Manoel Afonso Guimarães Gonçalves

Transition of cervical carcinoma in situ to invasive cancer: Role of p16INK4a expression in progression and in recurrence

To investigate the expression of p16(INK4a) in cervical carcinoma and its relation to the transition of carcinoma in situ to invasive carcinoma, and its role in recurrence of cervical lesions as well, a series of 90 patients with cervical carcinoma (49 with in situ lesion and 41 with invasive lesion) were selected from July 2001 and September 2002. Groups with in situ and invasive lesions were paired for a series of risk variables for cervical cancer and followed up for 60 months. The follow-up visits occurred every 6 months in the first three years and annually up to the fifth year. It was observed that 87.9% of the patients with invasive lesion showed overexpression of p16(INK4a), in comparison with 37.6% of those with in situ lesion (X(2): 13.68; 2 df; p=0.0002; OR: 12.08), demonstrating overexpression of p16(INK4a) as a risk of invasion of the basal layer by dysplastic cells. We also observed an association between overexpression of p16(INK4a) and staging of cancer (X(2): 18.38; 6 df; p=0.0003). A prospective analysis, when controlled for interaction with cervical lesion groups (by Cox regression), demonstrated a risk of recurrence of 4.83 times attributed to overexpression of p16(INK4a), albeit not statistically significant (p=0.14).

Discordance between Cytology and Biopsy Histology of the Cervix: What to Consider and What to Do

Objective: Since cytology is the examination utilized for the screening of cervical cancer, it is important to determine its correlation with histologic examination, the gold standard in the diagnosis of cervical disease. Study Design: A retrospective evaluation was made of 431 patients who presented with colposcopic indication for cervical biopsy between 2003 and 2007. Results: In 90.8% (289/318) of the patients, cytology showing cervical intraepithelial neoplasia (CIN) was confirmed as CIN in the histology of the cervix, while 62.8% (71/113) of patients with normal cytology had a confirmation of a normal histology (ĸ = 0.558). Conclusion: Cytology demonstrated a sensitivity and specificity of 87.3 and 71.0%, respectively. The agreement between cervical cytology and histology, considering the presence of CIN, was moderate. Correlations between accuracy and errors of cytology are discussed with therapeutic emphasis.

Adenocarcinoma viloglandular de cérvice uterina

PuRPOse : the villoglandular adenocarcinoma (VGA) of the cervix has been identified as a variant of cervical adenocarcinoma that occurs in young women, which has an excellent prognosis. Considering the scarcity of studies related to the subject, we report six cases of VGA of the cervix. MethOds : we followed the development of six cases of VGA in the period from 1995 to 2006 at Hospital Sao Lucas of Pontificia Universidade Catolica do Rio Grande do Sul (PUC-RS). We collected clinical and histologic information of the patients and submitted all the surgical specimens to histological review. Results : mean age at diagnosis was 43.5 years (range 27-61 years). Four patients were submitted to Wertheim-Meigs radical hysterectomy and bilateral pelvic lymphadenectomy, one to conization and subsequent radiotherapy and one to pelvic lymphadenectomy followed by radiotherapy. All the patients were alive and well at the time of this writing, without evidence of recurrence. COnClusiOns : the implications of therapy are discussed. We propose here the inclusion of the study of the pattern of lymphovascular involvement in determining the diagnosis of VGA. Thus, in referring to this diagnosis, we will be able to opt, with caution, for conservative therapy, except for particularities of each case.Purpose: the villoglandular adenocarcinoma (VGA) of the cervix has been identified as a variant of cervical adenocarcinoma that occurs in young women which has an excellent prognosis. Considering the scarcity of studies related to the subject we report six cases of VGA of the cervix. Methods: we followed the development of six cases of VGA in the period from 1995 to 2006 at Hospital Sao Lucas of Pontificia Universidade Catolica do Rio Grande do Sul (PUC-RS). We collected clinical and histologic information of the patients and submitted all the surgical specimens to histological review. Results: mean age at diagnosis was 43.5 years (range 27-61 years). Four patients were submitted to Wertheim-Meigs radical hysterectomy and bilateral pelvic lymphadenectomy one to conization and subsequent radiotherapy and one to pelvic lymphadenectomy followed by radiotherapy. All the patients were alive and well at the time of this writing without evidence of recurrence. Conclusions: the implications of therapy are discussed. We propose here the inclusion of the study of the pattern of lymphovascular involvement in determining the diagnosis of VGA. Thus in referring to this diagnosis we will be able to opt with caution for conservative therapy except for particularities of each case.

