Jean Carlos de Matos

Value of the International Federation for Cervical Pathology and Colposcopy (IFCPC) Terminology in Predicting Cervical Disease

Objective. To evaluate the colposcopic accuracy according to the International Federation for Cervical Pathology and Colposcopy (IFCPC) 2002 terminology. Materials and Methods. A series of 3,040 women derived from a general population were screened by means of Pap smear, unaided visual inspection, and high-risk human papillomavirus testing. All colposcopic examination results with abnormal findings and with biopsy confirmation (n = 468) were recorded, reviewed by 2 blinded colposcopists according to the IFCPC nomenclature, and included in this analysis. Results. The IFCPC terminology was easily reproduced by the 2 observers with excellent interobserver agreement (&kgr; =.843). Colposcopy had a sensitivity of 86% and a specificity of 30.3% in distinguishing healthy cervix from that with cervical intraepithelial neoplasia (CIN)/carcinoma. In distinguishing healthy cervix/low-grade lesions (CIN 1) from that with high-grade lesions (CIN 2/3)/carcinoma, colposcopy had a sensitivity of 61.1% and a specificity of 94.4%. Colposcopic findings graded as major changes had the highest positive predictive value for detecting high-grade lesion/carcinoma. The colposcopic abnormalities within the transformation zone and large lesions were more closely related to high-grade lesion/carcinoma, whereas a sharp outer border, multiple colposcopic abnormalities, and iodine negativity were not statistically related to severe lesions. Conclusions. Colposcopy using the new IFCPC classification is a potentially effective screening method; when used for diagnosis, a histological sampling is necessary. The categorization of major changes and minor changes is appropriate. It is important to describe the lesion localization in relation to the transformation zone and the lesion size because these characteristics are related to high-grade lesions.

Increased risk of oncogenic human papillomavirus infections and incident high-grade cervical intraepithelial neoplasia among smokers: experience from the Latin American screening study.

Background: The purpose of this study was to assess the effect of smoking on the prevalence and incidence of high-risk human papillomavirus (hr-HPV) infection and cervical intraepithelial neoplasia (CIN) in a large sample of Latin American women. Methods: The study examines baseline data on over 12,000 women included in the Latin American Screening Study (Brazil and Argentina), and over 1000 women followed-up for a period of 36 months. Three groups were formed: never smokers, current, and past smokers. The prevalence of hr-HPV infection and CIN were compared between the study groups. In the prospective analysis, women were controlled at 6-month intervals to assess the cumulative risk of incident hr-HPV infection, smear abnormalities, and CIN. Results: A higher prevalence (21.7%) of hr-HPV infection was found among current smokers as compared to never smokers (16.5%) or past smokers (13.5%). Being current smoker was significantly (P <0.01) associated with hr-HPV detection (OR = 1.6; 95% CI = 1.2–2.1). Being a current smoker was a significant predictor of incident hr-HPV during the follow-up [Hazards ratio (HR) = 1.4; 95% CI 1.0–1.9]. For incident CIN2+, being a past smoker (HR = 3.6; 95% CI 1.6–9.8) or current smoker (HR = 3.6; 95% CI 1.5–8.6) were the significant independent predictors. Current and past smokers had a significantly increased risk of incident CIN2+ (P <0.01). Conclusions: Smoking increases the risk of contracting hr-HPV infection and modifies the effect of a persistent hr-HPV infection by further increasing the risk of developing CIN2+. It seems that this effect modification persists over several years after smoking cessation.

Associação entre idade ao início da atividade sexual e subseqüente infecção por papilomavírus humano : resultados de um programa de rastreamento brasileiro

PuRPOse : to investigate women’s age at their first sexual intercourse and its correlation with their present age, human papillomavirus (HPV) infection and cytological abnormalities at Pap smear. MethOds : women from the general population were invited to be screened for cervical cancer and pre-malignant lesions. After answering a behavior questionnaire, they were submitted to screening with cervical cytology and high-risk HPV testing with Hybrid Capture 2 (HC2). This report is part of the Latin American Screening (LAMS) study, that comprises centers from Brazil and Argentina, and the data presented herein refer to the Brazilian women evaluated at the cities of Porto Alegre, Sao Paulo and Campinas. Results : from 8,649 women that answered the questionnaire, 8,641 reported previous sexual activity and were included in this analysis. The mean age at the interview was 38.1±11.0 years and the mean age at the first sexual intercourse was

