Maria Grazia Fallani

Carbon-dioxide Laser Vaporization of the Bartholin Gland Cyst: A Retrospective Analysis on 200 Cases

STUDY OBJECTIVE To evaluate the effectiveness of carbon-dioxide laser vaporization as definitive treatment for Bartholin gland cyst. DESIGN Retrospective analysis (Canadian Task Force classification II-3). SETTING University teaching hospital. PATIENTS A consecutive series of 200 patients with monolateral or bilateral Bartholin gland cyst. INTERVENTIONS A standardized technique of cyst vaporization performed by carbon-dioxide laser in outpatient setting and local anesthesia. MEASUREMENTS AND MAIN RESULTS Records of all patients were reviewed for anamnestic information, anatomic parameters, intraoperative and postoperative outcomes, and follow-up data. Seven patients having bilateral cyst were treated in a single session; 207 procedures were performed. The cyst mean size was 6.3 +/- 2.3 cm (95% CI 5.93-6.67). All treatments were completed in outpatient regimen and local anesthesia with a median operative time of 17 minutes (range: 7-45). Three (1.5%) cases of intraoperative major bleeding were observed. The cure rate of a single laser treatment was 95.7%. The 9 patients with recurrent disease observed during follow-up underwent carbon-dioxide laser reintervention by the same therapeutic strategy with a 100% cure rate after 2 or 3 treatments. CONCLUSION Carbon-dioxide laser vaporization of Bartholin gland cyst represents a safe and effective procedure with complete healing and positive follow-up outcomes. Further randomized trials should be conducted to confirm these findings and to establish the best surgical strategy.

CO2 laser treatment for Bartholin's gland cyst

Cystic enlargement of Bartholin’s gland is a common gynecologic problem due to inflammatory or cicatricial obstruction of the duct. When medical therapy fails, the current treatment is by cold knife surgical intervention, usually under general anesthesia and with ordinary hospitalization. The most commonly employed methods are: surgical excision, marsupialization of the cyst, incision and drainage 1 . Few data have been published so far on CO laser treatment of Bartholin’s 2 gland cysts and such data are related to a small number of patients 2,3 . The purpose of this retrospective study is to evaluate CO laser treat2 ment when used for excisional and ablative procedures in the treatment of Bartholin’s gland cyst. Ž During the study-period January 1994 July . 1999 , 111 patients underwent CO laser treat2 ment in day-surgery after local anesthesia by in-

PCR detection rates of high risk human papillomavirus DNA in paired self-collected urine and cervical scrapes after laser CO2 conization for high-grade cervical intraepithelial neoplasia

OBJECTIVE To compare the PCR detection rates of high risk human papillomavirus DNA in self-collected urine and cervical scrapes during follow-up of patients treated for HG-CIN by laser CO2 conization. PATIENTS AND METHODS 52 women who submitted to laser conization for HG-CIN were enrolled into this prospective follow-up study receiving liquid-based cytology and HR-HPV testing by PCR assay on self-collected urine and cervical scrapes before and at 3, 6 and 12 months after treatment. Diagnostic accuracy and predictive values for treatment failure were evaluated for both urinary and cervical HPV testing and follow-up cytology. RESULTS 3 cases (5.8%) of recurrent HG-CIN occurred during follow-up. Positive margins and HR-HPV persistence resulted to significant risk factors for recurrence (p=0.01). The overall concordance on HR-HPV detection between paired urine and cervical samples was 96.6% and discord trend between agreement rates during follow-up were excluded by overall fixed-effect index (OR 1.03; 95% CI 0.62-1.70). No difference was observed comparing the three- and six-month cumulative sensitivity and NPV for recurrent disease of urinary and cervical HPV detections, with an increase of 5.6% in specificity associated with urinary testing. CONCLUSIONS PCR detection of HR-HPV in paired urine and cervical samples during follow-up revealed an excellent concordance, suggesting a potential equivalent role of the two methods within post-treatment follow-up. In our experience HPV testing on self-collected urine was more sensitive than cytology and more specific than cervical HPV detection to predict treatment failure. Larger studies are needed to definitively establish the role of urine-based HPV testing during follow-up.

Laser CO2 vaporization for high-grade cervical intraepithelial neoplasia: a long-term follow-up series

OBJECTIVE The goal of this study was to evaluate the effectiveness of laser CO(2) vaporization for conservative treatment of ectocervical high-grade cervical intraepithelial neoplasia (CIN) particularly by the evaluation of the reappearance risk of disease in long-term follow-up. METHODS One hundred fifty-nine patients were submitted to CO(2) laser vaporization for high-grade CIN and followed up for a minimum of 5 years. Selection of cases, depth of ablation, complications, and cure rate (percentage of treated patients in whom there was no recurrent/persistent high-grade CIN at the 5-year follow-up examination) were retrospectively evaluated. RESULTS Selected cases for colposcopy were submitted to a 6-mm mean depth of vaporization without intra- or postoperative complications. The cure rate for a single treatment was 97.5% and a satisfactory colposcopic follow-up was possible in 99.4% of treated patients. No case of invasive carcinoma occurred after a mean follow-up of 7.1 years. Four cases (2.5%) were high-grade CIN persistence observed after a mean time of 3.75 months, suggesting incomplete destruction of the deepest part of the lesion involving the glandular crypt base. CONCLUSIONS Long-term follow-up proves that laser CO(2) vaporization still has a place in the treatment of CIN. In selected cases it represents a safe alternative for conization in the treatment of high-grade CIN, but colposcopic expertise is essential for adequate preoperative selection of cases.

