José Focchi

Atypical glandular cells of undetermined significance: Cytologic predictive value for glandular involvement in high grade squamous intraepithelial lesions

OBJECTIVE To verify the cytologic predictive value of a diagnosis of atypical glandular cells of undetermined significance (AGUS) in high grade squamous intraepithelial lesions (HSIL) cases. STUDY DESIGN In a retrospective study, 98 cases of HSIL were reviewed. All patients were referred for colposcopy and directed biopsy to confirm the cytologic diagnoses. Loop excision of the transformation zone was performed to treat clinical lesions. Sensitivity, specificity, positive and negative predictive value were evaluated. Kappa statistics and logistic regression analysis were used to evaluate the findings statistically. RESULTS By logistic regression analysis, we found that the chance of finding squamous intraepithelial lesions involving glands in AGUS smears was 5.32 times higher than in those with no AGUS. It was 5.74 times higher in cervical intraepithelial neoplasia (CIN) 3 lesions than in CIN 2. CONCLUSION The cytologic predictive value for HSIL involving glands is statistically significant when specific and objective criteria are used for the AGUS diagnosis.

Avaliação dos Métodos Empregados no Programa Nacional de Combate ao Câncer do Colo Uterino do Ministério da Saúde

Purpose: to evaluate a populational sample of the screening proposed by the National Program of Uterine Cervical Cancer Control (PNCC), regarding the following issues: frequency of unsatisfactory cytologic results, cytologic frequency of atypical squamous or glandular cells of undetermined significance (ASCUS, AGCUS), low- or high-grade squamous intraepithelial lesions (SIL), comparing the cytologic results with anatomicopathological results of colposcopically directed biopsies. Methods: through the written, broadcasting television and oral midia, women between 35 and 49 years were requested to have a preventive cytopathological test, to be collected by the authorized public health or other institutions accredited by SUS. The slides were analyzed by the program-authorized laboratories and all those patients from the populational sample from the municipality of Navirai in the State of Mato Grosso do Sul with cellular alterations were submitted to colposcopy and directed biopsy. Results: the frequency of cytologic alterations of the ASCUS, AGCUS and SIL types was 3.3%, an index that is close to that predicted by the PNCC (4%); the percentage of samples that were unsatisfactory for evaluation was high (12.5%); among the ASCUS, AGCUS or low grade-SIL patients, 27.3% presented intraepithelial lesions of a high grade in the anatomicopathological study; while patients with cytology compatible with high grade-SIL, the directed biopsy revealed that 12.5% presented low-grade intraepithelial lesions. Conclusions: the choice of oncological cytology as the only method for the screening in the program allowed high indexes of false-negatives (27.3%) and of false-positives (12.5%). In the screening of cervical neoplasms, colposcopy has shown to be an important and indispensable method to guide the therapeutical management to be adopted.

Fibroma de Vulva (Molluscum Pendulum): Relato de Caso

A vulvar fibroma, of the molluscum pendulum type, was present in a 20-year-old patient. The tumor began to develop slowly after her menarche, when she was 14 years of age. The physical examination revealed a mass with considerable volume, painless, located at the upper third of the greator left lip, elastic consistency, greater diameter at its distal portion measuring 12 cm by 23 cm in length. The treatment was exeresis from the base of the pedicle, under local anesthesia. The tumor weighed 950 g. A literature review is included.

