行,VaIN病变均应严密随访。     

1134例宫颈组织病理检查结果分析

目的:探讨宫颈癌及CIN的发病趋势。方法:对2000~2001年及2004~2005年我院1134例宫颈组织病理学检查、HPV检测结果及患者年龄进行比较分析。结果:与2000~2001年比较,2004~2005年宫颈癌的发生率下降;CINⅡ~Ⅲ的发生率,尤其是≤35岁的CINⅡ~Ⅲ的发生率显著升高,差异有显著性或非常显著性(P<0.05,P<0.01);宫颈癌、CINⅡ~Ⅲ的平均发病年龄均下降(P<0.05);HPV感染发生率升高(P<0.01);宫颈癌、CIN患者中HPV感染平均年龄下降(P<0.05),≤35岁的宫颈癌、CIN患者HPV感染发生率高于>35岁者,差异有显著性(P<0.05)。结论:宫颈癌、CINⅡ~Ⅲ的年轻化趋势明显,且与HPV感染有关。     

The increased detection of cervical intraepithelial neoplasia when using a second biopsy at colposcopy

Objective

It has been suggested that colposcopy can miss a significant percentage of high-grade cervical intraepithelial neoplasia (CIN2 +). Improved disease ascertainment was evaluated by taking multiple lesion-directed biopsies.

Methods

In a cross-sectional multicenter study in the Netherlands and Spain, 610 women referred to colposcopy following abnormal cervical cytology results were included. Multiple directed biopsies were collected from lesions and ranked according to impression. A non-directed biopsy of normal-appearing tissue was added if fewer than four biopsies were collected. We evaluated the additional CIN2 + yield for one and two directed biopsies. Colposcopic images were reviewed for quality control.

Results

In women with at least two lesion-directed biopsies the yield for CIN2 + increased from 51.7% (95%CI; 45.7–57.7) for one directed biopsy to 60.4% (95%CI; 54.4–66.2, p < 0.001) for two biopsies. The highest CIN2 + yield was observed in women who were HPV16-positive, had high-grade squamous intraepithelial lesion (HSIL) cytology, and high-grade colposcopy impression. The yield increased from 83.1% (95%CI; 71.5–90.5) with one directed biopsy to 93.2% (95%CI; 83.8–97.3) with two directed biopsies. Only 4.5% additional CIN2 + were detected in biopsies not targeting abnormal areas on the cervix.

Conclusions

A second lesion-directed biopsy is associated with a significant increase in CIN2 + detection. Performing a second lesion-directed biopsy and using a low threshold for abnormality of any acetowhitening should become the standard clinical practice of colposcopy.     

Conization for CIN associated with human papillomavirus infection

Summary We report results of follow-up by PAP smears and colposcopy in 116 women treated since 1981 by conization for cervical intraepithelial neoplasia with human papillomavirus infection (HPV-CIN). The mean follow-up time was 31.9 (SD 19) months. Preoperative diagnosis was HPV-CIN II (with extension into the endocervix) in 11 cases and HPV-CIN III in 103 cases; two diagnostic conizations were performed. The histological examination of the cone biopsies showed complete excision of CIN in 109 cases (94%). Three patients underwent hysterectomy after conization; one had microinvasion in the cone biopsy, one had suspicion of microinvasion and one had non-radical conization. Three patients (2.6%) were lost to follow-up. After excluding these six patients the primary cure rate of HPV lesions (normal cytological and colposcopical finding after conization) was 82.7%. Four patients (4.6%) had residual CIN after conization. During the follow-up 15 patients had recurrence of HPV infection, only one had HPV-CIN I. HPV 16 was the most common HPV type (56/116, 48.2%) in the conization group and also in the recurrent cases (9/15, 60%). The results support the role of HPV 16 in cervical carcinogenesis.     

Risk factors for human papillomavirus persistence among women undergoing cold-knife conization for treatment of high-grade cervical intraepithelial neoplasia

Objective

To investigate the risk factors potentially associated with high-risk human papillomavirus (HPV) persistence in women undergoing cold-knife conization (CKC) for treatment of high-grade cervical intraepithelial neoplasia (CIN).