HIGH-GRADE CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN) IN PREGNANCY : CLINICOTHERAPEUTIC MANAGEMENT

An increasing incidence of cervical intraepithelial neoplasia (CIN) among young women has been noticed in recent years. For this reason pregnancy might represent a peculiar opportunity to undergo cytocolposcopic examination for those women who do not take part in a screening program for cervical carcinoma. Diagnosis of CIN during pregnancy poses the question of the management of this disease and particularly of whether it is better to treat the lesion or not during pregnancy. To contribute to the solution of this issue we initiated a study on the management of high-grade CIN in pregnancy. Material and methods Five hundred and seventy-one pregnant women underwent cytologic, colposcopic and, when necessary, histologic examination. Those in whom a CIN was discovered in the first four months of gestation underwent laser conization. When the diagnosis of CIN was made after the sixteenth week of gestation, cytocolposcopic monitoring was performed every eighth week during pregnancy and two months after childbirth. Laser conization was performed under colposcopic guidance in the outpatient setting in all cases. All treated patients were submitted to cytologic, colposcopic and, if necessary, histologic examination every third month in the first year after treatment, every sixth month in the second year and yearly from the third year onwards. Results In 14 (2.4%) of the 571 examined women a CIN III was discovered, 6 of which associated with a human papilloma virus (HPV) infection. Of these, 8 patients, whose diagnosis was made within the sixteenth week of pregnancy, underwent laser conization. In one case a minor hemorrhage occurred during treatment. Two patients reported minor bleeding up to ten days after treatment. No major hemorrhages or cervical stenosis were observed. Histologic examination of the cones confirmed the preoperative diagnosis based on cervical biopsies and the lesion was entirely removed by conization in all cases. Seven of the 8 patients who underwent laser conization during pregnancy had a spontaneous delivery at term. The remaining patient, who had had a previous cesarean section, was again delivered by cesarean section. All treated patients were cured after the first-year follow-up visit. In 6 patients CIN was diagnosed after the sixteenth week of pregnancy. These women underwent cytocolposcopic examination every eighth week during pregnancy and two months after delivery, when the cervical changes associated with gestation had disappeared. Four of these patients showed persistence of CIN at postpartum follow-up and therefore underwent laser conization. In two patients spontaneous regression of the lesion was observed. In no case did progression to invasive carcinoma occur. Conclusions Given the increasing incidence of CIN in young women, the beginning of pregnancy may represent a peculiar opportunity for all pregnant women who do not take part in cervical screening programs to undergo a cytocolposcopic examination. In case of a diagnosis of high-grade CIN within the first 16 weeks of pregnancy, a conservative excisional treatment, which does not expose the pregnancy to any risk, should be carried out in order to confirm the intraepithelial localization of the lesion.

Intralesional beta-interferon treatment of cervical intraepithelial neoplasia associated with human papillomavirus infection.

Aims and backround Interferons (IFN) have offered considerable advances in the therapy of genital warts even those associated with cervical intraepithelial neoplasia (CIN); intralesional therapy either alone or in combination with other modalities such as cryosurgery and laser surgery provides improved clearing and cure of these often recalcitrant lesions. The purpose of this study was to evaluate the effectiveness of intralesional IFN therapy in patients with CIN associated with human papillomavirus (HPV) infection. Methods Beta-IFN was injected intra-perilesionally into the cervix in 41 patients with CIN associated with HPV infection. Results The regimen of 3 million international units (IU) injected intralesionally daily in the 1st week and 3 times a week in the 2nd and 3rd weeks for a total of 11 injections and a total dosage of 33 million IU yielded an 80 percent cure rate and may be more advantageous than other treatment options in certain instances. Cytocolposcopic and histologic examination was carried out before and after treatment and 24 lesions were also analyzed for type-specific papillomaviruses using in situ DNA hybridization. CIN disappeared in 33 patients 6 months after the end of therapy. Side effects of intralesional IFN therapy are dose related and for the most part readily tolerated. Conclusions Intralesional IFN proved to be effective treatment for CIN associated with HPV infection (cure rate: 80%) and well accepted because hospitalization is not required and no important side effects occur.

