Komsun Suwannarurk

See-and-Treat Approach to Cervical Intraepithelial Lesions in HRH Princess Maha Chakri Sirindhorn Medical Center

BACKGROUND To evaluate the overtreatment rate with the see and treat approach in the management of women with abnormal cervical cytology. MATERIALS AND METHODS A retrospective review of patients with abnormal cervical cytology who underwent S and T at MSMC between January 2008 and December 2012 was conducted. Loop electrosurgical excision procedure (LEEP), histological results, cytology and colposcopic impression were analyzed to evaluate overtreatment rate, cyto-histologic correlation and related factors. RESULTS Average age of S and T cases was 42 years. Ninety seven percents were referred from affiliated health care providers. The study revealed 83.2% patients had HSIL or higher from cervical cytology. Correlation between HSIL and final histology was relatively low at 75% compared to other studies. Overtreatment rate was 28%. CONCLUSIONS S and T was done in 197 patients in a tertiary care health facility with patient satisfaction. Overtreatment occurred, but the rate can be reduced with appropriate recommendations. HSIL Pap smears should be reexamined before S and T while low grade and lesser colposcopic impression groups should obtain conventional colposcopic approach for patient future reproductive benefit.

Diagnostic value of endocervical curettage for detecting dysplastic lesions in women with atypical squamous cells of undetermined significance (ASC-US) and low grade squamous intraepithelial lesion (LSIL) Papanicolaou smears.

BACKGROUND To determine the frequency of dysplastic lesions in the endocervical curettage (ECC) specimens of women with ASC-US and LSIL Pap and to evaluate the possible factors associated with high grade dysplasia in those ECC specimens. MATERIALS AND METHODS Two hundred and sixty patients with ASC-US and LSIL cytologic smears who underwent an ECC at the time of colposcopic examination during January 2010 and December 2012 were reviewed. Demographic and clinicopathologic data were collected. Multivariate analysis using binary logistic regression was used to identify factors that might be associated with high grade endocervical dysplasia. RESULTS The frequency of endocervical dysplasia was 7.7% (20 out of 260 patients). Cervical intraepithelial neoplasia (CIN) 1 and CIN 2-3 lesions in the endocervical canal were observed in 12 and 8 patients, respectively. No microinvasive or invasive cervical cancers were identified. There was no difference in the frequency of high grade endocervical dysplasia between the patients with satisfactory and unsatisfactory colposcopic examinations (1.4% vs 5.1%, respectively, p=0.087). A multivariate logistic regression analysis demonstrated a significant association between high grade CIN on ectocervical biopsy as well as LSIL cytologic smears and high grade dysplasia in endocervical canal (OR=0.046, 95%CI=0.007-0.288; p=0.001 and OR=0.154, 95%CI=0.025-0.942; p=0.043, respectively). CONCLUSIONS The frequency of high grade endocervical dysplasia in women with ASC-US and LSIL cytologic smears was low. Therefore, routine performance of ECC in those women is debatable. High grade ectocervical dysplasia and LSIL cytologic smears may be used as predictors for high grade dysplasia in endocervical canal and ECC in these patients is reasonable.

Cytohistologic Discrepancy of High-Grade Squamous Intraepithelial Lesions in Papanicolaou Smears

OBJECTIVES To evaluate the frequency of cytohistologic discrepancy of high-grade squamous intraepithelial lesions (HSILs) in Pap smears and associated factors. METHODS Medical records of 223 women with HSIL Pap smears who were treated at Thammasat University Hospital were reviewed. Data on age, parity, menopausal status, contraceptive use and colposcopic directed biopsy and loop electrosurgical excision procedure (LEEP) pathology results were recorded. RESULTS Mean (SD) age of patients was 38.0 (9.4) years. The majority were premenopausal (86.5%) and multiparous (83.9%). Cytohistologic discrepancy between the Pap test and colposcopic-directed biopsy histology was 45.7% and that between the Pap test and LEEP histology was 29.5%. Fifty-four (24.2%) women had no high-grade CIN on both colposcopic directed biopsy and LEEP. Nulliparity, postmenopausal status and having no oral contraceptive pills use were factors associated with cytohistologic discrepancy. CONCLUSION The exact cytohistologic discrepancy rate was relatively high (24.2%). Factors associated with cytohistologic discrepancy were nulliparity and postmenopausal status and having no oral contraceptive pill use.

