Maria Aparecida Tristão

Recurrence of cervical intraepithelial neoplasia grades 2 or 3 in HIV-infected women treated by large loop excision of the transformation zone (LLETZ)

CONTEXT AND OBJECTIVE Women infected by HIV are more likely to have cervical cancer and its precursors. Treatment of the precursor lesions can prevent this neoplasia. The aim of this study was to assess the likelihood of recurrent cervical intraepithelial neoplasia grades 2 or 3 (CIN 2-3) in HIV-infected women, compared with HIV-negative women, all treated by large loop excision of the transformation zone (LLETZ). DESIGN AND SETTING A cohort study in Instituto Fernandes Figueira, Fundação Oswaldo Cruz (IFF-Fiocruz), Rio de Janeiro. METHOD 55 HIV-positive and 212 HIV-negative women were followed up after LLETZ for CIN 2-3 (range: 6-133 months). RESULTS The incidence of recurrent CIN 2-3 was 30.06/10,000 woman-months in the HIV-positive group and 4.88/10,000 woman-months in the HIV-negative group (relative risk, RR = 6.16; 95% confidence interval, CI: 2.07-18.34). The likelihood of recurrence reached 26% at the 62nd month of follow-up among the HIV-positive women, and remained stable at almost 0.6% at the 93rd month of follow-up among the HIV-negative women. We were unable to demonstrate other prognostic factors relating to CIN recurrence, but the use of highly active antiretroviral therapy (HAART) may decrease the risk of this occurrence among HIV patients. CONCLUSION After LLETZ there is a higher risk of recurrence of CIN 2-3 among HIV-positive women than among HIV-negative women. This higher risk was not influenced by margin status or grade of cervical disease treated. The use of HAART may decrease the risk of this occurrence in HIV patients.

Recurrence of cervical intraepithelial neoplasia in human immunodeficiency virus-infected women treated by means of electrosurgical excision of the transformation zone (LLETZ) in Rio de Janeiro, Brazil

CONTEXT AND OBJECTIVE Human immunodeficiency virus (HIV)-infected women have higher incidence, prevalence, persistence and recurrence of pre-invasive cervical lesions (CIN II or III). The aim here was to investigate the risk of recurrence of CIN II/III among HIV-infected women (HIV+) and uninfected women in a cohort treated by means of large-loop excision of the transformation zone (LLETZ). DESIGN AND SETTING Cohort study conducted at Instituto Fernandes Figueira/Fundação Oswaldo Cruz (IFF/Fiocruz). METHODS 60 HIV+ and 209 HIV-negative patients were included in a cohort for follow-up after undergoing LLETZ to treat CIN II/III. A histopathological diagnosis of CIN II/III during the follow-up was taken to constitute recurrence. The following possible confounding variables were assessed: age at treatment and at end of follow-up; histological grade of intraepithelial disease treated; surgical margin involvement; adequacy of colposcopy during the follow-up; CD4+ lymphocyte count; HIV viral load; and type of antiretroviral therapy. RESULTS Among the 60 HIV+ women, six showed recurrent disease during the follow-up. However, among the 209 HIV-negative women, seven showed a new precursor lesion. The relative risk of disease recurrence in the HIV+ women was 4.21 (95% CI = 1.42 to 12.43). The Kaplan-Meyer curve showed that the risk of recurrence was significantly higher among HIV+ women (log-rank test: P = 0.0111). CONCLUSION The HIV+ women in our cohort presented a risk of CIN II/III recurrence at least 42% higher than among the HIV-negative women. These patients should form part of a rigorous screening and follow-up protocol for identification and appropriate treatment of cervical cancer precursor lesions.