Hormonal Contraceptives and the Length of Their Use Are Not Independent Risk Factors for High-Risk HPV Infections or High-Grade CIN

Aims: To evaluate the role of hormonal contraceptives as a risk factor of high-risk human papillomavirus (HR-HPV), cervical intraepithelial lesions (CIN) and cervical cancer in our multi-center population-based LAMS (Latin American Screening) study. Methods: A cohort study with >12,000 women from Brazil and Argentina using logistic regression to analyze the covariates of hormonal contraception (HOC – oral, injections, patches, implants, vaginal ring and progesterone intrauterine system) use followed by multivariate modeling for predictors of HR-HPV and CIN2+. Results: HR-HPV infection was a consistent risk factor of high-grade CIN in all three groups of women. The length of HOC use was not significantly related to high-grade squamous intraepithelial lesions (HSIL)+ Pap (p = 0.069), LSIL+ Pap (p = 0.781) or ASCUS+ (p = 0.231). The same was true with the length of HOC use and histology CIN3+ (p = 0.115) and CIN2+ (p = 0.515). Frequently, HOC users have previously shown more HPV-related lesions, as well as lower HPV prevalence if they were current smokers. But HOC use and time of usage were not independent risk factors of either HR-HPV infection or high-grade CIN using multiple logistic regressions. Conclusions: No evidence was found for an association between the use of HOC with an increased risk for HR-HPV infection or high-grade CIN in this cohort.

Efficacy, safety, and acceptability of thermocoagulation for treatment of cervical intraepithelial neoplasia in a hospital setting in Brazil

To analyze the acceptability, safety, and effectiveness of thermocoagulation for the treatment of histologically proven cervical intraepithelial neoplasia grade 2–3 (CIN2–3) lesions.

p300 expression is related to high-risk human papillomavirus infections and severity of cervical intraepithelial neoplasia but not to viral or disease outcomes in a longitudinal setting.

To evaluate the role of the expression of the transcription factor p300 as an independent predictor of high-risk human papillomavirus (HR-HPV) infections and outcome of the cervical disease.Cervical biopsy samples taken at enrolment from 225 women of the Latin American Screening study cohort were analyzed for p300 using immunohistochemistry to assess its value as predictor of (a) cervical intraepithelial neoplasia (CIN) grade, and (b) HR-HPV at baseline, as well as (c) outcomes of HR-HPV infections, and (d) development of incident CIN as surrogate endpoints of progressive disease.There was a significant linear trend in increasing upregulation (=pattern shift) of p300 (P=0.0001) in parallel with increasing grade of CIN. When dichotomized (normal/moderately increase vs. strong-intense), upregulated p300 expression predicted CIN3+ with odds ratio=4.16 (95% confidence interval: 1.95-8.86) (P=0.0001) and CIN2+ with odds ratio=3.48 (95% confidence interval: 1.86-6.48) (P=0.0001). p300 was upregulated more often in HR-HPV+ lesions than in those remaining negative. Semiquantitative viral loads were also directly related to upregulation of p300 (P=0.036), but p300 was not a significant predictor of disease progression to either CIN1+ or CIN2+.p300 expression was upregulated in CIN lesions and related to detection and viral load of HR-HPV but not to their outcome or to incident CIN.

Competing-risks regression models in analysis of biomarkers as predictors of high-risk human papillomavirus (HPV) infection outcomes and incident CIN in the LAMS cohort.