Knowledge, Attitudes and Practices Regarding Cervical Cancer Screening Among Village Health Volunteers

BACKGROUND In the years 2014, coverage rates of cervical cancer screening in Nakornnayok province accounted to 76.5%. This was lower than the governments specified goal of 80%. Community health volunteers are members of a Thai healthcare alliance established to help promoting healthcare service communication and collaboration at the primary level. Such village health volunteers (VHVs) are established in most villages. OBJECTIVE To assess the knowledge and attitudes of cervical cancer screening among VHVs. MATERIALS AND METHODS The subjects were 128 VHVs from four Nakornnayok sub-districts; namely KlongYai, Chomphol, Buangsan and Suksara, Thailand. The study was conducted from December 2014 to January 2015. The questionnaire was designed to assess the knowledge and attitude of cervical cancer screening provided by the VHVs. In addition, cervical cancer screening coverage rates of each area were collected. The demographic data, scores of knowledge, attitudes, practices and the cervical cancer screening coverage rates were analyzed by one-way ANOVA. RESULTS The questionnaire reliability was assessed as 0.81. The total knowledge and attitude scores were 10 and 15 points. The mean knowledge scores of KlongYai, Chomphol, Buangsan and Suksara were 6.8, 7.0, 6.5 and 9.0 points, respectively. The VHVs had a high level of overall knowledge about cervical cancer screening. The mean attitude scores were 12.4, 13.2, 13.4 and 13.1 points. VHVs had a positive attitude to the promotion of cervical cancer screening at the overall level. The percentages of VHVs promoting cervical cancer information in respective districts were 72.2, 94.3, 94.9 and 50.0. However, the cervical cancer screening coverage rates were 62.4%, 34.7%, 80.3% and 47.3% respectively. CONCLUSIONS The knowledge, attitudes and percentages of promoting information of cervical cancer screening among VHVs in the four sub-districts were high but did not correlate with the cervical screening coverage rates for each area. VHVs needed to understand socio-cultural beliefs of the women in the target population and design suitable strategies to encourage higher cervical screening coverage.

Is the correlation between Papanicolaou smear and histopathology results affected by time to colposcopy

BACKGROUND Time to colposcopy (TC) after abnormal Pap smears was evaluated for influence on cytohistologic correlation (CHC). MATERIALS AND METHODS This retrospective study assessed the correlation between TC and CHC of women who had abnormal Pap smears. Colposcopic chart review included participants from 2010- 2013 who attended a colposcopic clinic, Thammasat University Hospital, Thailand. RESULTS Four hundred and sixty cases who had abnormal Pap smears were recruited. Pap reports were atypical smears with low grade squamous intraepithelial lesion (SIL), high grade SIL and cancer at 339, 114 and 7 cases, respectively. One hundred and twenty four patients underwent loop electrosurgical excision procedure (LEEP). A half of the cases were colposcopically examined within 1-2 months after abnormal Pap collection. CHC was 88 percent and not affected at all by TC. Subjects who attended cervical cancer screening from affiliated health providers had shorter TC than those screened in our tertiary hospital. CONCLUSIONS Time to colposcopy with abnormal Pap smears conducted at Thammasat University Hospital had a highest frequency of 42 days, in line with the literature. Length of TC does not affect the correlation between Pap and histopathologic reports. A longer waiting period for colposcopy did not alter progression or regression of the disease.

Transvaginal color Doppler study of uterine artery: Is there a role in chronic pelvic pain?

Aim:  To determine the value of transvaginal color Doppler study of uterine artery and investigate the differences in blood flow of uterine artery among women with chronic pelvic pain (CPP).

Possibility of using superoxide dismutase and glutathione peroxidase as endometriosis biomarkers

Objective To study the possibility of using superoxide dismutase (SOD) and glutathione peroxidase (GPx) as combined preoperative biomarkers for endometriosis. Participants and methods Female patients aged between 18 and 45 years old who came to the Gynecology outpatient clinic, Thammasat University Hospital, during September 2013–2016 with the complaint of gynecologic symptoms suspected of endometriosis, and who were positively diagnosed with endometriosis, were included in this study. All patients underwent conservative laparoscopic ovarian cystectomy with histopathological report. The control group consisted of healthy females of reproductive age who came to the outpatient clinic. The plasma SOD and GPx were measured from blood samples with commercial kits. A receiver operating characteristic curve was generated for plasma activity of SOD, GPx, and combined tests. The cutoff values were selected at the most appropriate sensitivity and specificity. Result All 36 cases were included in this study. Mean ages of patients in the patient and control groups were 33.1 and 28.6 years old, respectively. SOD and GPx activities of disease and control group were 6.15 and 8.11, 463.9 and 472.34 nmole/min/mL unit, respectively. The sensitivity and 1–specificity of the combined test were calculated at 0.78, with sensitivity, specificity, accuracy, positive predictive value, and negative predictive value being 68.75, 80.77, 76.50, 69.23, and 80.33, respectively. Conclusion A combination testing of SOD and GPx can possibly be used as preoperative biomarker for endometriosis.

Accuracy of visual inspection with acetic acid in detecting high-grade cervical intraepithelial neoplasia in pre- and post-menopausal Thai women with minor cervical cytological abnormalities.

