Leila Cristina Soares

Family planning in Brazil: why not tubal sterilisation during childbirth?

Sterilisation is the most desired method of contraception worldwide. In 1996, the Brazilian Congress approved a family planning law that legitimised female and male sterilisation, but forbade sterilisation during childbirth. As a result of this law, procedures currently occur in a clandestine nature upon payment. Despite the law, sterilisations continue to be performed during caesarean sections. The permanence of the method is an important consideration; therefore, information about other methods must be made available. Tubal sterilisation must not be the only choice. We argue that review of this restriction will not contribute to the increase in caesarean sections but will allow for greater sterilisation choice for men and women.

Response to: Survey of Japanese mothers of daughters eligible for human papillomavirus vaccination on attitudes about media reports of adverse events and the suspension of governmental recommendation for vaccination.

We recently read the article about how the news of the adverse effects and the government suspension of recommendation for human papillomavirus (HPV) vaccination decreased the vaccine uptake in Japan. In Brazil, insufficient health access and geographical difficulties make cervical cancer a public health concern. In 2014, the Ministry of Health initiated a campaign of vaccination against HPV, and the goal was to vaccinate 80% of the population. Administration of the first dose began in March 2014, amid doubts that the achievement of this goal would be hindered by geographical and cultural problems. The Health Ministry posted a ‘vaccinometer’ on its website to show the adherence to HPV vaccination in each state and city. The result showed high adherence in most states, with compliance rates of approximately 100%. During the second stage of vaccination in September 2014, adherence to vaccination was only 37.71% in the first 2 months in Brazil. Three teenagers were admitted because of restrictive leg movements after vaccination and eight other patients had symptoms such as numbness in the limbs, headache, and dizziness. None of these events were shown to be due to the vaccine. Although the media’s role is to inform, reporting without proper confirmation can be a barrier to adherence, as is evident in the cases described. The possible effects of vaccines should always be disclosed responsibly and be presented with information about their efficacy and security. The Interinstitutional Committee for Pharmacosurveillance of Vaccines and other Immunobiologicals, founded in 2008 in Brazil, investigates cases of possible adverse events related to routine immunization. Similar to the situation in Japan, in Brazil, media disclosure of adverse events affected the vaccination acceptance; however, the Brazilian government has not withdrawn support for vaccines. Fortunately, HPV vaccination has increased and the vaccinometer of the health ministry indicated that 59.96% and 50.29% of girls in Brazil received the second dose of HPV vaccination in 2014 and the first dose in 2015, respectively. The goal of HPV vaccination in Brazil has not yet been achieved, but the number ofHPVvaccinations is increasing. It is important to prioritize the increase in awareness regarding vaccination to significantly reduce cervical cancer incidence in the next decades. Full compliance in completing all vaccine doses is expected. Thus far, there has not been any absolute contraindication for the use of these vaccines. Overall, the Brazilian population is moving closer towards reducing morbidity and mortality owing to cervical cancer.

Sister Mary Joseph Nodule and peritoneal carcinomatosis from squamous cell cervical carcinoma

Sister Mary Joseph nodule is an eponym assigned to a nurse, first reported in 1949, denoting a rare form of cutaneous umbilical metastasis. The primary neoplasm is usually adenocarcinoma and the gastrointestinal tract is the most common primary site. The present case report describes a 79 year old woman with squamous cell cervical carcinoma. Her disease was managed with radiation and concurrent chemotherapy and no evidence of loco-regional recurrent disease was noted on follow-up examination. Eight months after treatment, gynecological examination suggested recurrent disease. Three weeks later, the patient presented with a painless umbilical nodule and the biopsy revealed a poorly differentiated carcinoma. Computed tomography showed ascites, diffuse peritoneal carcinomatosis including an umbilical nodule, multiple pulmonary nodules, bilateral pleural effusion, and retroperitoneal lymphadenopathy. She died 63 days after this manifestation. Review of the literature shows that a Sister Mary Joseph nodule is a sign of advanced neoplastic disease and is associated with poor prognosis. The treatment remains palliative either by radiation, chemotherapy or surgery.

Histological outcomes in conventional cervical cytology for invasive carcinoma: not always cancer

Abstract The value of cytology for the detection of invasive cancer remains unknown. We performed a retrospective cohort study with 884 patients diagnosed of premalignant lesions and invasive carcinoma in cytology. 382 (43.2%) of them had cytological results of high-grade squamous intraepithelial lesions (HSIL), 244 (27.6%) showed low-grade squamous intraepithelial lesions (LSIL), 120 (13.6%) patients had atypical squamous cells of undetermined significance (ASC-US), 67 (7.6%) patients with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H), 38 (4.3%) had invasive carcinoma and 33 (3.7%) patients presented with atypical glandular cells (ACG). From 38 patients with cytological results of invasive carcinoma, 24 had confirmatory histological results (63.2%). The other 14 had 4 benign lesions and 10 HSIL. The predictive positive value (PPV) was 63.2%. Cytology results of carcinoma do not confer a definitive diagnosis of invasive lesion, but it is strongly an indication of, at least, a precancerous lesion.

