Adriana Bittencourt Campaner

Primary hypothyroidism presenting as ovarian tumor and precocious puberty in a prepubertal girl

We report a case of a prepubertal girl with juvenile primary hypothyroidism presenting as ovarian cysts and precocious puberty. The 7-year-old female was referred to our clinic because of a pelvic/abdominal mass and vaginal bleeding. Besides these findings, on physical examination we noticed the thyroid gland globally increased and the presence of secondary sexual characteristics. Based upon the clinical profile and investigations, the patient was diagnosed with juvenile primary hypothyroidism due to autoimmune thyroiditis. The cysts and precocious puberty resolved spontaneously after the simple replacement of thyroid hormone. It is important to bear in mind hypothyroidism in cases of girls presenting ovarian cysts and precocious puberty in order to avoid unnecessary surgery on the ovaries.

Evaluation of density of Langerhans cells in human cervical intraepithelial neoplasia

Objective. To compare the number of Langerhans cells in areas of CIN 3 and in areas without histopathological alteration adjacent to CIN 3 with those found in histologically normal control cases. Material and methods. Specimens were obtained from 46 normal cervixes from women undergoing hysterectomies due to uterine leiomyomata and 71 from conization specimens for CIN 3. The identification of the Langerhans cells was performed by immunohistochemical analysis, using antibodies to S‐100 protein. The number of intraepithelial Langerhans cells was counted at a 400× magnification under light microscope and a 10 field count was performed in areas of epithelium of the normal cervix (group A), areas of CIN 3 in the conization specimens (group B), and areas of epithelium without histopathologic alteration adjacent to CIN 3 (group C). Results were expressed as number of cells per square millimeter of epithelium. Results. Comparing groups A and B, we observed that the number of Langerhans cells was significantly higher in the latter group; between groups A and C, the number of cells was significantly lower in the second group. The number of Langerhans cells was also compared between groups B and C and it was significantly lower in the latter, independent of smoking habits. Conclusions. We theorize that the increase in the population of Langerhans cells in areas of CIN 3 could be explained by migration of these cells from adjacent areas without histopathologic alterations in order to act in the restraint of the development of neoplasia; cigarette smoking did not influence this migration.

The effect of cigarette smoking on cervical langerhans cells and T and B lymphocytes in normal uterine cervix epithelium.

The objective of our study was to evaluate the effect of smoking on intraepithelial Langerhans cells and T and B lymphocytes in normal cervical epithelium. A total of 47 women who underwent hysterectomies because of uterine leiomyomata were investigated. Thirty-two individuals were nonsmokers and 15 were current smokers. A segment of tissue was taken from the cervix after the removal of the uterus and was formalin-fixed and paraffin-embedded for histologic analysis. The identification of the Langerhans cells and T and B lymphocytes was carried out by immunohistochemical analysis. The number of intraepithelial Langerhans cells was expressed by the amount of cells per square millimeter of epithelium. For T and B lymphocytes, a score expressed the cell count. The comparison of the number of intraepithelial Langerhans cells between smoking and nonsmoking women showed a significant difference (P=0.045), but it did not occur in relation to the number of T and B cells between the 2 groups. There was also no significant difference in relation to the number of cigarettes smoked per day, time of consumption, and total amount of cigarettes smoked throughout the lifetime. It was shown that smoking reduces the number of intraepithelial Langerhans cells in a normal cervix but does not influence the number of T and B lymphocytes.

Application of an easy and useful morphometric technique for immunohistochemistry counting

