Beth Cronin

Vaginal cuff dehiscence: risk factors and management.

Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence.

Evaluation of anal cytology and dysplasia in women with a history of lower genital tract dysplasia and malignancy.

OBJECTIVE To compare the prevalence of abnormal anal cytology, high-risk anal HPV and biopsy proven anal dysplasia among women with a history of lower genital tract malignancy compared to those with dysplasia. METHODS A prospective cohort study was performed from December 2012 to February 2014 at outpatient clinics at an academic medical center. Women with a history of high-grade cervical, vulvar, or vaginal dysplasia, or malignancy were recruited. Anal cytology and HPV genotyping were performed. All women with abnormal anal cytology were referred for high-resolution anoscopy and biopsy. RESULTS Sixty-seven women had a lower genital tract malignancy and 123 had a history of genital dysplasia. Average age in the malignancy group was 52.6years (range 27-86) versus 43.5years (range 21-81) in the dysplasia group (p<0.0002). Similar rates of anal dysplasia were seen in both groups, 12.99% (10 cases) in the malignancy group, versus 12.20% (15) in the dysplasia group (p=1.0). Six women in the malignancy group had anal intraepithelial neoplasia (AIN2+) compared to 2 in the dysplasia group (p=0.03). CONCLUSIONS We found high rates of abnormal anal cytology and HPV in women with lower genital tract dysplasia and malignancy. We also found high rates of anal dysplasia in both groups with a trend towards increased rate in those women with history of genital malignancy. Since precancerous anal lesions are detectable and treatable, anal cancer screening may be potentially useful in both of these higher risk groups.

Anal Cytology and Human Papillomavirus Genotyping in Women With a History of Lower Genital Tract Neoplasia Compared With Low-Risk Women.

OBJECTIVE: To compare the prevalence of abnormal anal cytology and high-risk human papillomavirus (HPV) among women with a history of HPV-related genital neoplasia with women without a history of HPV-related genital neoplasia. METHODS: A cross-sectional cohort study was performed from December 2012 to February 2014. Women were recruited from outpatient clinics at an academic medical center. Women with a history of high-grade cervical, vulvar, or vaginal cytology, dysplasia, or cancer were considered the high-risk group. Women with no history of high-grade anogenital dysplasia or cancer were considered the low-risk group. Human immunodeficiency virus–positive women were excluded. Anal cytology and HPV genotyping were performed. Women with abnormal anal cytology were referred for high-resolution anoscopy. RESULTS: There were 190 women in the high-risk group and 83 in the low-risk group. The high-risk group was slightly older: 57 years compared with 47 years (P=.045); 21.7% of low-risk women had abnormal anal cytology compared with 41.2% of high-risk women (P=.006). High-risk HPV was detected in the anal canal of 1.2% of the low-risk group compared with 20.8% of the high-risk group (P<.001). Among women who underwent anoscopy, no anal dysplasia was detected in the low-risk group, whereas 13.4% in the high-risk group had anal dysplasia with 4.2% having anal intraepithelial neoplasia 2 or greater (P<.001). CONCLUSION: Human immunodeficiency virus–negative women with a history of lower genital tract neoplasia are more likely to have positive anal cytology, anal high-risk HPV, and anal intraepithelial neoplasia. Anal cancer screening should be considered for these high-risk women. LEVEL OF EVIDENCE: II

The effects of age on treatment and outcomes in women with stages IB1–IIB cervical cancer

OBJECTIVE Age may affect the treatment choice and subsequent outcome in elderly patients with cervical cancer. Given the potential for cure with either surgery or chemoradiation in early stage disease, we aimed to determine whether a patients age influenced treatment received and the ensuing outcome. MATERIALS AND METHODS We identified 303 patients with stages IB1-IIB cervical carcinoma treated at our institution between 2000 and 2010, who were divided into two groups based on age at time of diagnosis: < 65 and ≥ 65 years. Adjusted odd ratios were calculated to determine variables associated with treatment received. Single and multivariate Cox proportional hazards modeling were used to estimate hazard ratios (HRs) for variables associated with disease-specific survival. RESULTS Patients were more commonly <65 years at diagnosis (83% versus 17% ≥ 65 years). There was no difference between the two groups in terms of tumor histology, stage at presentation, and grade. Women ≥ 65 years of age were less likely to receive primary surgical management (p=0.03). Age did not influence disease-specific or all-cause mortality. However, women over 65 years who underwent primary surgery were at significantly increased risk of all-cause mortality compared to younger women (HR 6.53, 95% CI: 2.57-16.6). CONCLUSIONS Age appears to influence treatment received by patients with stages IB1-IIB cervical cancer. Although there was no difference in cancer-specific mortality stratified by type of treatment received, surgery was associated with a 6.5-fold increased risk of all-cause mortality among women 65 years or over.