Methods

Medical records of women who underwent CKC for treatment of CIN 2/3 between 2007 and 2012 at a tertiary hospital in Ankara, Turkey, were retrospectively analyzed. Cases involving persistent HPV infection after 1 year of follow-up were identified. Using univariate and multivariate analyses, the impact of various factors such as patient age, menopausal status, parity, high-risk HPV type, excised cone dimensions (width, height, and depth), and surgical margin status on high-risk HPV persistence was assessed.

Results

A total of 292 women underwent CKC for treatment of CIN 2/3 within the study period. After women with a subsequent diagnosis of cervical cancer, subsequent total hysterectomy, and inadequate follow-up data were eliminated, 113 women were eligible for final analysis. High-risk HPV persistence was detected in 24 (21.2%) women, and multivariate analysis revealed that patient age and cone depth were significant independent predictors (P < 0.05).

Conclusion

High-risk HPV persistence may be encountered after CKC procedures. It is important to evaluate persistent HPV infections after treatment because affected women are at increased risk for disease persistence, recurrence, and progression.     

宫颈上皮内瘤变与人类白细胞抗原及人乳头瘤病毒感染相关性的研究

目的:探讨宫颈上皮内瘤变(CIN)与人乳头瘤病毒(HPV)感染及人类白细胞抗原(HLA)的相关性。方法:选取宫颈活检组织病理学诊断为CINⅠ42例、CINⅡ40例、CINⅢ29例、宫颈湿疣40例、慢性宫颈炎90例,从液基薄片检测剩余的保存液中提取宫颈脱落细胞学的基因组DNA,采用PCR方法及HLA试剂盒进行HPV16/18及HLA分型检测。结果:HPV16/18检出率CINⅠ组为21.4%,CINⅡ组为47.5%,CINⅢ组为55.2%,湿疣组为32.5%,宫颈炎组为1.1%。HLA分型表明,DR15(2)、DQ6(1)、DQ4在CIN组中阳性率分别为37.0%、44.0%、12.0%,明显高于宫颈炎组的17.5%、18.8%、3.8%(P<0.05),并且DR4阳性率随着CIN级别增高而增高(CINⅠ5.6%,CINⅡ13.9%、CINⅢ28.6%)。结论:HPV16/18感染和HLA分型与CIN及其分级密切相关,提示HLA在宫颈癌的发生、发展中可能起一定的作用。     

不同女性人群生殖道人乳头瘤病毒感染状况分析

目的:调查不同女性人群生殖道人乳头瘤病毒(HPV)感染状况,为制定不同人群宫颈癌筛查策略提供理论依据。方法:选择2010年1月至2015年12月在重庆市妇幼保健院妇产科门诊体检和就诊的3376例妇女,分为5组:普通人群组770例,妇科疾病患者组1069例,宫颈上皮内瘤变(CIN)患者组560例,不孕症患者组648例,产褥期妇女组329例。采用HPV基因分型技术进行HPV检查,分析HPV DNA亚型感染状况。结果:(1)共检出HPV 22个型别,最常见类型依次为6型(14.81%,500/3376),16型(14.16%,478/3376),52型(12.59%,425/3376),58型(11.91%,402/3376),43型(6.66%,225/3376),未检测出HPV 44型。(2)不同人群HPV总阳性率及高危型阳性率不同,由高到低依次为CIN患者组[89.46%(501/560),85.89%(481/560)],不孕症患者组[66.67%(432/648),58.80%(381/648)],妇科疾病患者组[62.77%(671/1069),55.57%(594/1069)],普通人群组[24.03%(185/770),19.22%(148/770)],产褥期妇女组[13.07%(43/329),10.03%(33/329)]。(3)不同人群中HPV DNA亚型分布有差异,CIN患者组及不孕症患者组以高危型HPV感染为主,感染HPV型别构成比相似,最常见类型均为HPV16、58、52型,且HPV多重感染百分率高于其他组(P0.01),但妇科疾病患者组总体高危型HPV感染率及多重感染率明显高于普通人群及产褥期妇女组。(4)CIN患者组中随CIN病变级别增高,HPV总阳性率及高危型HPV阳性率皆增高,差异有统计学意义(χ~2总=57.49,P0.01;χ~2高危型=58.40,P0.01)。三重及以上HPV感染在高级别病变(CINⅡ、Ⅲ)中更常见(χ~2=8.96,P0.05),在CINⅡ、CINⅢ组中HPV16型检出率高于CINⅠ组,差异有统计学意义(χ~2=33.24,P0.01)。结论:不孕症患者及妇科疾病患者是高危型HPV感染及CIN的高危人群,重视机会性筛查是提高CIN检出率的有效手段。不同女性人群HPV感染状态不同,应针对不同女性人群制定特异筛查模式。     

