Barbara B. Bennett

Do Qualifiers of ASCUS Distinguish Between Low- and High-Risk Patients?

OBJECTIVE To evaluate the qualification of a Pap smear classified as atypical squamous cells of undetermined significance (ASCUS) favor reactive or neoplasia as recommended by the Bethesda System. STUDY DESIGN The smears from 105 concurrent patients with a cytologic diagnosis of ASCUS not otherwise qualified were reviewed and subclassified as ASCUS favor reactive, low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL) based on the Bethesda System criteria. The cervical biopsy diagnoses were correlated. RESULTS Of the 105 cases classified as ASCUS, 37 were subclassified as favor reactive, 51 as favor LSIL and 17 as favor HSIL on cytologic review. In the ASCUS favor reactive group, 19 (51%) had reactive changes on biopsy, 17 (46%) had cervical intraepithelial neoplasia (CIN) 1, and 1 (2%) had CIN 3. A total of 48% patients had CIN. In the favor LSIL group, there was CIN 1 in 28 cases (55%), CIN 2 or 3 in 12 (23%) and benign changes in 11 (22%) on biopsy. Seventy-eight percent had CIN. In the 17 cases classified as ASCUS favor HSIL group, all had CIN. CONCLUSION Of the total 105 cases of ASCUS, 71% had CIN, 29% had reactive changes on follow-up biopsies, and 48% of patients in the ASCUS favor reactive group had CIN. Qualifiers of ASCUS have questionable utility in patient management.

Pneumoperitoneum as a Risk Factor for Endobronchial Intubation During Laparoscopic Gynecologic Surgery

Patients undergoing gynecological surgery under laparoscopic guidance usually receive general anesthesia with endotracheal intubation and mechanical ventilation.The creation of a pneumoperitoneum and the Trendelenburg position, both of which are used to improve visualization, are associated with cephalad movement of the diaphragm. This may increase the risk of endobronchial intubation. We studied the change in the distance from the tip of the endotracheal tube (ETT) to the carina with a fiberoptic bronchoscope in 30 patients aged 21-40 yr who were undergoing laparoscopic tubal ligation (n = 28) or hysterectomy (n = 2). Measurements were taken in the supine and Trendelenburg positions before and after pneumoperitoneum. The average distance from the ETT to the carina in the supine position was 2.1 +/- 0.8 cm and in the Trendelenburg position was 1.8 +/- 0.8 cm (P = not significant). After insufflation of the abdominal cavity, the mean distance decreased to 0.7 +/- 1.4 cm in the supine position (P < 0.05) and was associated with endobronchial intubation in eight patients. The addition of the Trendelenburg position to an established pneumoperitoneum resulted in minimal displacement (0.54 +/- 1.4 cm, P < 0.05) and one additional endobronchial intubation. We conclude that the insufflation of gas in the abdominal cavity, and not the change in patient position, is the main risk factor for endobronchial intubation in patients undergoing laparoscopic gynecologic surgery. Implications: This study demonstrated that in anesthetized women, the insufflation of gas into the abdomen during laparoscopy for gynecologic surgery is the main risk factor for migration of the endotracheal tube into a bronchus. (Anesth Analg 1998;86:301-3)

Differential expression of matrix metalloproteinase and tissue inhibitor of MMP in serosal tissue of intraperitoneal organs and adhesions

Objective To comparatively analyse the expression of matrix metalloproteinase (MMP‐3) and tissue inhibitor of MMP (TIMP‐2) in serosal tissue of intraperitoneal organs and adhesions, as well as peritoneal fluid and serum of subjects with and without adhesions.

Matrix metalloproteinase (MMP-1) and tissue inhibitor of MMP in peritoneal fluids and sera and correlation with peritoneal adhesions