Feasibility and outcome of laser CO2 conization performed within the 18th week of gestation

The purpose of this study is to evaluate the feasibility, safety, and potential therapeutic benefit of laser CO2 conization of the cervix for in situ and minimally invasive carcinoma diagnosed during pregnancy. Twenty-six pregnant patients with biopsy-proven carcinoma in situ/cervical intraepithelial neoplasia III but colposcopically suspicious for invasion underwent laser CO2 conization during the 18th week of gestation in an outpatient setting under local anesthesia. No major intraoperative or postoperative complications occurred, and cervical cerclage was not required in any case. Two cases (7.7%) of occult FIGO stage IA1 minimally invasive cervical cancers with free surgical margins were diagnosed. Both patients delivered vaginally at term and were free of disease at postpartum follow-up. Median length of gestation was 39.1 weeks with a median birth weight of 3450 g. All 1-min Apgar scores were 8 or greater. Twenty patients (76.9%) delivered vaginally, while six patients underwent cesarean section for indications not related to the prior conization. After a mean postpartum follow-up of 18 months (range 3–42), 92.3% of patients continued to have both cytologic and colposcopic evaluations negative for persistent or recurrent disease. Two cases of persistent intraepithelial disease were successfully managed by reconization. In summary, our data suggest that laser CO2 conization performed within the 18th week of gestation is safe for both the patient and the fetus, provides reliable histologic diagnosis, and can be curative. Further studies are required to confirm the favorable risk–benefit ratio of laser CO2 conization in the management of non-reassuring cervical lesions observed in the first half of pregnancy.

HPV-related cervical disease and oropharyngeal cancer

Human papillomavirus (HPV), especially HPV 16, is associated with the development of both cervical and oral cancer. We show the case of a woman affected by HPV-related cervical disease and oropharyngeal squamous cell carcinoma (OPSCC). A 41-year-old woman arrived at our Colposcopy Center following an abnormal Pap smear result (ASC-H) and a diagnosis of moderate cervical dysplasia obtained by a cervical biopsy. She underwent a colposcopy that showed a cervical abnormal transformation zone grade 2. A laser conization was performed in November 2010. Histology reported a moderate/severe dysplasia. The cone resection margins were free. Follow-up colposcopy and cytology were negative. The HPV testing showed an infection by HPV 16. In October 2012, the patient presented to the Head–Neck ER after episodes of hemoptysis; a lesion was found in the left tonsillar lodge. A biopsy was performed with a result of squamous cell carcinoma with low-grade differentiation. The HPV testing detected a high-risk HPV and the immunohistochemical analysis was positive for p16. She was treated by chemotherapy and brachytherapy. She was followed at the head–neck center with monthly visits with oral visual inspection that showed complete absence of mucosal abnormalities. HPV-related OPSCC and cervical precancerous/cancerous lesions have significant similarities in terms of pathogenesis. They are both caused largely by HPV 16, as in the present case. In conclusion, because of this association found in literature and in our case, we think that women with HPV cervical lesions should have regular surveillance for oropharyngeal cancer, whereas women with OPSCC should be encouraged to have diligent cervical screening.

Management of cervical intraepithelial neoplasia: the role of biopsy

Colposcopically directed biopsy is the standard procedure to assess the severity of cervical lesions in women with abnormal cytological screening results. Because of a significant inter-observer disagreement in the identification of the site of most severe abnormalities, the reliability of biopsy findings in preoperative histological evaluation of cervical intraepithelial neoplasia(CIN) has recently been questionedw1,2x. To clarify the role of punch biopsy in the management of cervical pathology, the histological findings of 942 laser conizations, performed from 1988 to 2001 at the authors’ institution, were compared with the preoperative histologic laboratory results obtained from colposcopically directed biopsy(Table 1). The concordance between preoperative histologic findings and final diagnosis exceeded 50% only in cases of microinvasive carcinomas (90%) and grade 3 CINs(70.4%), while it did not reach 30% for CINs of a lower grade. The diagnosis based on punch biopsy results was consistent with the final diagnosis in 53.4%

Colposcopic patterns of vaginal intraepithelial neoplasia: a study from the Italian Society of Colposcopy and Cervico-Vaginal Pathology.

The aim of this study was to evaluate the colposcopic patterns observed in women with a histopathological diagnosis of vaginal intraepithelial neoplasia (VaIN). The medical charts and the colposcopy records of women diagnosed with VaIN from January 1995 to December 2013 were analysed in a multicentre retrospective case series. The abnormal colposcopic patterns observed in women with VaIN1, VaIN2 and VaIN3 were compared. The vascular patterns and micropapillary pattern were considered separately. A grade II abnormal colposcopic pattern was more commonly observed in women with a biopsy diagnosis of VaIN3 rather than with VaIN1 or VaIN2 (P<0.001). Vascular patterns were also more common in women with VaIN3 rather than with VaIN1 or VaIN2 (P<0.001). Moreover, in women with grade I colposcopy, the rate of VaIN3 was significantly higher when a vascular pattern was observed (62.5 vs. 37.5%; P=0.04). The micropapillary pattern was more common in women with grade I colposcopy and it was more frequently observed in women with VaIN1 rather than in those with VaIN2 or VaIN3 (P<0.001). Grade II abnormal colposcopic pattern was more commonly observed in women with VaIN3. Moreover, the detection of vascular patterns appeared to be associated with more severe disease (VaIN3) even in women with grade I colposcopy, whereas the micropapillary pattern should be considered an expression of a less severe disease (VaIN1 and VaIN2).