宫颈环形电切术后切缘状态350例临床分析

目的:分析宫颈环形电切术(LEEP)后切缘状态相关因素,评价切缘阳性结果。方法:回顾性分析我院经阴道镜活检诊断为宫颈上皮内瘤变(CIN)Ⅱ～Ⅲ且接受LEEP的患者350例,分析术后切缘阳性及预后的有关因素。结果:①350例患者,切缘阳性89例,其中CINⅡ87例,切缘阳性6例(6.90%);CINⅢ250例,切缘阳性77例(30.80%);宫颈癌13例,切缘阳性6例(46.15%)。②LEEP后行子宫全切除术29例和术后再次行冷刀锥切术1例,共有10例患者CIN病变残留,CIN病变残留率:切缘阴性者14.29%(2/14),切缘阳性者50.00%(8/16)。③对242例患者术后随访,12例CIN病变持续或进展。其中8例为切缘阴性患者,4例为切缘阳性患者(2例进展为宫颈浸润癌)。12例中,4例薄层液基细胞学涂片(TCT)检查阳性;10例人乳头瘤病毒(HPV)检查阳性,其中8例为HPV16亚型持续阳性。④单因素分析表明,切缘阳性与病变严重程度有关(z=4.731,P<0.001),切缘阳性是CIN病变残留的高危因素(r=0.378,P=0.039)。LEEP后TCT检查异常、高危亚型HPV阳性以及同一亚型HPV...     

The health care costs of cervical human papillomavirus--related disease

OBJECTIVE: The purpose of this study was to examine the health care costs of cervical human papillomavirus-related disease in a US health care setting. STUDY DESIGN: We conducted an observational cohort study using 1997 through 2002 administrative and laboratory records from 103,476 female enrollees of the Kaiser Permanente Northwest health plan (Portland, Ore). We examined the cost per case and annual cost per 1000 enrollees for cervical human papillomavirus-related events. RESULTS: A cervical examination with a normal routine papanicolaou smear incurred costs of 57 dollars (95% CI, 57-57). Costs that were associated with abnormal routine screening diagnoses ranged from 299 dollars for atypical squamous cells (95% CI, 245-352) to 2349 dollars for high-grade squamous intraepithelial lesion (95% CI, 1,047-3,650). The costs of histologically confirmed cervical intraepithelial neoplasia ranged from 1026 dollars for cervical intraepithelial neoplasia 1 (95% CI, 862-1191) to 3235 dollars for cervical intraepithelial neoplasia 3 (95% CI, 2051-4419); a cost of 376 dollars (95% CI, 315-436) was associated with false-positive test results. At the level of the health plan, overall annual cervical cancer prevention and treatment costs were 26,415 dollars per 1000 female enrollees, with routine cervical cancer screening accounting for expenditures of 16,746 dollars per 1000 female enrollees, cervical intraepithelial neoplasia accounting for expenditures of 4535 dollars per 1000 female enrollees, cervical cancer accounting for expenditures of 2629 dollars per 1000 female enrollees, and false-positive test results accounting for expenditures of 2394 dollars per 1000 female enrollees. CONCLUSION: These are the first direct estimates of both individual and population level costs of cervical human papillomavirus-related disease in a general US health care setting. Routine cervical cancer screening comprises nearly two thirds of total annual cervical human papillomavirus-related health care costs, with 10% of expenditures dedicated to the treatment of invasive cervical cancer, 17% to the management of cervical precancers, and 9% to dealing with false-positive Papanicolaou test results.     