Prevalence of cervical intraepithelial neoplasia grades II/III and cervical cancer in patients with cytological diagnosis of atypical squamous cells when high-grade intraepithelial lesions (ASC-H) cannot be ruled out

CONTEXT AND OBJECTIVE The latest update of the Bethesda System divided the category of atypical squamous cells of undetermined significance (ASCUS) into ASC-US (undetermined significance) and ASC-H (high-grade intraepithelial lesion cannot be ruled out). The aims here were to measure the prevalence of pre-invasive lesions (cervical intraepithelial neoplasia, CIN II/III) and cervical cancer among patients referred to Instituto Fernandes Figueira (IFF) with ASC-H cytology, and compare them with ASC-US cases. DESIGN AND SETTING Cross-sectional study with retrospective data collection, at the IFF Cervical Pathology outpatient clinic. METHODS ASCUS cases referred to IFF from November 1997 to September 2007 were reviewed according to the 2001 Bethesda System to reach cytological consensus. The resulting ASC-H and ASC-US cases, along with new cases, were analyzed relative to the outcome of interest. The histological diagnosis (or cytocolposcopic follow-up in cases without such diagnosis) was taken as the gold standard. RESULTS The prevalence of CIN II/III in cases with ASC-H cytology was 19.29% (95% confidence interval, CI, 9.05-29.55%) and the risk of these lesions was greater among patients with ASC-H than with ASC-US cytology (prevalence ratio, PR, 10.42; 95% CI, 2.39-45.47; P = 0.0000764). Pre-invasive lesions were more frequently found in patients under 50 years of age with ASC-H cytology (PR, 2.67; 95% CI, 0.38-18.83); P = 0.2786998). There were no uterine cervical cancer cases. CONCLUSION The prevalence of CIN II/III in patients with ASC-H cytology was significantly higher than with ASC-US, and division into ASC diagnostic subcategories had good capacity for discriminating the presence of pre-invasive lesions.

Prevalência das lesões intra-epiteliais de alto grau em pacientes com citologia com diagnóstico persistente de ASCUS

OBJETIVO: verificar a prevalencia de lesoes intra-epiteliais de alto grau (LIAG) e câncer invasor em mulheres com citologia com diagnostico de ASCUS (atipias em celulas escamosas de significado indeterminado) persistente apos 6 meses e verificar se a idade e fator indicador para a existencia destas lesoes neste grupo de mulheres. METODOS: foram incluidos 215 casos de mulheres nao-gestantes e HIV-negativas com diagnostico de ASCUS (sem especificacao) persistente em duas citologias com intervalo minimo de 6 meses. Tais resultados foram confrontados com o resultado histologico de biopsias, exereses da zona de transformacao (large loop excision of the transformation zone) ou cones. Foram considerados negativos para LIAG ou câncer quando a colposcopia foi satisfatoria e sem alteracoes ou quando, apesar de insatisfatoria, nao foi detectada lesao em pelo menos um seguimento citologico e colposcopico. Para estabelecer a prevalencia de lesoes, calculamos a frequencia de diagnosticos com seus respectivos intervalos de confianca a 95% (IC 95%). Para analise estatistica da diferenca de proporcoes de LIAG ou câncer em cada faixa de idade, foi utilizado teste do c2, e ainda estimamos o risco destas lesoes entre mulheres com mais de 35 anos pela razao de prevalencias com seu IC 95%. RESULTADOS: encontramos um total de negativos de 49,3% dos casos (IC 95%: 42,6-55,9). A prevalencia de lesoes intra-epiteliais de baixo grau foi de 38,6% (IC 95%: 32,1-45,1) e de LIAG de 10,7% (IC 95%: 6,5-14,8). Casos de câncer foram encontrados em 1,4% das pacientes (IC 95%: 0-2,9). Nao foi possivel estabelecer, de forma significativa, maior risco de LIAG/câncer considerando o corte de idade em 35 anos. CONCLUSAO: a prevalencia de LIAG/câncer encontrada em nosso estudo mostra que o risco de encontrarmos este tipo de lesao em mulheres atendidas no Sistema Unico de Saude em nosso municipio com duas citologias com diagnostico de ASCUS e de cerca de 12%. Nao foi possivel evidenciar maior probabilidade de LIAG/câncer em qualquer das faixas etarias analisadas, porem este resultado pode ter sido limitado pelo pequeno tamanho amostral.