Ureter: How to Avoid Injuries in Various Hysterectomy Techniques

Hysterectomy is one of the most common surgical procedures in the practice of gynecology. The various surgical techniques for hysterectomy, including those by the abdominal approach as well as those by the vaginal route, deserve special attention with regard to possible transoperative urological injuries. These complications raise questions about the anatomic knowledge for all gynecologists. The ureters are vulnerable to injuries during gynecological surgeries and even obstetric ones due to the anatomic proximity to the organs of the female reproductive system. 1 The general incidence of ureteral injuries is estimated to be 0.03% to 2.0% for abdominal hysterectomy, 0.02% to 0.5% for vaginal hysterectomy, and 0.2% to 6.0% for laparoscopy-assisted vaginal hysterectomy. 2, 3, 4, 5, 6 There are four critical points of potential ureteral injury during a hysterectomy. The first critical point is situated at the entrance of the ureter in the pelvic bone, when the ovarian vessels cross over it. The second critical point is identified next to the uterosacral ligament, where the ureter is situated lateral to this ligament. The third critical point is at the level of the uterine artery, where the ureter crosses below the uterine artery through the cardinal ligament at the level of the ischial spine. The fourth critical points occurs in the bladder, where the ureter turns medially, crossing the anterior portion of the vaginal dome and entering the bladder wall. 7 Certainly, the ability to recognize the anatomy, as well the ability of the surgeon in recognizing the points of greater risk of ureter injury, will help in lowering these percentages.

Associação entre o polimorfismo no códon 72 da p53 e as lesões pré-malignas e malignas cervicais

OBJETIVOS: testar a hipotese de que o polimorfismo no codon 72 do gene TP53 e fator de risco para as lesoes pre-malignas e malignas cervicais associadas ou nao ao papilomavirus humano (HPV). METODOS: foram incluidas amostras de cervice uterina, para pesquisa de DNA de HPV e do polimorfismo no codon 72 da p53 com o uso da reacao em cadeia da polimerase (PCR), de 155 pacientes que se submeteram a biopsia cervical. Foram formados tres grupos de acordo com o diagnostico histologico: lesao escamosa intra-epitelial de baixo grau (LSIL), lesao escamosa intra-epitelial de alto grau (HSIL) e carcinoma cervical. Aquelas pacientes sem alteracoes displasicas, citologicas e histologicas, foram consideradas controles. Para testar a associacao entre o polimorfismo no codon 72 do gene TP53 e os grupos, foi utilizado o teste de c2. Considerou-se como significativo o intervalo de confianca no nivel de 95% (a=0,05). RESULTADOS: quarenta pacientes tiveram o diagnostico histologico de carcinoma cervical, 18 tinham HSIL, 24 tinham LSIL e 73 foram consideradas controles. O genotipo Arg/Arg p53 foi encontrado em 60,0% das pacientes com câncer, 50,0% dos casos com HSIL, 45,8% dos casos com LSIL e em 45,2% dos controles. Nao houve diferenca significativa entre as proporcoes de cada genotipo da p53 nos diferentes grupos independente da presenca do HPV (c2: 3,7; p=0,716). CONCLUSOES: nossos dados nao suportam a hipotese de que o polimorfismo no codon 72 do gene TP53 e importante no desenvolvimento de lesoes cervicais pre-malignas e malignas associadas ou nao ao HPV.

