Kunio Miyazawa

Discrepancy in the interpretation of cervical histology by gynecologic pathologists.

OBJECTIVE To determine if subspecialty review of cervical histology improves diagnostic consensus of cervical intra‐epithelial neoplasia (CIN). METHODS After routine histologic assessment within the hospital pathology department, 119 colposcopic cervical biopsies were interpreted by two subspecialty‐trained gynecologic pathologists (GYN I and GYN II) blinded to each others interpretations and to the interpretations of the hospital general pathologists (GEN). Biopsies were classified as normal (including cervicitis), low grade (LG, including CIN I and human papillomavirus changes), and high grade (HG, including CIN II/III). The interobserver agreement rates between GEN and GYN I, between GEN and GYN II, and between GYN I and GYN II were described using the κ statistic. The proportions of biopsies assigned to each biopsy class were compared using McNemar test. RESULTS Interobserver agreement rates between GEN and GYN I were moderate for normal (κ = 0.53) and LG (κ = 0.46) and excellent for HG (κ = 0.76). There were no significant differences in the classifications between GEN and GYN I. Interobserver agreement rates between GEN and GYN II were moderate for normal (κ = 0.50) and LG (κ = 0.44) and excellent for HG (κ = 0.84). Also, GYN II was significantly more likely to classify biopsies as normal (P < .001) and less likely to classify biopsies as LG (P < .001). The interobserver agreement rates between GYN I and GYN II were moderate for normal (κ = 0.61) and LG (κ = 0.41) and excellent for HG (κ = 0.84). Also, GYN II was significantly more likely to classify biopsies as normal (P < .001) and less likely to classify biopsies as LG (P = .01). CONCLUSION Interobserver agreement between two gynecologic pathologists was no better than that observed between general and gynecologic pathologists. Subspecialty review of cervical histology does not enhance diagnostic consensus of CIN.

Risk factors for early cytologic abnormalities after loop electrosurgical excision procedure

OBJECTIVE To evaluate risk factors for early cytologic abnormalities and recurrent cervical dysplasia after loop electrosurgical excision procedure (LEEP). METHODS A retrospective analysis was performed of all pathology records for LEEPs performed at our institution from January 1996 through July 1998. Follow‐up cytology from 2 through 12 months after LEEP was reviewed. Patients with abnormal cytology were referred for further colposcopic evaluation. Statistical analysis using χ2 test for trend, proportional hazards model test, Fisher exact tests, and life table analysis were performed to identify risk factors for early cytologic abnormalities after LEEP and to determine relative risk of recurrent dysplasia. RESULTS A total of 298 women underwent LEEP during the study period, and 29% of these had cytologic abnormalities after LEEP. Grade of dysplasia, ectocervical marginal status, endocervical marginal status, and glandular involvement with dysplasia were not found to be independent risk factors for early cytologic abnormalities. However, when risk factors were analyzed cumulatively, the abnormal cytology rate increased from 24% with no risk factors to 67% with three risk factors present (P = .037). Of patients with abnormal cytology after LEEP, 40% developed subsequent dysplasia, and the mean time to diagnosis was approximately 6 months. The relative risk of subsequent dysplasia ranged from a 20% increase to twice the risk if post‐LEEP cytology was low‐grade squamous intra‐epithelial lesion or high‐grade squamous intraepithelial lesion, respectively. CONCLUSION Based on these results, consideration should be given for early colposcopic examination of patients who have evidence of marginal involvement or endocervical glandular involvement with dysplasia. These patients are at increased risk for abnormal cytology and recurrent dysplasia. This initial visit should occur at 6 months, as the mean time to recurrence of dysplasia was 6.5 months.

Partial hydatidiform moles: a review.

The current study was undertaken in an effort to identify the clinical characteristics and natural history of partial moles. Three cases recently managed at Tripler Army Medical Center and 52 cases collected from the medical literature were reviewed. The mean age of the women at diagnosis was 25.6 years. The mean gestational age at diagnosis was 23.8 weeks. The most common presenting symptom was vaginal bleeding in 69 per cent of women. Although triploidy was the most frequent karyotype (68 per cent), normal 46,XY or XX karyotypes were present, and phenotypically normal infants were delivered of mothers with a coexisting molar pregnancy. Malignant trophoblastic disease occurred in 14.5 per cent of the women. All of them achieved remission with adjuvant therapy. Partial moles are considered a less virulent form of molar pregnancy. The clinical characteristics and natural history are not entirely dissimilar from the complete mole. Malignant sequelae can occur after the evacuation of a partial mole. These women should be followed with serial serum beta-HCG.

