Louis Camilien

Multiple recurrences of cervical intraepithelial neoplasia in women with the human immunodeficiency virus

Objective To evaluate the long-term outcomes after treatment of cervical intraepithelial neoplasia (CIN) in women infected with the human immunodeficiency virus (HIV). Methods Human immunodeficiency virus-infected and HIV-negative women treated for CIN by ablation or excision were followed-up prospectively by cytology and colposcopy for periods of up to 73 months. Results Among 127 HIV-infected CIN patients, 62% developed recurrent CIN by 36 months after treatment, compared with 18% of 193 HIV-negative CIN patients. Recurrence rates reached 87% in 41 HIV-infected women with CD4 counts less than 200 cells/mm3. Progression to higher-grade neoplasia, including one invasive cancer, occurred by 36 months in 25% of HIV-infected and 2% of HIV-negative women. After adjusting for age, CIN severity, and treatment type, predictors of recurrence included HIV infection (rate ratio 4.4), and, in HIV-positive women, low CD4 count (rate ratio 2.2). In patients treated by excision, predictors of recurrence included HIV infection (rate ratio 2.0) and residual CIN after treatment (rate ratio 2.7). After a second treatment, a second CIN recurrence developed in 14 of 33 HIV-infected and in one of 17 HIV-negative women. After a third treatment, three of six HIV-infected women developed a third recurrence. With long-term follow-up, 45% of treated HIV-infected CIN patients had chronic condylomatous changes in the cervix compared with 5% of HIV-negative women. Conclusion In HIV-infected women, CIN may recur despite multiple treatments, and chronic condylomatous changes are common. Innovative therapies for controlling CIN in HIV-infected women are needed.

Vaginal intraepithelial neoplasia: Risk factors for persistence, recurrence, and invasion and its management

OBJECTIVE Our purpose was to profile patients with vaginal intraepithelial neoplasia, evaluate the response to treatment and define risk factors for persistence and progression. STUDY DESIGN We reviewed records and histopathology slides of 94 patients with vaginal intraepithelial neoplasia diagnosed from 1977 to 1986. For 74 patients with follow-up, we evaluated risk factors by univariate and multivariate analyses. RESULTS Sixty-four of 94 patients (68%) had prior or concurrent anogenital squamous neoplasia, including 21 with invasive and 43 with intraepithelial. Twenty-three had prior radiotherapy, 10 had anogenital neoplastic syndrome, and 11 were immunosuppressed. In 52 of 74 treated patients (70%), vaginal intraepithelial neoplasia went into remission after a single treatment. In 18 patients (70%) vaginal intraepithelial neoplasia went into remission after a single treatment. In 18 patients (24%) recurrent vaginal intraepithelial neoplasia went into remission after chemosurgery, upper vaginectomy, or other treatments; in 4 (5%) it progressed to invasion. Significant multivariate risk factors for persistence or progression were multifocal lesions and anogenital neoplastic syndrome but not vaginal intraepithelial neoplasia grade, associated cervical neoplasia, or immunosuppression. CONCLUSIONS Although most vaginal intraepithelial neoplasia goes into remission after treatment, 5% of cases may progress from occult foci to invasion in spite of close follow-up.

Characteristics of cervical intraepithelial neoplasia in women infected with the human immunodeficiency virus

OBJECTIVE Our purpose was to compare characteristics of cervical intraepithelial neoplasia in relation to human immunodeficiency virus infection among women referred to a public hospital colposcopy clinic with Papanicolaou smears showing cervical intraepithelial neoplasia. STUDY DESIGN An evaluation of cervical intraepithelial neoplasia severity, lesion size, and vulvovaginal lesions with respect to human immunodeficiency virus status was performed. RESULTS (1) Human immunodeficiency virus prevalence in 482 women with cytologic characteristics of cervical intraepithelial neoplasia was 13%. (2) In human immunodeficiency virus-infected patients, Papanicolaou smears were less adequate for evaluation and correlated less well with histologic findings than in uninfected patients (p < 0.05). (3) Human immunodeficiency virus-infected patients (n = 47) had more advanced cervical intraepithelial neoplasia, larger cervical lesions, and more associated vulvovaginal lesions than human immunodeficiency virus-negative patients (n = 161). In human immunodeficiency virus-positive women, the severity of cervical intraepithelial neoplasia was not associated with age, whereas in human immunodeficiency virus-negative women, increasing severity was significantly associated with increasing age. CONCLUSION High rates of human immunodeficiency virus infection in inner-city colposcopy services and high-grade, extensive cervical lesions in infected women warrant special attention.

Predictive value of computerized tomography in the presurgical evaluation of primary carcinoma of the cervix

To determine the predictive value of abdominal-pelvic CT scan in assessing pelvic and paraaortic node metastases in untreated cervical carcinoma, the preoperative CT scans of 61 patients were compared with the gross and microscopic surgical findings. Although 75% of enlarged pelvic nodes on CT contained metastases, and 97% of patients with negative pelvic nodes had negative CT scans (specificity = 97%), histologically positive pelvic nodes were often missed on CT scan (sensitivity = 25%). For paraaortic nodes the CT scan had a specificity of 100% and a sensitivity of 67%. No paraaortic nodes were enlarged in stages I-IIA (0/51). CT scans are recommended for routine evaluation of paraaortic nodes in stages II-IV, but are not warranted in pretreatment evaluation of the pelvic nodes in stage I.

11β‐Hydroxysteroid Dehydrogenase Activity in Pregnancies Complicated by Hydatidiform Mole

11β‐Hydroxysteroid dehydrogenase (11β‐HSD) plays an important role in regulating active glucocorticoid reaching the fetus. In normal pregnancy, placental 11β‐HSD functions primarily in oxidative direction. Placental tissue of patients with pregnancies complicated by pre‐eclampsia exhibit significantly lower type 1 and 2 11β‐HSD activities and significantly high cortisol level in cord blood suggesting fetal exposure to higher level of active glucocorticoids. The activity of 11β‐HSD in gestational trophoblastic disease has not been determined. The objective of this study was to assess 11β‐HSD activity in tissue from normal second trimester and pregnancies complicated by hydatidiform mole.

Uterine rupture secondary to a malignant mixed mesodermal (mullerian) tumor: a case report.

A case of uterine rupture resulting from tumor penetration of the myometrium in a patient with malignant mixed mesodermal tumor is described; the first in the literature known to the authors. Notable features include rapid progression of disease, hemoperitoneum, and diffuse intraoperative bleeding controlled by radiographic embolization.

Diagnostic imaging of gynecological diseases: The clinician’s view

The introduction of ultrasonography, computerized tomography, and magnetic resonance imaging has led to tremendous progress in the diagnostic evaluation of gynecologic diseases. Refinements in these techniques have allowed the gynecologist to diagnose unsuspected pathology, define disease and its extent, and select the most appropriate treatment despite limitations in specificity experience and cost. Practically the most appropriate imaging modalities are: ultrasonography for adnexal masses, computerized tomography for advanced cervical cancers, and magnetic resonance imaging for corpus cancers and selected cervical cancers.