Relação entre angiogênese e estádio no carcinoma do endométrio

OBJETIVO: avaliar se o numero de vasos neoformados e fator importante para o prognostico do adenocarcinoma endometrial, comparando-o com o grau de diferenciacao histologica e o estadiamento do tumor. METODOS: foram estudadas 56 amostras de tecido endometrial, sendo 11 com o diagnostico histologico de endometrio atrofico, 10 endometrios proliferativos (ambos caracterizados como grupos controle), 10 amostras de adenocarcinomas GI, 13 adenocarcinomas GII e 12 adenocarcinomas GIII, caracterizados como grupos de estudo. Dois cortes histologicos foram obtidos de cada caso: um foi corado pela hematoxilina-eosina e o outro, para estudo imuno-histoquimico, foi tratado com anti-CD34, com a finalidade de corar vasos. A contagem vascular foi realizada na interface do crescimento tumoral com o estroma adjacente, em dez campos de 100 vezes de aumento, mediante estudo morfometrico pelo sistema computadorizado Kontron S300. No grupo controle, foi selecionada a interface entre glândulas endometriais e estroma adjacente. RESULTADOS: a media de vasos contados em 10 campos foi de 11,6 para o endometrio atrofico; 13,2 para o proliferativo; 15,3 para o adenocarcinoma GI; 19 para o adenocarcinoma GII e 22,7 para o adenocarcinoma GIII. A media de quantificacao vascular para os tumores das pacientes incluidas no estadiamento clinico I foi 18,6, semelhante estatisticamente aquelas dos estadiamentos II, III e IV (20,9) computados em conjunto. CONCLUSAO: concluimos que o adenocarcinoma pouco diferenciado apresenta maior numero de vasos por campo que o endometrio normal e que o carcinoma bem diferenciado. A quantificacao vascular nao foi influenciada pelo estadiamento como fator isolado.

Avaliação do Grau e da Extensão das Alterações Térmicas Produzidas pela Cirurgia de Alta Freqüência no Colo Uterino

Purpose: to evaluate the incidence of thermal damage to the specimens excised through large loop excision of the transformation zone (LLETZ) and to determine qualitatively and quantitatively the thermal injury to the ectocervical and endocervical epithelia as well as the influence of the menstrual phase on such process. Methods: we performed a prospective study of 100 patients with high-grade squamous intraepithelial lesions (HGSIL). Thermal damage was subdivided into three grades according to Messing et al1. Results: thermal injury occurred in all the cases, however, through statistical analysis we found that in 91% of the cases it was insignificant, thus leading to a precise histological evaluation, hence to measure the thermal injury was unnecessary. The grade and extent of thermal damage in excised specimens using LLETZ had no relation to the menstrual phase. The extension of thermal tissue alteration in the endocervical epithelia was 271,6 m while the extension in ectocervical epithelia was 254,8 m, showing that the extension of thermal damage is significantly higher in endocervical epithelia. Of the one hundred patients, 80 were in menacme and 20 in menopause correlating the grade and extension of thermal damage with the menstrual state. Conclusion: there was no significant difference in both qualitative and quantitative evaluations. There is no need to measure the thermal damage.

Valor do dilatador higroscópico para visualização do canal endocervical na conização com cirurgia de alta freqüência

OBJECTIVE: to evaluate the effectiveness of the hygroscopic dilator in the colposcopic examination of the endocervical canal in patients with high-grade lesion in the cytopathology and unsatisfactory colposcopy. METHODS: prospective study, including 62 patients with unsatisfactory colposcopic examination and cytology compatible with high-grade intraepithelial lesion. The patients were submitted to dilation of the endocervical canal by means of a hygroscopic dilator. After dilation, the new colposcopic findings were recorded, and then conization was made through loop electrosurgical excision procedure. The incidence of neoplasic involvement of surgical margins was compared between patients with examinations modified toward satisfactory results and those that remained with unsatisfactory colposcopy. In order to compare the incidence of involved margins and the incidence of residual disease, two retrospective control-groups were used: the GinSat group (n = 35): patients with unsatisfactory colposcopy; GSat group (n = 38): patients with satisfactory colposcopy and endocervical atypy. RESULTS: 80.6% of the cases presented satisfactory colposcopic vision after dilation. 80.4% of those presented disease-free resection margins. The incidence of disease-free resection margins in patients with persistent unsatisfactory colposcopy after dilation was 36.3%. Affected surgical margins occurred in 28% of the group that had undergone dilation, 28.5% of the cases in GinSat group, and 31.5% in the Gsat group. Follow-up showed the incidence of residual disease in 7.5% of the patients under dilation, 28.5% in the GinSat group and 28.9% in the GSat group. CONCLUSION: the use of hygroscopic dilation improved visualization of lesions of difficult access to the colposcopic examination, thus permitting reduction in the percentage of residual neoplasic disease in patients with unsatisfactory colposcopy treated with loop electrosurgical excision procedure.