Cervical carcinosarcoma: A case report

Cervical sarcomas and carcinosarcomas are exceedingly rare. The clinicopathologic characteristics, management and outcome of a patient with cervical carcinosarcoma is presented.

Technique for total abdominal hysterectomy: historical and clinical perspective.

Since the first refined total abdominal hysterectomy was performed by Wilhelm Alexander Freund of Breslau on January 30, 1878, various techniques have been introduced over the past 110 years. Hysterectomy, numbering over 650,000 procedures annually, is the most commonly performed major surgical procedure next to cesarean section in the United States. Although CREOG (Council on Resident Education in Obstetrics and Gynecology) emphasizes the importance of basic pelvic surgical skills and competency in gynecological surgical procedures, cost-effective patient management dictates the shortest hospitalization and most uncomplicated procedure possible. Various techniques of abdominal hysterectomy have been reappraised in view of present-day medical practice concepts. It seems that we are entering a new age wherein a simplified, cost-effective alternative to a classical total abdominal hysterectomy is indeed needed for some cases, and if a hysterectomy is planned, it should be performed in the safest way in the shortest possible operating time for a well-indicated case. Keeping this objective in mind, one Japanese technique of total abdominal hysterectomy and its modification are described with the intent that this will assist Ob/Gyn resident physicians in surgical skill development and also help gynecologists in practice to meet rapidly changing practice patterns of the specialty.

Peritoneal endometriosis in women requesting reversal of sterilization.

Seventy-six women requesting reversal of sterilization underwent at least 1 operative procedure during a 27-month period, and 14 (18.4%) were found to have pelvic endometriosis. The endometriosis patients were noted to have had significantly fewer pregnancies (1.8 versus 2.9, P less than 0.01) before sterilization than those without endometriosis, but the two groups did not differ significantly in mean age (30.8 versus 30.3 years), type of sterilization or in mean number of years since sterilization (5.0 versus 5.5 years). In only two individuals were proximal tubal segment fistulas found at the time of reversal, and neither had endometriosis. We conclude that pelvic endometriosis is more common in patients with bilateral tubal occlusion than previously suspected and that its presence indicates that endometriosis implants can persist for prolonged periods of time, can give rise to new implants, or do not require the tubal reflux of menstrual debris to form.

A Combination of Gonadotropin-Releasing Hormone Analog and Human Menopausal Gonadotropins for Ovulation Induction in Premature Ovarian Failure

A combination of gonadotropin‐releasing hormone agonist and human menopausal gonadotropins was used for ovulation induction in a patient with premature ovarian failure. A paradoxical suppression of any ovarian response was noted despite increasing doses of human menopausal gonadotropins.

Discrepancy in the Interpretation of Cervical Histology by Gynecologic Pathologists

Two gynecologic pathologists with board certification in pathology and obstetrics and gynecology, with 8 and 10 years of experience, independently reviewed 119 colposcopic cervical biopsy samples. The biopsies were originally read by a group of 16 general pathologists who made the initial clinical diagnosis. The results of these reviews were compared to determine if subspecialty review improved the diagnostic consensus of cervical intraepithelial neoplasia (CIN). The generalists diagnosed 42% of the 119 biopsies as normal, whereas the subspecialists (GYN I and GYN II) identified 50% and 65% as normal. A diagnosis of low grade (including CIN I and human papillomavirus changes) was made in 41% of the samples by generalists and in 33% and 21% by the subspecialists. There was greater agreement for a diagnosis of high grade (including CIN 2 and 3). The specimens were identified as high grade by the generalists, GYN I, and GYN II in 17%, 17%, and 14% of the cases, respectively. Between the two subspecialists the overall interobserver agreement rate was 76%. The overall agreement rate between the generalists and GYN I and the generalists and GYN II was 72% each. The difference in agreement between GYN I and the generalists was not statistically significant. However, compared with generalists GYN II was significantly more likely to identify a specimen as normal (P <.001) and less likely to diagnose low grade (P <.001). Also, when compared with the other subspecialist, GYN II was significantly more likely to identify the specimen as normal (P < .001) and less likely to diagnose low grade (P <.01).