We have been performing several scientific works related to prognostic factors of preneoplasic and neoplasic lesions of the cervix, due to the presence of post-graduation students in our department. In order to perform such studies we have been using immunohistochemistry with a certain frequency. When working with immunohistochemistry, sometimes we wish to determine the concentration of a certain cell that is being analyzed in order to compare them in different situations. Such cell count, according to a certain space unit, is called morphometry. The term morphometry is comprised by the Greek radical — morphé, which means shape, related to the Greek radical — metrikós, or to the Latin — metricu, which means act of measuring or process of establishing measurements. Thus, several computer softwares of morphometry were developed and are commercially available to use in daily clinical practice. However, in centers with scarce resources, as in our case, purchasing such softwares is not viable due to their high cost. Thus, instead of using these softwares, one of the most common ways of getting such an estimate would be through counting cells in a regular optical microscope. Due to that setback in getting such morphometry softwares, we have developed a morphometric method that is quite easy to perform, and that can be used by any research center, by making use of a Neubauer chamber, also known as Hemocytometer or Counting Chamber, which is easily found in clinical pathology labs. The Neubauer Chamber consists of a glass slide, thicker than a regular slide, where there are usually two chambers engraved in the glass (two darker parts in the center). Each Neubauer Chamber has the design of a grid, dividing it into squares with known dimensions, which are visualized only through the optical microscope. The Neubauer Counting Chamber is divided into 9 large squares of 1 mm each side by means of triple lines (the area of a large square=1 mm). Each large square contains 16 (4×4) medium size squares. Eachmedium size square is further divided by triple lines into 25 (5×5) small squares, eachwith side 1/5 of a mm. Thus the dimension of an individual small square of 0.05×0.05 mm=0.0025 mm and 0.1 mm deep (Fig. 1). The system we implemented used a regular optical microscope adapted to a microcamera and screen. Thus, the image observed through the microscope lenses is captured by the video camera and showed in the chosen monitor. The Neubauer Chamber is then placed in the optical microscope, under a objective which increases 400 times the original size of the object (large magnification field), or any other increase chosen by the researcher. At last, the area of the large magnification field (400× magnification) is estimated, in mm, by counting the total number of individual small squares of 0.0025 mm of the chamber present in the magnification area that was chosen. In our evaluation, the total area of a large magnification corresponded to 0.094 mm. In such a manner, each section prepared by immunohistochemical method was evaluated under light microscope. The number of cells in study was counted at 400× magnification. A 10 field count was performed in the different situations we were evaluating. The mean number of cells present in this 10 field count represents, as mentioned before, 0.094 mm. By means of a simple rule of three, the number of cells is converted into 1 mm. The cells count was expressed as numerical densities, i.e. number of positive cells per square millimeter of epithelium. Available online at www.sciencedirect.com

Prognostic value of p16INK4a as a marker of clinical evolution in patients with cervical intraepithelial neoplasia grade 3 (CIN 3) treated by cervical conization

The aim of this study was to assess the prognostic value of p16INK4a as a marker of post‐conization relapse in patients treated for cervical intraepithelial neoplasia grade 3 (CIN 3). A retrospective study of 76 women with CIN 3 diagnoses, treated at the Hospital of Santa Casa de Misericórdia of São Paulo (Brazil) between January 2003 and September 2004, was performed. The study samples were obtained from cervical conization procedures, where paraffin blocks containing areas with the greatest amount of neoplastic tissue were selected. Immunohistochemical techniques were used on individual paraffin blocks for each case to detect p16INK4a protein expression. The p16INK4a cell counts were performed in 10 different high‐amplification fields (400x) by light microscopy and total cell count expressed as number of cells per mm2. Patients involved in this study were followed up at the colposcopy outpatient unit for at least 48 months after cervical conization. The correlation of p16INK4a values with post‐conization evolution in the patients (disease relapse or disease free) was determined. A significantly higher count of cells expressing p16INK4a was found in those patients with disease relapse during follow‐up (p < 0.001). The variables age, number of gestations, and births correlated positively with number of cells expressing p16INK4a cells (p < 0.001; p = 0.001; 0.009, respectively). No correlation was found for the variables menopause, hormonal contraception, or smoking (p = 0.369, 0.425 and 0.853, respectively). p16INK4a can be considered a biomarker of cervical intraepithelial neoplasia grade 3 cases presenting high risk of relapse or evolution to invasive carcinoma.

Células glandulares atípicas em esfregaços cervicovaginais: significância e aspectos atuais

Atypical glandular cells (AGC) on cervical smears are unusual but important cytologic diagnosis. The incidence of AGC ranges from 0.08% to 0.81 % of all cervical smears tests. The 2001 Bethesda System nomenclature classifi es these glandular lesions as AGC not otherwise specifi ed, AGC favor neoplasia, endocervical adenocarcinoma in situ (AIS) and invasive adenocarcinoma. Of women with AGC smears, a great number will have no histologic abnormalities on further evaluation. However, 17.4% to 62.2% are found to have signifi cant histologic lesions such as cervical intraepithelial neoplasia, AIS, squamous and glandular cancers from sites farther the cervix and endometrium. The risk of signifi cant disease is related to the AGC subclassifi cation that was found. Because of the high likelihood that AGC is associated with signifi cant histological disease, simply repeating the cytological smear is not suffi cient for the management of this condition. This review describes the epidemiology, evaluation and management of patients with these citologic readings.Atypical glandular cells (AGC) on cervical smears are unusual but important cytologic diagnosis. The incidence of AGC ranges from 0.08% to 0.81 % of all cervical smears tests. The 2001 Bethesda System nomenclature classifies these glandular lesions as AGC not otherwise specified, AGC favor neoplasia, endocervical adenocarcinoma in situ (AIS) and invasive adenocarcinoma. Of women with AGC smears, a great number will have no histologic abnormalities on further evaluation. However, 17.4% to 62.2% are found to have significant histologic lesions such as cervical intraepithelial neoplasia, AIS, squamous and glandular cancers from sites farther the cervix and endometrium. The risk of significant disease is related to the AGC subclassification that was found. Because of the high likelihood that AGC is associated with significant histological disease, simply repeating the cytological smear is not sufficient for the management of this condition. This review describes the epidemiology, evaluation and management of patients with these citologic readings.