OBJECTIVE To assess the presence of matrix metalloproteinase (MMP-1) and tissue inhibitor of MMP (TIMP-1) in peritoneal fluid and serum of subjects with and without adhesions. DESIGN Cross-sectional study. SETTING Academic research centers. PATIENT(S) Sixty-three patients who underwent abdominal/pelvic surgery. INTERVENTION(S) MMP-1, TIMP-1, and MMP-1-TIMP-1 complex content. MAIN OUTCOME MEASURE(S) ELISA. RESULT(S) Peritoneal fluids (PF) and sera of subjects with and without peritoneal adhesions contain MMP-1, TIMP-1, and MMP-1-TIMP-1 complex at varying levels with 10- to 100-fold higher TIMP-1 than MMP-1. Compared with serum, PF contains a lower level of MMP-1 in subjects with mild adhesions and without adhesions, higher TIMP-1 in subjects with extensive adhesions, and lower MMP-1-TIMP-1 complex in subjects with moderate adhesions. However, the serum and PF content of MMP-1, TIMP-1, and MMP-1-TIMP-1 complex was not statistically different among subjects with or without adhesions, with the exception of TIMP-1 in PF of subjects with extensive adhesions. MMP1-TIMP-1 ratio indicates that a major portion of MMP-1 is in complex with TIMP-1. There was no age- or gender-dependent difference in MMP-1 and TIMP-1 content in serum or PF. CONCLUSION(S) Despite differences in MMP-1 and TIMP-1 levels in serum and PF of subjects with extensive and moderate adhesions, there is no correlation between MMP-1 and TIMP-1, with the exception of higher TIMP-1 in PF of subjects with extensive adhesions.

Squamous intraepithelial lesions of the cervix in a high-risk population.

Objectives We set out to examine our use of the squamous intraepithelial lesion (SIL) category, compare our SIL rate to rates reported by others, and determine the corre-lation between SIL and histologically proven cervical intraepithelial neoplasia (CIN) in our population. Materials and Methods Reports from all Papanicolaou smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. Results Of 39,484 Papanicolaou smears, 2,101 (5.3%) were classified as low-grade squamous intraepithelial lesion (LGSIL) and 1,366 (3.5%) were classified as high-grade (HGSIL). Of the LGSIL cases, 972 (46.3%) underwent timely biopsy: Findings were benign in 29.9%; 41.7% had CIN1,20.9% had CIN2, and 7.5% had CIN3. Of the HGSIL cases, 932 (68.2%) underwent timely biopsy: Findings were benign in 12.3%; 17.1% had CIN1, 26.7% had CIN2, 42.2% had CIN3, and 1.6% showed squamous cell carcinoma. Condusions. Our LGSIL rate is similar to reported rates, but our HGSIL rate of 3.5% is higher. We found good correlation between SIL on Papanicolaou smear and CIN on biopsy (70.1% for LGSIL and 86% for HGSIL).

Atypical glandular cells of undetermined significance and other glandular cell abnormalities in a high-risk population.

Objectives We set out to determine our rate of atypical glandular cells of undetermined significance (AGUS) classification, to compare our AGUS rate to rates reported by others, and to determine the correlation between AGUS and histological abnormalities in our population. Materials and Methods Reports from all Papanicolaou (Pap) smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. Results A total of 462 (1.2%) of 39,484 Pap smears were classified as epithelial cell abnormality-glandular cell, with 328 (0.83%) AGUS, 102 (0.26%) endometrial cells out of phase or in a postmenopausal woman, and 32 (0.08%) adenocarcinoma. A total of 146 (45%) of the AGUS cases had timely biopsies: 95 (65.1%) had benign findings, 27 (18.5%) had cervical intraepithelial neoplasia, 14 (9.6%) had adenocarcinoma (10 endometrial, 2 endocervical, 2 extrauterine), 9 (6%) had endometrial hyperplasia, and 1 (0.7%) showed endocervical glandular cell dysplasia. Conclusions AGUS on Pap is associated with a clinically significant histological abnormality in a moderate percentage of patients. Both squamous and glandular lesions are seen, supporting the need for aggressive evaluation of the cervix, endocervix, and endometrium when AGUS is reported.

Deep loop excision for prehysterectomy endocervical evaluation

Abstract OBJECTIVE: Our purpose was to determine whether office deep loop excision should replace cone biopsy for frozen-section endocervical evaluation before planned hysterectomy. STUDY DESIGN: This cohort study comprised 31 patients who underwent office deep loop excision with frozen-section analysis followed by hysterectomy and 50 historic controls who underwent cone biopsy with frozen-section analysis followed by hysterectomy. Diagnostic accuracy, margin status, presence of residual disease, morbidity, and cost were compared. RESULTS: Loop excision frozen sections had sensitivity (ectocervical specimen, 96%; deepest endocervical specimen, 93%), specificity (100%, 86%), and positive (100%, 88%) and negative (75%, 92%) predictive values similar to those of frozen cone biopsy (95%, 80%, 98%, and 67%, respectively). No differences in margin status, presence of residual dysplasia, or morbidity were observed. The shorter operating room time for vaginal hysterectomy after loop excision ( p CONCLUSION: Office loop excision is a cost-effective option for endocervical evaluation before planned hysterectomy. (Am J Obstet Gynecol 1997;176:82-6.)