In situ hybridization analysis of HPV DNA in cervical precancer and cervical cancers from China

Summary A series of 103 cervical biopsies derived from 103 women during July 1958 to September 1963 from Beijing, China were investigated with in situ hybridization for the presence of HPV6, 11, 16, 18, 31 and 33 DNA. The mean age of the patients was 46.1 + 10.6 years with a range of 24–74 years. Morphological features of HPV infection were found in 80 (77.7%) biopsies. Invasive cervical cancer was diagnosed in 43 biopsies and cervical intraepithelial neoplasia CIN I, CIN II and CIN III in 9, 9, and 27 cases, respectively. A total of 63.1% (65/103) of the lesions had morphological features of HPV infections associated with CIN or invasive carcinomas. Altogether, 31.1% (32/103) of the biopsies were shown to contain HPV DNA. Of the cases showing HPV morphology, 43.1% were HPV DNA positive. HPV16 (30/32) was the most frequent type, followed by HPV11 and 18, whereas no lesions with HPV6, 31 or 33 were found. A total of 19/43 (44.2%) of the invasive carcinomas contained HPV DNA. HPV DNA positivity and the grade of CIN showed a statistically significant correlation (P=0.0011). Our study demonstrated the presence of HPV in cervical lesions among Chinese women in the late 1950's and early 1960's when a single sexual partner was the rule and also supports the concept that HPV has as an important etiological role in cervical cancer, the highest risk being associated with HPV type 16. The applicability of in situ hybridization in retrospective assessment is emphasized.     

Diagnostic accuracy of colposcopy in relation to human papillomavirus genotypes and multiple infection

Objective

The aim of this study is to evaluate the diagnostic accuracy of colposcopy for cervical intraepithelial neoplasia grade 3 or worse (CIN3 +) in relation to the detection of human papillomavirus (HPV) type 16 and multiple HPV infection.

Methods

A cohort study of 2526 subjects attending a colposcopic service because of cytological abnormalities. HPV genotypes were identified using the INNO–LIPA genotyping system.

Results

The final colposcopic/pathological diagnoses were as follows: 1282 (50.8%) negative, 709 (28.1%) CIN1, 169 (6.7%) CIN2, 318 (12.6%) CIN3 and 48 (1.9%) invasive cervical cancer, respectively. Among women with ASCUS/LSIL, assuming any colposcopic abnormality as a cut-off, there were no significant differences in the sensitivities (83.8%, 95% CI = 76–89.6 as compared to 84.1%, 95% CI = 73.2–91.1, p = 0.9) and ROC curves (0.61, 95% CI = 0.58–0.65 as compared to 0.59, 95% CI = 0.54–0.64, p = 0.5) in the detection of CIN3 + lesions between subjects with single and multiple high-risk infection, and between subjects infected by HPV16 (83.1%, 95% CI = 73.7–89.7, ROC = 0.59, 95% CI = 0.54–063) or other high-risk HPVs (84.7%, 95% CI = 75.6–90.8, ROC = 0.62, 95% CI = 0.58–0.66, p = 0.8 and p = 0.6 compared to HPV16). After correction for confounders, the odds ratios of CIN3 + associated with any abnormal colposcopic findings were 2.47 (95%CI = 1.44–4.23, p = 0.001) among HPV16 positive, 3.34 (95% CI = 2.16–5.42, p < 0.001) among other high-risk HPVs and 1.3 (95% CI = 0.72–2.48, p = 0.36) among subjects with negative/low-risk HPVs.

Conclusion

In routine clinical practice, multiple infection or HPV16 positivity did not affect colposcopic accuracy in the diagnosis of CIN3 + lesions. The sensitivity of colposcopy was poor among subjects who were uninfected or infected by low-risk HPV genotypes.     