Achados histeroscópicos em mulheres na pós-menopausa com diagnóstico de espessamento endometrial por ultra-sonografia transvaginal

PURPOSE: to correlate endometrial thickening diagnosed by ultrasonography with hysteroscopic findings in postmenopausal women. METHODS: a transversal study with hysteroscopic evaluation was performed in 121 postmenopausal women, with endometrial thickening diagnosed through transvaginal ultrasonography. In 98 women there was no history of hormonal replacement therapy, while the remaining 23 received different types of hormone; 55 patients complained of vaginal bleeding and the remaining did not present this condition. The endoscopic examinations were performed in the outpatient clinic, using a 4 mm rigid hysteroscope. For uterine cavity distention carbon dioxide (CO2) was used. Biopsy was performed in all patients, with a 3 mm Novak type curette, and the collected material was submitted to a histopathological study. RESULTS: endometrial thickening varied from 6 to 38 mm, with a mean of 10.7 ± 5.3 mm. The hysteroscopic findings were: polypoid lesion in 51 patients (42.1%); atrophic endometrium in 15 patients (12.4%); senile synechia in 15 patients (12.4%), focal thickening in 13 patients (10.7%); cerebroid lesion in 6 patients (5.0%); proliferative endometrium in 5 patients (4.1%); mucus in 5 patients (4.1%); myoma in 4 patients (3.3%); secreting endometrium in 3 patients (2.5%); endometrial hyperplasia in 3 patients (2.5%); and cystic atrophy in 1 patient (0.8%). Correlation between hysteroscopic findings and cytopathology was observed in 30 of 51 cases of polypoid lesion, in 12 of 15 cases of atrophic endometrium and in all cases in which the diagnosis of endometrial hyperplasia or adenocarcinoma was suspected. CONCLUSION: in the majority of the patients, the hysteroscopic examinations revealed that there was no genuine endometrial thickening but rather other types of lesion in the uterine cavity.

Avaliação histológica de pólipos endometriais em mulheres após a menopausa e correlação com o risco de malignização

OBJETIVOS: caracterizar histologicamente polipos endometriais em mulheres apos a menopausa e avaliar o risco de lesoes hiperplasicas e neoplasicas neles contidos. METODOS: analise retrospectiva de 82 casos de mulheres portadoras de histopatologia confirmatoria de polipo endometrial, submetidas a polipectomia histeroscopica devido ao diagnostico de espessamento endometrial a ultra-sonografia transvaginal. Todos os prontuarios pertinentes foram revisados para obtencao da historia clinica, antecedentes, dados referentes ao exame histeroscopico e resultado final da histopatologia. RESULTADOS: das 82 mulheres avaliadas, 10,9% faziam uso de algum tipo de terapia hormonal e 28 (34,1%) queixavam-se de sangramento por via vaginal. Polipo solitario foi encontrado em 56 mulheres (68,3%), em 19 casos (23,2%) foram encontrados dois polipos e em 7 casos (3,6%), tres ou mais polipos. A avaliacao histologica definitiva evidenciou polipo benigno em 63 mulheres (76,8%), polipos com hiperplasia em 17 casos (20,8%), sendo dez com hiperplasia simples sem atipias (12,2%) e sete com hiperplasia complexa sem atipias (8,6%). Em dois polipos foi encontrada neoplasia associada (2,4%). Para a analise estatistica foi empregado o teste do c2, corrigido por Yates. Correlacionou-se a histologia dos polipos com a presenca ou nao de sangramento genital (p=0,0056), o numero de polipos encontrados por mulher (p=0,921), e o tempo decorrido apos a menopausa (p=0,720). CONCLUSOES: polipos endometriais sao entidades frequentemente encontradas apos a menopausa, associando-se com baixa frequencia a hiperplasias e carcinomas endometriais e apenas o estudo histologico de todo especime nos permite afastar malignidade.

