Bruce A. Barron

A follow-up study of patients with cervical dysplasia

Abstract Five hundred and fifty-seven patients with cervical dysplasia detected cytologically were followed without biopsy or therapy to examine the natural history of the disease. At the end of the follow-up period transition probabilities were calculated and transit times of mild, moderate, and severe dysplasia to carcinoma in situ were computed. These transit times ranged from a median of 86 months for patients with mild dysplasia to 12 months for a patient with severe dysplasia. The median transit time to carcinoma in situ for all dysplasias was 44 months.

Endometrial polyps in postmenopausal patients receiving tamoxifen.

The histologic features of an endometrial polyp include irregular, often dilated glands, thick-walled blood vessels, and a fibrotic stroma. Such polyps may be responsive to some chemotherapeutic drugs that can exert hormonal effects. We report on endometrial polyps detected in three postmenopausal patients who were receiving tamoxifen for treatment of metastatic breast carcinoma. The clinical presentation in all cases was vaginal bleeding and all had documented uterine enlargement suggestive of an intrauterine malignancy. The polyps were large, measuring up to 9 cm in largest diameter. On histologic examination each polyp had extensive cystic glandular hyperplasia. In one case foci of atypical epithelial proliferation and predecidualization were noted. The atypical proliferation suggested a borderline neoplastic process and was strongly positive for carcinoembryonic antigen. These findings underscore the marked proliferative changes that can be induced in endometrial polyps in postmenopausal women receiving hormonally active chemotherapeutic agents.

Atypical immature metaplasia (AIM). A subset of human papilloma virus infection of the cervix

Atypical immature squamous metaplasia (AIM) is a poorly understood lesion with uncertain biological and clinical significance. This report reviews 170 cases of cervical condylomata and 60 cases of highgrade cervical intraepithelial neoplasia (CIN II/III); AIM was found in association with 34% of condylomata and 16% of high‐grade CIN. Thirty‐seven cases of AIM alone were reviewed and nearly all presented with a cytologic diagnosis of CIN I or condyloma and a colposcopic appearance of white epithelium with or without punctation and mosaic structure. The mean ages of patients with condylomata, AIM, CIN II, and CIN III were 27, 27, 32, and 37 years, respectively. By immunoperoxidase techniques 75% of condylomata, 16% of AIM, and 0% of CIN lesions were positive. The histologic criteria for the diagnosis of AIM and its morphologic distinction from CIN and relationship to condylomata, are outlined. AIM is a distinct histologic entity that shares similar epidemiologic, morphologic and biologic characteristics with condyloma. When AIM is found alone in biopsy material, careful correlation of cytology, colposcopy, and biopsy results should be performed and therapy should be based on the size and distribution of the lesion.

Screening strategies for cervical cancer and cervical intraepithelial neoplasia

Exfoliative cytology is a highly sensitive and inexpensive screening technique for cervical cancer and its precursors. The detection and eradication of the precursors have led to a significant fall in cervical cancer incidence rates and death rates in those areas in which there has been widespread and prolonged use. Recently, however, the utility and cost‐effectiveness of cytology has been questioned, and it has been suggested that screening strategies be altered. A consideration of the effect of the transit times of cervical intraepithelial neoplasia on screening intervals and the impact of the changing patterns of cervix cancer epidemiology on screening strategy suggests that a significant change in screening intervals may be counterproductive. Cancer 47:1176–1181, 1981.

Human papilloma virus infection (condyloma) of the cervix and cervical intraepithelial neoplasia: A histopathologic and statistical analysis

Two hundred fifty consecutive cases previously diagnosed as advanced intraepithelial neoplasia (CIN 2 and CIN III) were reviewed and examined for the presence of coexisting condyloma. When the mean ages and age distributions were analyzed, there was a consistent shift of the age distribution to a younger age among women with CIN and condyloma as opposed to CIN alone. Furthermore, when the relationship between age and case accumulation was normalized from a curvilinear to a linear relationship, there were significant differences in the slope of the accumulation rate between cohorts of CIN III with and without condyloma. These differences suggest that the concordant observation of both lesions in a given patient is not a random process resulting from two independent events but rather indicates an underlying dependence between the two (i.e., condyloma and CIN). It cannot, however, be determined statistically whether the associated condyloma is directly responsible for the CIN lesion or hastens its transit time.

A statistical model of the natural history of cervical neoplastic disease: The duration of carcinoma in situ

Abstract Estimates of the duration of the in situ stage of cervical intraepithelial neoplastic disease are presented in this report, based on the data obtained from Papanicolaou smear screening programs carried out in British Columbia, Canada, and Barbados, West Indies. Using established statistical techniques we have examined the properties of the expected age distribution of cases in a defined population at risk based on estimates of the age-specific incidence and prevalence rates of carcinoma in situ (CIS). We find that the duration of CIS in the aggregate is a variable that has a distribution with estimated upper and lower limits of the order of 10 and 3 years, respectively. Furthermore, based on these results we suggest that the natural history of the established CIS lesion is independent of the age of the woman at the time of incidence. The results presented here concerning the duration of CIS are contrasted with those reported by other workers. The differences in the estimates of the duration of CIS, or equivalently the transition time of this lesion in the aggregate, given here and those of other investigators are discussed. The application of the results presented in this report to the establishment of optimal intervals between Papanicolaou smear screening examinations is outlined.

Insertion of Lippes Loop by Nurse-Midwives and Doctors

Follow-up studies of 7 to 19 months of two groups of 500 women each in Barbados, in one of which a Lippes loop had been inserted by a doctor and in the other by a nurse-midwife, showed a slightly higher incidence of pregnancy and expulsion of the loop in the second group, though the difference was not statistically significant. The insertion of loops by paramedical personnel when this is an economic necessity is thought not to be contraindicated, but adequate training is essential.

Screening protocols for cervical neoplastic disease

Recently, changes have been recommended in regimens for screening for cervical neoplastic disease. These changes are based on a variety of statistical and epidemiological assumptions. These assumptions are examined here together with available data from several sources. A discussion of the characteristics of indices of use in evaluating the potential effects of screening protocols is presented. An analysis of the data is shown which provides evidence that the changes recommended in the interval between successive Papanicolaou smears may result in an increase in the incidence of invasive cervical cancer in the population over time.

Pneumocystis pneumonia in a patient with cervical carcinoma treated with combination chemotherapy

Abstract A 62-year-old with metastatic cervical carcinoma being treated with combination chemotherapy developed diffuse pulmonary infiltrates. Bronchoscopic evaluation revealed pneumocystis pneumonia. She was successfully treated with trimethoprim-sulfamethoxazole. Gynecologists should be familiar with this opportunistic infection that can occur in patients receiving chemotherapy for gynecologic malignancies.