The association of asymptomatic bacterial vaginosis with upper genital tract infection.

Objective: To determine whether asymptomatic bacterial vaginosis (BV) is associated with upper genital tract inflammation or bacterial colonization.Methods: Fifty nonpregnant women with intact uteri who planned to undergo gynecologic surgery and had no recent symptoms of vaginal infection were enrolled. We obtained a vaginal swab for Gram stain, endocervical swab for chlamydia and gonorrhea DNA probe testing, and Pipelle endometrial biopsy for aerobic and anaerobic cultures and histology. We correlated surgical findings and histology of available surgical specimens with the microbiologic results. The diagnosis of BV was made according to Speigels criteria. Bacteria isolated from the uterus were classified as high virulence versus low virulence. Contingency tables were analyzed using the chi-square or Fisher Exact tests.Results: Twenty-one of 50 patients had BV on Gram stain, 3 had intermediate BV, and 3 had unreadable slides. Eleven patients had histologic endometritis, including 7 of the 21 with BV. The association between BV and endometritis was not statistically significant. Thirty-eight patients had a positive endometrial culture; 18 of these also had BV and 3 had intermediate BV. Of patients with a positive endometrial culture, isolates from those who also had BV or intermediate BV were more likely to be highly virulent pathogens compared to those who tested negative for BV (P <.05). No patients had positive gonorrhea or chlamydia tests. Of the 37 patients who underwent abdominal surgery, 20 had visible adhesions. The association between adhesions and endometritis, BV, or positive endometrial cultures was not significant.Conclusion: Patients with asymptomatic BV are more likely than patients without BV to have highly virulent bacteria isolated from the endometrium. BV may predispose to upper genital tract infection.

Atypical squamous cells of undetermined significance in a high-risk population.

Objectives. We set out to develop a benchmark for our use of the term atypical squamous cells of undetermined significance (ASCUS), to compare our ASCUS rate to rates reported by others, and to determine the correlation between ASCUS and histologically‐proved cervical intraepithelial neoplasia (CIN) in our population. Materials and Methods. All Papanicolaou (Pap) smears and associated cervical biopsies or endocervical curettages interpreted by the University of Florida Department of Pathology between 1992 and 1995 were reviewed. Results. Of 28,494 Pap smears; 17% were classified as “epithelial cell abnormality, squamous,” with 7.4% ASCUS, 5.6% low‐grade squamous intraepithelial lesion, and 4.0% high‐grade squamous intraepithelial lesion. Of the 2,100 ASCUS cases, 753 had timely biopsies; 45.8% were benign, 53.8% showed CIN, and 0.4% showed carcinoma. Of the CIN cases, 39.2% were CIN1, 8.1% were CIN2, and 6.5% were CIN3. Conclusions. Our 7.4% ASCUS rate is similar to published rates. Our high rate of neoplasia associated with ASCUS (54.2%) and our low ASCUS‐squamous intraepithelial lesion ratio (0.77) indicate that we do not overuse the ASCUS classification.

Deep Loop Excision for Prehysterectomy Endocervical Evaluation

OBJECTIVE Our purpose was to determine whether office deep loop excision should replace cone biopsy for frozen-section endocervical evaluation before planned hysterectomy. STUDY DESIGN This cohort study comprised 31 patients who underwent office deep loop excision with frozen-section analysis followed by hysterectomy and 50 historic controls who underwent cone biopsy with frozen-section analysis followed by hysterectomy. Diagnostic accuracy, margin status, presence of residual disease, morbidity, and cost were compared. RESULTS Loop excision frozen sections had sensitivity (ectocervical specimen, 96%; deepest endocervical specimen, 93%), specificity (100%, 86%), and positive (100%, 88%) and negative (75%, 92%) predictive values similar to those of frozen cone biopsy (95%, 80%, 98%, and 67%, respectively. No differences in margin status, presence of residual dysplasia, or morbidity were observed. The shorter operating room time for vaginal hysterectomy after loop excision (p < 0.01) resulted in an approximate