Effectiveness of see-and-treat for approaching pre-invasive lesions of uterine cervix

OBJECTIVE To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9% (95% CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4% (95% CI: 0.04;2.7) and 5.% (95% CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0% (95% CI: 0.4;3.6). CONCLUSIONS The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.

Large loop versus straight-wire excision of the transformation zone for treatment of cervical intraepithelial neoplasia: a randomised controlled trial of electrosurgical techniques

To compare two electrosurgical techniques, straight‐wire excision of transformation zone (SWETZ) with large loop excision of transformation zone, as a cone procedure (LLETZ‐cone), for the treatment of cervical intraepithelial neoplasia (CIN), when disease is present at the cervical canal.

Hidropisia fetal: análise de 80 casos

OBJETIVO: descrever a etiologia, evolucao e prevalencia de hidropisia fetal em coorte de gestantes em 10 anos de acompanhamento (1992 a 2002), em uma maternidade terciaria. METODOS: estudo retrospectivo foi realizado em pacientes referidas para a maternidade do Instituto Fernandes Figueira com o diagnostico de hidropisia fetal, detectado pelo exame de ultra-sonografia, durante o periodo compreendido entre 1992 e 2002. Os casos foram selecionados quanto a etiologia (imune ou nao-imune), sendo comparados quanto a evolucao, procedimentos invasivos realizados e sobrevivencia. A analise das variaveis foi realizada por meio do programa Epi-Info 6.0, sendo considerado valor de significância estatistica um valor de p<0,05. RESULTADOS: durante o periodo de estudo, 80 gestantes foram atendidas com diagnostico inicial de hidropisia fetal. A frequencia de hidropisia nesta populacao foi de 1 para 157 nascidos vivos. Isoimunizacao Rh (grupo imune - GI) foi diagnosticada em 13 casos (16,2%), restando portanto 67 casos (83,8%) considerados como devidos a causas nao imunes (grupo nao imune - GNI). As causas mais comuns de hidropisia fetal nao imune sao: idiopaticas (40,2%), geneticas (20,8%), infecciosas (20,7%) e cardiopatia fetal (7,4%). Foi encontrada diferenca em relacao a idade materna do grupo imune (media = 32,8 anos) quando comparada com o grupo nao imune (media=28,7) (p=0,03), porem a idade gestacional ao nascimento foi similar em ambos os grupo, (media de 33,6 semanas no grupo imune e de 33,1 semanas no grupo nao imune (p=0,66). Amniocentese e transfusao sanguinea in utero foram realizadas com maior frequencia no grupo imune (p<0,001) e a letalidade perinatal encontrada foi de 53,8% no grupo imune e 68,6% no grupo nao imune (p=0,47). A pesquisa complementar de anticorpos IgG anti-parvovirus B19 foi realizada em 41 dos 67 casos de hidropisia fetal nao imune e somente 16 apresentaram resultado positivo. CONCLUSAO: a etiologia nao imune foi a forma mais comum de apresentacao de hidropisia fetal em nossa casuistica. A letalidade perinatal desta entidade continua elevada e uma proporcao significativa de casos nao teve causa identificada. A utilizacao da analise do cariotipo fetal e do diagnostico especifico para parvovirus B19 pode aumentar a identificacao causal de hidropisia fetal nao imune classificada como idiopatica.