Incomplete excision of cervical intraepithelial neoplasia in conization does not require immediate excisional procedure

Cervical conization, which is the recommended treatment for cervical intraepithelial neoplasias (CIN) grade 2 and 3 due to the overall high risk of progression to cervical cancer of these lesions, can be performed using traditional technique (cold-knife conization), laser conization and through the loop electrosurgical excision procedure (LEEP) [1–3]. Moreover, operator experience, costs, patients’ clinical conditions, equipments availability may be a consideration in choosing between these techniques [4]. Despite these diVerences, many randomized studies have demonstrated that all of the aforementioned techniques present satisfactory and similar results in the treatment of high-grade lesions of the uterine cervix as long as the entire transformation zone is removed [4]. Independent of the type of conization performed, inWltration of the surgical margins by the neoplastic process is a frequently observed reality. The main reasons related to this occurrence are the use of inadequate surgical techniques (failure in learning, teaching hospitals), extensive cervical lesions and lesions with higher histological grading [5]. It is known that positive surgical margins may inXuence the postoperative evolution of patients submitted to cervical conization. So, some authors recommend further excision in cases of incomplete excision of CIN in conization specimens [6–8]. We evaluated prospectively 76 patients operated on for cervical intraepithelial neoplasia grade 3 (CIN 3); cervical conization was performed using the LEEP technique. All patients included in the study were attended at the Santa Casa Sao Paulo Hospital in the period ranging from January of 2003 to September of 2004. Informed consent was obtained from each patient and the ethics committee of the hospital approved the research. We included in our study all patients diagnosed with CIN 3 on cervical conization specimens, regardless of age, menopause and parity. The exclusion criteria adopted were malignant neoplasia, systemic infectious or immunosuppressive disease, clinical cervical and vaginal infection, previous treatment of the cervix and use of potentially immunosuppressant or immune stimulating medications. Patients from study group (76 women) had ages between 17 and 65 years (mean of 39.34 § 10.74 years). Seven women had not been pregnant before and the other 69 referred one to 11 pregnancies (mean of 3.65 § 2.55). Regarding the habit of smoking, 31(41%) of the patients were smokers and 45 (59%) were nonsmokers, with 17 (40%) patients of the latter category being former smokers. Fourteen (18.5%) of the women were in the postmenopause period and 62 (81.5%) were in the menacme. Hormonal contraception was used by 14 women (18.5%). The histological sections related to the selected cases were evaluated by the same pathologist to conWrm the histopathological diagnosis. The specimens’ surgical margins were also evaluated and were classiWed as either free or inWltrated/aVected by the neoplastic process. The patients with histopathological sections demonstrating inWltrated surgical margins had their Wrst follow-up 4 months after conization while those with free margins were evaluated only after 6 months. This evaluation consisted of cervical cytology and colposcopy with punch biopsy, if necessary. In case, these exams were negative, the patient would be evaluated every 6 months during a period of 2 years. For A. B. Campaner (&) · F. A. Cardoso Department of Obstetrics and Gynecology, Santa Casa of Sao Paulo Medical School, Av Reboucas, 1511 ap. 142-CEP 05401-200, Jd. America, Sao Paulo, SP, Brazil e-mail: abcampaner@terra.com.br

Cervical Cancer Screening of Adolescents Should Not Be Encouraged.

Objective The study aims to assess the frequency of cytological abnormalities in adolescents and young women, to establish the optimum age to start screening. Methods A retrospective study of cervical cytology results were obtained from the data center at the Santa Casa Hospital of São Paulo between January 2006 and December 2014, adopting the Bethesda nomenclature system. The cytology exams were divided into 3 groups: group 1—adolescents (10–19 years old); group 2—young women (20–24 years old); and group 3—adults, comprising the remaining cytology exams. The frequency of cytological abnormalities in the 3 groups was compared using version 3.4.3 of the Epi Info software program and the chi-square statistical test (p < .05). Results A total of 177,075 satisfactory cytology exams were included in the study. The cytological abnormalities detected in the adolescent group were predominantly low-grade lesions (97.4%); in the young women group, low-grade lesions represented 89.12%, and in the adult group, 76.33%. A significantly greater proportion of high-grade lesions were noted in the adult group, accounting for approximately 24% of all abnormalities detected; in the young women group, it was approximately 11%, and in the adolescent group, it was 2.6%. Conclusions The natural history of HPV infection shows it is transient in young women, with most cases regressing within 2 years of presentation. Our data confirm that screening of adolescents is not recommended because serious cytological abnormalities and cancer are rare in this group.