Discussion: ‘Treatment of symptomatic uterine fibroids’ by van der Kooij et al

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: van der Kooij SM, Hehenkamp WJK, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-years outcome from the randomized EMMY trial. Am J Obstet Gynecol 2010;203:105.e1-13.

Understanding the Sexual Behaviors of Women That May Put Them at Risk for HPV-Related Neoplasias [21J]

INTRODUCTION: The human papilloma virus (HPV) is a multifocal infection that can involve the cervix, vagina, vulva, anus, and oropharynx. The objective of our study was to determine if standard sexual history questions capture the sexual behaviors of women that put them at increased risk for HPV-related neoplasias. METHODS: We conducted a cross-sectional survey study at the Colposcopy Clinic at Women and Infants Hospital. Women who presented with HPV-related cervical, vulvar, or vaginal abnormalities were eligible. All eligible women were offered enrollment, signed informed consent and a sexual history questionnaire was self-administered. Additional demographic information was obtained from chart review. RESULTS: Interim analysis was conducted half way through recruitment. Seventy one eligible women were approached, 63 (89%) consented and all 63 enrolled (ages 22–64). Sixty-five percent of women reported receiving oral penetration of the vagina, 81% reported receiving vaginal fingering and 100% participated in vaginal intercourse. Forty-six percent reported participating in some type of anal-related sexual practice, including anal fingering, oral penetration on the anus and anal intercourse. Of those participating in anal-related practices, 10% reported only anal fingering or oral-anal penetration. Forty-eight percent of respondents said they used sex toys, 100% vaginal and 13% anal. CONCLUSION: We found women are willing to report their participation in a wide range of sexual practices. Ten percent of women only participated in anal play and not anal intercourse, which would be missed by the standard sexual history questions. These results will enable clinicians to better counsel their patients on risky sexual behaviors.

Long-Term Follow-up of Young Women With High Grade Squamous Intraepithelial Lesions [1D]

INTRODUCTION: Current cervical cancer screening guidelines allow for expectant management in lieu of excision for high-grade dysplasia in women under 25 years. Some practitioners worry about the safety of this practice. The objective of this study was to demonstrate the safety of expectant management in young women with high-grade dysplasia. METHODS: This was a retrospective cohort study of women under 25 years presenting to a resident clinic with high-grade cytology or histology between 1999 and 2012. Women were grouped by management category: expectant (EM) versus immediate excision (IE). RESULTS: 493 women met eligibility criteria. 417 were included in the primary analysis: 145 in the IE group and 272 in the EM group. The EM group underwent a mean of 0.2 excisional procedures compared to 1.1 in the IE group (P=<.0001). Two years after initial presentation, 27.4% of women in the EM group and 3.5% of women in the IE group had CIN2+ histology. Of the 129 women expectantly managed with CIN2+ on initial biopsy, 79 (61.2%) showed regression, and 10 (7.8%) showed progression from CIN2 to CIN3. All regressions took place by year 5, with the majority (91%) by year 2. There were no cancer diagnoses at baseline or end of study period. CONCLUSION: Expectantly managed young women will have fewer excisional procedures over time. In this study, young women with high-grade dysplasia managed expectantly, showed regression 61% of the time and there were no progressions to cancer. Expectant management is safe for young women with high-grade cervical lesions.

Evaluation and Management of Women Presenting with a Pelvic Mass

Management of women with a pelvic mass is a very common scenario for gynecologists. Often these are benign masses that can either be observed or managed with straightforward laparoscopic surgery, but complex, potentially malignant masses require careful consideration and triaging for appropriate care. This article aims to outline the presentation, management, and triage guidelines for women presenting with an ovarian cyst or pelvic mass. We discuss data surrounding the use of triage guidelines, as well as the role of promising biomarkers that can assist in better predicting benign versus malignant pathology.