A comparison between type 3 excision of the transformation zone by straight wire excision of the transformation zone (SWETZ) and large loop excision of the transformation zone (LLETZ): a randomized study

BackgroundThe management of preinvasive cervical lesions has the objective to ensure the absence of invasive lesions and to prevent progression to cancer. Excisional procedures have been preferred to treat these lesions as they report the presence of unsuspected invasive lesions and the status of surgical margins, allowing inferring full excision when such are free of disease. The purpose of this study is to determine whether Straight Wire Excision of the Transformation Zone (SWETZ) is a better alternative than Large Loop Excision of the Transformation Zone (LLETZ-cone) as a type 3 excision of the Transformation Zone (TZ) to reduce incomplete excision and concerning other outcomes of surgical interest.MethodRandomized controlled trial including women who needed type 3 excision of the TZ referred to a colposcopy clinic after cytological screening between January 2008 thru December 2011. The interventions were performed using local anesthesia and sedation in an inpatient basis by different experienced surgeons. The study enrolled and randomized 164 women, of which 82 were allocated to each group. After exclusions, 78 remained in SWETZ and 76 in LLETZ-cone groups for the analysis of outcomes of surgical interest and 52 and 54, respectively, for the margins analysis.ResultsThere was an even distribution between the groups after randomization and exclusions, concerning mean age, parity, current smoking, prior cytological diagnosis and histopathological diagnosis obtained in cone specimen even after exclusions. We observed significantly higher risk of compromised or damaged endocervical margin in specimens resulting from the LLETZ-cone in relation to SWETZ (RR 1.72, 95% CI: 1.14 to 2.6), with an absolute risk reduction (ARR) of 26.4% (95% CI: 8.1 to 44.8) for patients operated by SWETZ. The specimens obtained by SWETZ showed less fragmentation (ARR = 19.8%, 95% CI: 10.3 - 29.3%), but the procedure took longer. There were complications in 5.6% of the procedures, with no significant differences between the groups.ConclusionThis study showed a lower proportion of compromised or damaged endocervical surgical margin in specimens resulting from SWETZ in relation to LLETZ-cone. SWETZ demonstrated to be more efficient than LLETZ-cone concerning less fragmentation of the specimen obtained. However, it accounted for longer surgical time. Both techniques showed morbidityTrial registrationNumber at ClinicalTrials.gov: NCT01929993 (June 10, 2012).

Efetividade da abordagem "ver e tratar" em lesões pré-invasivas no colo uterino

OBJECTIVE To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9% (95% CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4% (95% CI: 0.04;2.7) and 5.% (95% CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0% (95% CI: 0.4;3.6). CONCLUSIONS The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.

Efectividad del abordaje "ver y tratar" en lesiones pre-invasivas en el colon uterino

OBJECTIVE To compare the effectiveness between the see-and-treat (S&T) approach and the conventional one (with prior biopsy) for squamous intraepithelial lesions of uterine cervix. METHODS A cross-sectional study was conducted with 900 nonpregnant women with cytology suggestive of high grade squamous intraepithelial lesions in the city of Rio de Janeiro, Southeastern Brazil, between 1998 and 2004. The S&T approach consists of a large loop excision of the transformation zone procedure and is recommended when cytology is suggestive of high grade squamous intraepithelial lesion, satisfactory colposcopy with abnormalities compatible with the suspected cytological results, and the lesion is limited to the ectocervix or extends up to one centimeter of the endocervical canal. A subgroup of 336 patients whose colposcopy was considered satisfactory was analyzed, and they were divided into two groups for comparison: patients treated without prior biopsy (n = 288) and patients treated after a biopsy showing high grade squamous intraepithelial lesions (n = 48). Patients who were not treated or only treated more than a year later after recruitment at the colposcopy unit were considered dropouts. RESULTS Of patients recruited during the study period, 71 were not treated or were only treated for at least a year. The overall dropout rate was 7.9% (95% CI: 6.1;9.7). Mean time elapsed between patient recruitment and treatment was 17.5 days in the S&T group and 102.5 days in the prior biopsy group. Dropout rates were 1.4% (95% CI: 0.04;2.7) and 5.% (95% CI: 0;12.3), respectively (p=0.07). The proportion of overtreated cases (negative histology) in the S&T group was 2.0% (95% CI: 0.4;3.6). CONCLUSIONS The difference in the mean time elapsed between patient recruitment and treatment indicates that S&T is a time-saving approach The proportion of negative cases from using the S&T approach can be regarded as low.