人乳头瘤病毒分型检测在不同年龄CINⅡ～Ⅲ患者LEEP治疗后随访的临床研究

目的:检测不同年龄组患者宫颈上皮内瘤变Ⅱ～Ⅲ(CINⅡ～Ⅲ)高频电刀锥切术(LEEP)治疗后高危型人乳头瘤病毒(HPV)及亚型清除的情况,评价手术疗效及随访价值。方法:336例因CINⅡ～Ⅲ接受LEEP手术治疗的患者,随机将随访资料完整的101例患者按年龄分为3组,术前HPVDNA检测证实高危型HPV感染。治疗后6个月再次检测HPVDNA及液基细胞检测(TCT),如为高危型HPV持续感染再次行活检病理学检查。比较各组HPV术后清除率及HPV亚型持续感染率及残存率。结果:①3个年龄组LEEP治疗后HPV清除率分别为93.8%(30/32)、71.4%(25/35),64.7%(22/34)。21～30岁组治疗后HPV清除率与其他两组比较差异有统计学意义(P<0.05),后两个年龄组差异无统计学意义(P>0.05)。②术后6个月41～50岁组HPV16亚型持续感染率与21～30岁组相比差异有统计学意义(P<0.05);HPV16亚型与其他亚型相比持续感染率差异无统计学意义(P>0.05)。③术后6个月41～50岁组HPV16亚型持续感染残留率与21～30岁组相比差异有统计学意义(P<0.05)。结论:LEEP是一种简单安全的手术。可在切除病变的同时清除HPV。术后6个月HPV分型检测是一种较好的随访方法。对年龄较大尤其是术后HPV16亚型持续感染人群应密切长时间的随访。     

宫颈上皮内瘤变Ⅰ级的自然转归研究

目的:了解我国宫颈上皮内瘤变Ⅰ级(CINⅠ)的自然转归情况。方法:对经病理诊断为CINⅠ的548例患者进行24～48个月的定期随访。以液基细胞学检查(LCT)联合高危型HPV检测(HC-Ⅱ)作为监测手段。对LCT≥ASCUS,高危型HPV阳性或LCT≥LSIL者,行阴道镜下多点活检,以病理为最终诊断评价CINⅠ在6、12、24和36个月的自然转归情况。以寿命表法计算病变转归率。结果:(1)随访36个月时,累积失访率为10.22%。(2)随访36个月,CINⅠ向高级别进展者16例,病情稳定者29例,病变逆转447例。CINⅠ随访6个月时病变进展、持续存在和逆转为正常的百分率分别为0.58%、67.11%、37.39%;12个月时分别为1.15%、48.13%、55.61%;24个月时分别为2.30%,20.90%,77.28%;36个月时分别为3.07%,5.56%,85.71%。(3)高危型HPV阳性的CINⅠ患者6、12、24和36个月HPV累计自然清除率分别为52.76%、61.84%、82.64%和94.52%。结论:绝大多数CINⅠ可在36个月内自然逆转,其携带高危型HPV病毒亦可被自然清除。CINⅠ可能由高危型HPV一过性感染所致。     

人乳头瘤病毒与宫颈上皮内瘤样病变术后复发的关系

宫颈上皮内瘤样病变（CIN）是一种癌前病变,可分为CINⅠ、CINⅡ和CINⅢ。国内对CINⅡ及以上者主要采取手术治疗,但术后仍有一定的复发率。影响复发的因素较多,包括切缘阳性、宫颈管诊刮阳性、机体免疫力降低、高龄等。人乳头瘤病毒（HPV）与CIN复发的关系尚不十分明确,但基本能够确定HPV持续感染可增加CIN复发率,且HPV亚型和HPV负荷量在其中起重要作用。综述HPV对CIN复发的影响。     

Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions

OBJECTIVE: The aim of the study was to evaluate human papillomavirus (HPV) testing during the follow-up of patients after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesion. METHODS: A prospective study was conducted on 205 patients who underwent conization for high-grade squamous intraepithelial lesion (CIN 2 or 3). Loop electrosurgical excision procedure (LEEP) was used in all cases. High-risk HPV testing was realized by the Hybrid Capture II system before and 3 months after conization. RESULTS: Of the 205 patients, 193 (94.1%) were positive for the HPV test before conization. Seventy-one were HPV positive after conization (34.6%). The margins were positive in 36.1%. Residual disease was observed in 27 cases (13.2%). Four patients (2%) developed a recurrence after a mean follow-up of 18.1 months (+/-12). There was no correlation between pretreatment HPV testing and the residual disease or recurrence. Patients with positive margins were significantly more likely to have residual disease than those with negative margins (P < 0.0001). Residual disease was more likely to occur when the posttreatment HPV test was positive (P < 10(-7)). All recurrences were observed in patients with a positive posttreatment HPV test (P < 0.05). Residual disease and recurrence were correctly predicted with a sensitivity of 81 and 100%, respectively, and a negative predictive value of 96 and 100%. CONCLUSION: Posttreatment HPV testing could be useful in the follow-up of patients after conization. In case of negative posttreatment HPV testing, the frequency of follow-up could be reduced, particularly in those patients with free margins.     

Cervical intraepithelial neoplasia in adolescents: study of cytological findings between 1987 and 1995 in São Paulo State-Brazil

The purpose of the present study was to ascertain the frequency of Pap smears abnormalities (SIL/carcinoma) in two populations in the State of S. Paulo (Brazil) who were screened for cervical cancer during the last nine years: adolescents (up to the age of 21) and adults (over 21). Statistical analysis showed a tendency to linear increase in frequency of abnormal Pap smears in both groups (adolescent: slope = 0.118±0.56; adult: slope = 0.079±0.021), being greater in the adolescent group (slope 0.039±0.038) than in the adult group. Between 1987 and 1995 the prevalence of abnormal smears tripled in the adult group (from 0.37 to 1.18) and almost quadruplicated in the adolescent group (from 0.64 to 2.10). Low grade squamous intraepithelial lesions (SIL) were the most frequent findings in cervical cytology in both groups: 92.3% in the adolescent group and 69.8% in the adult group. Few cases of high grade squamous intrapeithelial lesions (HSIL) (7.7%) and no cases of carcinoma were found in adolescent population. We suggested that sexually active adolescents should be included in cervical screening programs. Received: 1 April 1997 / Accepted: 20 January 1998     

Hybrid capture 2 viral load and the 2-year cumulative risk of cervical intraepithelial neoplasia grade 3 or cancer

OBJECTIVE: The purpose of this study was to determine the clinical value of a semiquantitative measure of human papillomavirus viral load by the hybrid capture 2 assay for stratification of the risk of histologic cervical intraepithelial neoplasia grade 3 or carcinoma. STUDY DESIGN: The Atypical Cells of Unknown Significance and Low-Grade Squamous Intraepithelial Lesions Triage Study was a randomized clinical trial of 5060 women with 2 years of follow-up to evaluate treatment strategies for women with equivocal or mildly abnormal cervical cytologic condition. The usefulness of the continuous hybrid capture 2 output relative light units/positive controls that were above the positive threshold (1.0 relative light units/positive controls), which was a surrogate for human papillomavirus viral load, for distinguishing between hybrid capture 2 positive women who were diagnosed with cervical intraepithelial neoplasia grade 3 or carcinoma during the study from those who were not diagnosed with cervical intraepithelial neoplasia grade 3 or carcinoma was examined with the use of receiver-operator characteristic analyses. RESULTS: Relative light units/positive controls values did not further discriminate between hybrid capture 2 positive women with cervical intraepithelial neoplasia grade 3 or carcinoma from those with less than cervical intraepithelial neoplasia grade 3 or carcinoma. The use of a cervical intraepithelial neoplasia grade 2 or more severe or carcinoma case definition did not alter our findings. CONCLUSION: Among women with atypical cells of unknown significance or low-grade squamous intraepithelial lesion cervical cytologic findings, the hybrid capture 2 viral load measurement did not improve the detection of 2-year cumulative cases of cervical intraepithelial neoplasia grade 3 or carcinoma significantly.