PURPOSE To determine the accuracy of visual inspection with acetic acid (VIA) in detecting high-grade cervical intraepithelial neoplasia (CIN) in pre- and post-menopausal women with atypical squamous cells of undetermined significance (ASC-US) and low grade squamous intraepithelial lesion (LSIL) Papanicolaou (Pap) smears. MATERIALS AND METHODS Two hundred women (150 pre-menopausal and 50 post-menopausal) with ASC- US and LSIL cytology who attended the colposcopy clinic, Thammasat University Hospital, between March 2013 and August 2014 were included. All women underwent VIA testing and colposcopy by gynecologic oncologists. Diagnostic values of VIA testing including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for detecting high-grade CIN were determined using the histopathology obtained from colposcopic-directed biopsy as a gold standard. RESULTS VIA testing was positive in 54/150 (36%) pre-menopausal women and 5/50 (10%) post-menopausal women. Out of 54 pre-menopausal women with positive VIA testing, 15 (27.8%) had high-grade CIN and 39 (72.2%) had either CIN 1 or insignificant pathology. Ten (10.4%), 43 (44.8%) and 43 (44.8%) out of the remaining 96 pre-menopausal women with negative VIA testing had high- grade CIN, CIN 1 and insignificant pathology, respectively. Out of 5 post-menopausal women with positive VIA testing, there were 4 (80%) women with high-grade CIN, and 1 (20%) women with insignificant pathology. Out of 45 VIA-negative post-menopausal women, 42 (93.3%) women had CIN 1 and insignificant pathology, and 3 (6.7%) had high-grade CIN. Sensitivity, specificity, PPV and NPV of the VIA testing were 59.4%, 76.2%, 32.2% and 90.8%, respectively (60%, 68.8%, 27.8% and 89.6% in pre-menopausal women and 57.1%, 97.7%, 80% and 93.3% in post-menopausal women). CONCLUSIONS VIA testing may be used as a screening tool for detecting high-grade CIN in women with minor cervical cytological abnormalities in a low-resource setting in order to lower the rate of colposcopy referral.

Colposcopy Requirement of Papanicolaou Smear after Atypical Squamous Cells of Undetermined Significance (ASC-US) by Follow-up Protocol in an Urban Gynaecology Clinic, a Retrospective Study in Thailand

BACKGROUND ASC-US cases are managed according to the current American Society for Colposcopy and Cervical Pathology (ASCCP) guideline in which a human papillomavirus (HPV) test and repeat Pap smear are performed in the next 1 year. Colposcopy in cases of positive high risk HPV and persistent ASC-US or more in subsequent Pap smear is recommended. The HPV test is more expensive and still not currently a routine practice in Thailand. OBJECTIVE To identify the risk factors of persisted abnormal Pap smear and the colposcopic requirement rate in women with ASC-US. MATERIALS AND METHODS During 2008-2013, this study was conducted in Prapokklao Hospital, Chanthaburi, Thailand. Participants were women who attended gynaecology clinic for cervical cancer screening. Women who had cytological reports with ASC-US were recruited. During the study period, 503 cases were enrolled. Colposcopic requirement was defined as those who were detected with an ASC-US or more in subsequent Pap smears up to 1 year follow-up. RESULTS The colposcopic referral rate was 23.2 (85/365) percent at 12 months. Prevalence of cervical intraepithelial neoplasia (CIN) 2/3 was 3.3 (12/365) percent. Loss follow-up rate of subsequent Pap smear and colposcopic appointment were 27.4 (138/503) and 48.2 (41/85) percent, respectively. There was no invasive cancer. High risk factors for persisted abnormal Pap smears in subsequent test were premenopausal status, HIV infected patients and non-oral contraceptive pills (COC) users. CONCLUSIONS Referral rate for colposcopy in women with ASC-US reports was rather high. Loss to follow-up rate was the major limitation. Immediate colposcopy should be offered for women who had high risk for silent CIN.

Chitinase 3 like 1 (CHI3L1) promotes vasculogenic mimicry formation in cervical cancer

Vasculogenic mimicry (VM) is an alternative microvascular system which tumour cells orchestrate, independent of endothelial cell-mediated angiogenesis. VM develops tumour vascular networks that correlate with tumour growth, metastasis, and short survival time of patients with a number of cancers. However, little is known regarding VM in the vascularisation of cervical cancer. Chitinase 3 like 1 (CHI3L1) has been previously reported to display the ability to induce angiogenesis in cervical cancer. Here, we explored a pathological role of CHI3L1 in tumour cell-mediated vascularisation. Sixty-six samples of cervical cancer were collected to examine CHI3L1 expression and VM formation using immunohistochemistry and CD34-periodic acid-Schiff (PAS) dual staining. CHI3L1 expression was significantly correlated with formation of tumour cell-associated vascular channels in the absence of endothelial cells (p=0.031). Interestingly, tumour samples lacking VM were positively correlated with non-metastasis (p=0.035). Patients with VM positive tumours tended to have decreased overall survival (OS) compared to those with VM negative samples (43.9 versus 64.6 months, p=0.079). In addition, recombinant CHI3L1 enhanced cervical cancer cell lines to form tube-like structures, supporting the notion that CHI3L1 mediates VM in cervical cancer. Our present data reveal the crucial role of CHI3L1 in the formation of VM, which may contribute to tumour aggressiveness. Therefore, targeting CHI3L1 may be a valuable strategy for the reduction of cervical cancer vascularisation and metastasis.