To assess the prediction potential of a 5-biomarker panel for detecting high-risk human papillomavirus (HR-HPV) infections and/or cervical intraepithelial neoplasia (CIN) progression. Five biomarkers, lipocalin, plasminogen activator inhibitor-2, p300, interleukin-10, and stratifin, were assessed in cervical biopsies from 225 women of the Latin American Screening Study. Competing-risks regression models were constructed to assess their predictive power for (i) HR-HPV outcomes (negative, transient, or persistent infection) and (ii) CIN outcomes (no progression, incident CIN1, CIN2, or CIN3). p300, LCN2, stratifin were significantly associated with prevalent HR-HPV but lost their significance in multivariate analysis. In the multivariate model, only p300 was an independent predictor of CIN3 (odds ratio=2.63; 95% confidence interval, 1.05–6.61; P=0.039). In univariate competing-risks regression, lipocalin predicted permanent HR-HPV-negative status, but in the multivariate model, IL-10 emerged as a independent predictor of HPV-negative status (subhazard ratio=4.04; 95% confidence interval, 1.81–9.01; P=0.001). The clinical value of the panel in predicting longitudinal outcomes of HR-HPV infection and/or incident CIN is limited.

Necrotizing Fasciitis in Obstetric Patients

Purpose: the authors report their experience with necrotizing fasciitis (NF) cases which occurred in the Gynecology and Obstetrics Service of the Hospital de Clinicas de Porto Alegre, assessing the frequency of NF and analyzing the association between NF and certain risk factors cited in the literature. Methods: a retrospective study of patients a with diagnosis of necrotizing fasciitis at the Hospital de Clinicas de Porto Alegre from January 1990 to December 1997. Results: two post-cesarean section and one post-surgical (because of ectopic pregnancy) NF cases were found. None of the patients presented clinical complications nor NF risk factors and all surgeries were urgent. The NF frequency in this study was 2.6/10.000 cesarians and mortality was zero. Discussion: NF is a clinical syndrome which does not occur very often but is associated with high morbidity and mortality. This disease involves the surgical wound and the fascial plans. Fast handling and early and intensive treatment bring about good results and decrease in the mortality rate.

Valor de la terminología de la Federación Internacional de Patología Cervical y Colposcopia (IFCPC) en la predicción de la enfermedad cervical

Objetivo. Evaluar la exactitud de la colposcopia según la terminología de 2002 de la Federación Internacional de Patología Cervical y Colposcopia (IFCPC). Material y métodos. Se efectuó un cribado en una serie de 3.040 mujeres, procedentes de la población general, mediante citología de Papanicolaou, inspección visual directa y prueba de virus del papiloma humano de alto riesgo. Se recogieron todos los resultados de la exploración colposcópica con hallazgos anormales y confirmación por biopsia (n= 468), la terminología de la IFCPC fue revisada por dos colposcopistas que desconocían el diagnóstico asignado, y se incluyeron en este análisis. Resultados. Los 2 observadores reprodujeron fácilmente la terminología IFCPC con una coincidencia excelente entre ambos (&kgr; = 0,843). La colposcopia tuvo una sensibilidad del 86% y una especificidad del 30,3% en la distinción entre el cuello normal y la neoplasia cervical intraepitelial (CIN)/carcinoma. Para distinguir entre el cuello normal y el que presenta lesiones de bajo grado (CIN 1) respecto al que presenta lesiones de alto grado (CIN 2/3)/carcinoma, la colposcopia tuvo una sensibilidad del 61,1% y una especificidad del 94,4%. Los hallazgos de la colposcopia clasificados como cambios mayores tuvieron el mayor valor predictivo positivo en la detección de lesión de alto grado/carcinoma. Las anomalías colposcópicas dentro de la zona de transformación y las lesiones extensas estuvieron más estrechamente relacionadas con lesión de alto grado/carcinoma, mientras que un margen externo bien definido, anomalías colposcópicas múltiples y negatividad al yodo no estuvieron estadísticamente relacionados con lesiones graves. Conclusiones. La utilización de la nueva clasificación colposcópica de la IFCPC es un método de cribado potencialmente eficaz; cuando se utiliza para diagnóstico, precisa de una toma de muestra histológica. La clasificación de cambios mayores y cambios menores es adecuada. Es importante describir la localización de la lesión respecto a la zona de transformación, y el tamaño de la lesión, puesto que estas características están relacionadas con lesiones de alto grado. ▪