Resultado da cirurgia com alça de alta freqüência e localização colposcópica da área com atipia ectocervical

Purpose: to evaluate the histopathologic results of cone specimens of patients undergoing loop electrosurgical excision procedure (LEEP) and their relationship with the localization of the lesion. Methods: in a retrospective study, 134 clinical reports of patients with abnormal findings of cervical cytology and/or biopsy undergoing LEEP were reviewed. The colposcopic findings were divided into three groups according to the localization of the lesion. Group I (n = 36): patients with ectocervical lesions and fully visible squamocolumnar junction; Group II (n = 50): patients with lesions at the ectocervix and endocervix, and Group III (n = 48): patients with unsatisfactory colposcopy. Results: the mean age in Group I was 33 years and there were 8.3% positive margins. In Group II the mean age was 39 years, with 36% positive margins. Group III had a mean age of 48 years and presented 29.2% positive margins. The percentage of residual disease was 4.2% in Group I, 31.6% in Group II and 35.5% in Group III. Conclusion: patients with lesions at the endocervical canal showed a higher rate of positive margins. Patients with high-grade cervical intraepithelial neoplasia at the endocervical canal and older than 40 years have a greater chance of showing positive margins and residual disease, therefore requiring stricter cytologic and colposcopic follow-up.

Relação Entre a Atividade Proliferativa do Epitélio e a Resposta Angiogênica Estromal em Neoplasias Intra-epiteliais do Colo Uterino

Purpose: to quantify the vessels and epithelial proliferation, applying immunohistochemical staining with anti-CD34 as well as anti-PCNA markers, in intra-epithelial neoplasia of the uterine cervix. Methods: in the present study, 16 patients with CIN III, 16 with CIN II, 21 with CIN I and 11 with normal cervix (control group) were investigated. Slide analysis was performed at the same time by two observers, in 10 consecutive sites using 100X and 400X magnification, both in the highest vascularization (CD34) and proliferative activity sites (PCNA). Results: the means obtained with the use of anti-PCNA in intraepithelial neoplasias were: 78.2% (CIN III), 52.1% (CIN II), 33.3% (CIN I) and 4.6% (control group), while 199.1 vessels (CIN III), 162.0 vessels (CIN II), 111.7 vessels (CIN I) and 124.4 vessels (control group) were quantified using anti-CD34 as a vascular marker. Conclusion: the results showed that both markers, anti-PCNA and anti-CD34, are useful for investigating proliferative and angiogenic activity, respectively. However, anti-PCNA showed better and more accurate results than anti-CD34 in differentiating intraepithelial neoplasias.

Study of the glandular endocervical epithelium cells from post menopaused women receiving hormonal replacement therapy comparing a morphologic analyzes with pcna immunoexpression

Methods: PCRs with 5 pairs of primer labelled with fluorescence (D3S1110, D3S1228, THRB, D3S1289, D6S291) was done using DNA extracted from exfoliated cells and control stromal cells. The size and number of PCR products were relatively defined by GeneScan. Ratio between two allelic bands was compared between normal and tumor cells to determine the loss of heterozygosity (LOH). RESULT: LOH or alteration in one locus and two loci as a marker for HISL showed 82.2% and 64.7% in sensitivity, 74.1% and 91.6% in positive predictive value, 61.5% and 92.4% in specificity and 72.7% and 66.7% in negative predictive value, respectively. Conclusion: Microsatellite alteration as a possible triage for equivocal Paps is better than HPV testing. Pathologically it is more related to late event in carcinogenesis rather than early event involved by HPV.

Nevus composto do colo uterino: relato de caso

O nevus composto do colo uterino representa um achado muito raro. Relatos excepcionais de lesoes melanociticas benignas e malignas da endo e exocervice uterina tem sido publicados. Relatamos o achado ocasional do nevus composto da exocervice uterina em uma paciente de 47 anos de idade que nao apresentava queixas ginecologicas. O diagnostico foi sugerido pelo exame colposcopico e confirmado a histopatologia. Devido a possibilidade de transformacao maligna dessas lesoes e a dificuldade de seguimento da paciente, o tratamento foi concluido com a realizacao de histerectomia total abdominal.