How to Use CA-125 More Effectively in the Diagnosis of Deep Endometriosis

Deep infiltrative endometriosis (DIE) is a severe form of the disease. The median time interval from the onset of symptoms to diagnosis of endometriosis is around 8 years. In this prospective study patients were divided into two groups: cases (34 DIE patients) and control (20 tubal ligation patients). The main objective of this study was to evaluate the performance of CA-125 measurement in the menstrual and midcycle phases of the cycle, as well as the difference in its levels between the two phases, for the early diagnosis of DIE. Area Under the Curve (AUC) of CA-125 in menstrual phase and of the difference between menstrual and midcycle phases had the best performance (both with AUC = 0.96), followed by CA-125 in the midcycle (AUC = 0.89). The ratio between menstrual and midcycle phases had the worst performance. CA-125 may be useful for the diagnosis of deep endometriosis, especially when both are collected during menstruation and in midcycle. These may help to decrease the long interval until the definitive diagnosis of DIE. Multicentric studies with larger samples should be performed to better evaluate the cost-effectiveness of measuring CA-125 in two different phases of the menstrual cycle.

Vulvar Ulcers Leading to Cutaneous Perforation in an Immunocompetent Teenager: Expression of Cytomegalovirus Infection.

V ulvar ulcers are rare in teenagers, particularly those who are not sexually active. Evaluation of any genital ulcer requires consideration of the local epidemiology and demography, travel and sexual history, suggestive clinical features, extragenital physical examination, laboratory testing, and biopsy for histological study, if needed. Infectious causes may or may not include sexually transmitted diseases. Sexually transmitted infectious causes of vulvar ulcers include primary syphilis, lymphogranuloma venereum chancroid, granuloma inguinale, and herpes simplex virus (HSV). Nonsexually transmitted infections that potentially lead to vulvar ulcers include cytomegalovirus (CMV), Epstein-Barr virus (EBV), candida, parasites, and mycobacteria. Noninfectious ulcers include those caused by drug reactions or adverse effects, autoimmune or inflammatory diseases, trauma, and Lipschutz ulcers. Skin disease remains a rare manifestation of reactivated CMV disease in any setting but should be considered in the screening of ulcerative vulvar lesions.

Cervical Adenocarcinoma: Are We Screening and Treating Patients Appropriately?

T he incidence of cervical adenocarcinoma has gradually increased over the years for reasons that are not well understood. We strongly believe that as the incidence of this disease rises, it will become more and more important to develop new strategies for screening and diagnosis. In our opinion, cervix adenocarcinoma and squamous cell carcinoma behave differently and must therefore be addressed differently. The natural history of cervical adenocarcinoma differs from that of squamous cell carcinoma. Because many of the risk factors that have been identified for endometrial adenocarcinoma have a hormonal basis, it is logical to presume that hormonal risk factors are also important predictors for the risk of cervix adenocarcinoma. We should therefore pay more attention to such risk factors. Although squamous cell carcinomas and adenocarcinomas can be observed together and share risk factors, some factors, such as obesity, seem to be a risk factor for adenocarcinoma but not for squamous cell carcinoma. With regard to screening processes, it is highly evident that cytology screening is less effective in preventing adenocarcinoma than squamous cell carcinoma. The main purpose of screening is to detect cervical lesions in their early stages before they become invasive. Castanon et al, using prospectively recorded cervical screening data, showed that stage 1A adenocarcinoma was very unlikely to be detected within 3 years of a negative cytology test, suggesting that screening procedures are inefficient in preventing adenocarcinoma of the cervix. Thus, cytological screening does not work for adenocarcinoma and squamous cell carcinoma as a preventative measure but remains useful for early detection. A change in screening practices could contribute to earlier diagnosis. Both squamous cell carcinoma and adenocarcinoma are linked to human papillomavirus (HPV). Collectively, HPV 16 and 18 account for approximately 85% and 70% of adenocarcinoma and squamous cell carcinoma cases, respectively. However, HPV 18 is known to bemore common in adenocarcinomas than in squamous cell carcinomas. The incorporation of HPV molecular diagnostic testing into screening programs as either an adjunct to the Pap test or a primary screening protocol could help improve our chances of an earlier diagnosis. Nevertheless, adenocarcinomas encompass a heterogeneous group of tumors, and there is some evidence to suggest that some cancers remain HPV negative despite testing with multiple HPVassays. This can be explained by the fact that, unlike the usual types of endocervical adenocarcinoma, other types, including clear-cell and mesonephric

Portal Hypertension Caused by Immature Teratoma in an Adolescent Female

BACKGROUND Tumor compression is a cause of portal hypertension. In adolescents, most tumors are germ cell tumors. CASE We report the case of a 17-year-old female patient with progressive abdominal distention. Portal hypertension with ascites and esophageal varices were identified. A computed tomography scan showed a large ovarian mass that was consistent with a teratoma. After laparotomy, the portal hypertension was resolved. SUMMARY AND CONCLUSION Venous compression by an immature teratoma should be considered a cause of portal hypertension in adolescents.