Adenocarcinoma of the Endometrium — The Art of Its Diagnosis

The diagnostic process begins at the first meeting with the patient, where we must relate the symptoms and signs associated with endometrial disease. Communication skills are fundamental for excellence in medical care. Even with the development and improve‐ ment of new technologies in recent decades, be it endoscopy, ultrasound, computed to‐ mography or magnetic resonance imaging, the communication is also essential. We must have skills to recognize and elucidate a wide variety of signs and symptoms when we take a history and do a physical examination of the patient, where abnormal uterine bleeding is the first main sign that can lead to an early diagnosis of endometrial cancer. The endometrium, as every target organ of steroid hormones, shows involutional changes during ovarian failure. In peri-menopause, however, tissue hyperactivity stages occur with some frequency, showing a marked endometrial sensitivity to hormonal fluc‐ tuations, whether on an absolute or relative level. Irregular blood loss occurs in many women during this period, and although being most times of functional origin, it requires investigation. It is noteworthy that the most frequent cause of abnormal bleeding of or‐ ganic origin in menopause is endometrial. Endometrial pathologies appear with advanc‐ ing age. Therefore an appropriate workup should diagnose or rule out disease at this site. Thus, preventive measures should be adopted, such as screening and early diagnosis, and the best treatment for the patient should be established.

Cancer of the Vulva — A Review

Cancer of the Vulva: a review In reporting on cancer of the vulva, we should keep in mind some important aspects of its epidemiology and its early detection. Most of the pa‐ pers on the subject refer to vulvar cancer as a rare disease, accounting for 4 to 5% of all malignant neoplasms of the female genital tract and less than 1% of womens cancers. The incidence varies from 1 to 3.6 cases per 100,000 women, with peak incidence at ages 70-79 years. Even though the incidence increases with age, the proportion of young patients with vulvar cancer has greatly increased due to its association with infection with human papillomavirus (HPV). The risk of developing cancer of the vulva is related to behavioral, reproductive, hormonal and genetic aspects. Factors that increase risk include other geni‐ tal cancers, chronic inflammatory diseases of the vulva, smoking, history of genital warts and vulvar intraepithelial neoplasia (VIN). We can consider that, given the epidemiologi‐ cal evidence, there are two etiologic pathways for vulvar cancer: one related to older pa‐ tients, in the seventh or eighth decades of life, associated with mutations in TP53 and non-neoplastic epithelial disorders such as chronic inflammation or vulvar lichen, shows precursor lesions of differentiated VIN; the other is more common in young patients, ac‐ counts for approximately 43-60% of squamous carcinoma of the vulva, is associated with HPV infection, and is a common precursor lesion of VIN. Eighty-five to ninety percent of vulvar cancers are squamous in origin (squamous cell carcinoma); however, when con‐ sidering the embryological origin of the vulva the three germ layers different histolog‐ ic types can compose neoplasms affecting the region.

Microinvasive Carcinoma of the Cervix

There is a minimally invasive nosological entity among cervical precursor lesions and frank invasive cancer. Initially described by Mestwerdt in 1947, cases of microinvasive carcinoma of the uterine cervix represent a group of patients with better prognosis with the possibility of needing less radical treatment.1 Despite that microinvasion has been defined since the 1940s, the depth of invasion, as well as the lateral extension, are subjects of various classifications and certain controversy.

Estudo histeroscópico e anatomopatológico do endométrio de mulheres na pós-menopausa com câncer de mama, antes e após o uso de tamoxifeno

Objetivo : avaliar a influencia do tamoxifeno no aspecto histeroscopico do endometrio de pacientes com câncer de mama na pos-menopausa por meio da histeroscopia. Metodo: Estudaram-se, prospectivamente, 46 pacientes, das quais 20 utilizaram a droga por periodo medio de 12 meses. Efetuou-se, antes e apos o tratamento pelo farmaco, a histeroscopia associada a biopsia endometrial. Resultados: A taxa de endometrio ativo antes e apos a hormonioterapia adjuvante com tamoxifeno foi a mesma , atingindo 10,0(por cento). Conclusao: A hormonioterapia adjuvante com tamoxifeno nao aumentou a taxa de atividade proliferativa em pacientes com câncer de mama na pos-menopausa. Observaram-se numerosas vesiculas disseminadas po toda a cavidade uterina e isso constituiu o aspecto histeroscopico mais usual, talvez devido a atrofia cistica do endometrio