Narendra Pisal

Gestational trophoblastic disease: is intensive follow up essential in all women?

Objective  To determine the timescale of the registration process for gestational trophoblastic disease and its impact on hCG level at registration and subsequent need for chemotherapy.

Parasitic dermoid cyst managed laparoscopically in a 29-year-old woman: a case report

IntroductionDermoid cysts are one of the most frequently occurring ovarian cysts; parasitic dermoid cysts, however, are extremely rare.Case presentationWe report a case of a 29-year-old Japanese woman with an incidental finding of an adnexal mass on bimanual examination. Sonographic imaging reported an 8 cm mass in the Pouch of Douglas. This was found to be a parasitic dermoid cyst and was removed at laparoscopy.ConclusionWe believe laparoscopy to be a safe and effective means of managing parasitic ovarian dermoid cysts.

Smoking and multicentric vulval intraepithelial neoplasia

Summary This study was carried out in order to analyse the multicentric nature and anatomical distribution of vulval intraepithelial neoplasia Grade 3 (VIN3) and to assess the relationship between smoking and VIN3. This is a retrospective study of 80 women with a histologically confirmed diagnosis of VIN3. This study was carried out at a large district general and teaching hospital in North London in a dedicated vulval clinic. A total of 52 (65%) women were smokers and 54 out of the 80 (67.5%) women were diagnosed to have multicentric disease in the form of intraepithelial neoplasia in at least one other lower genital tract site (cervix, vagina or perianal region). Microinvasion at first excision was detected in 20/80 women (25%). Labia minora and fourchette were the commonest sites affected by VIN3. Only 22/80 women were cured with a single treatment, while 58 (72.5%) women needed multiple sessions of treatment. Multiple logistic regression analysis showed that smokers and women who had extensive vulval disease were also likely to have multicentric genital tract neoplasia. Women who continued to smoke after treatment were 30 times more likely to have persistent vulval disease. Women who smoke are statistically more likely to have multicentric genital tract neoplasia and a complete assessment of these cases should include proctoscopy in addition to the colposcopic examination of the cervix and vagina.

Measurement of Brn-3a levels in Pap smears provides a novel diagnostic marker for the detection of cervical neoplasia

OBJECTIVES We have previously demonstrated that Brn-3a cellular transcription factor activates transcription of the human papillomavirus (HPV) E6 and E7 oncogenes in human cervical cancer cells and that Brn-3a levels are dramatically elevated in biopsies from women with high-grade cervical neoplasia. The aim of this study was to establish the relationship between Brn-3a levels in Pap smears and the histological diagnoses. We also analysed whether Brn-3a levels can be used in combination with Pap smear to predict the presence of cervical intraepithelial lesion. METHODS Two hundred thirty-eight women who were referred with abnormal Pap smear underwent a diagnostic colposcopy, repeat in-study Pap smear, colposcopically directed biopsy, and assessment of Brn-3a and HPV-16 E6 m-RNA levels. Data were analysed to assess the association between Brn-3a levels and the histological diagnosis. RESULTS Brn-3a was readily measured in smears and showed a statistically significant correlation with the grade of cervical abnormality. Positive Brn-3a is associated with increased relative risk of higher-grade lesion. Moreover, measurement of Brn-3a levels in smears can be used to detect a significant proportion of cervical lesions that were missed by Pap smear. CONCLUSION Measurement of Brn-3a levels in routinely taken Pap smears is a feasible technique that correlates with the severity of the epithelial abnormality and is a useful adjunct to cytology. Brn-3a appears to have great promise since it detects activation of oncogenic HPVs rather than simply detecting their presence, as is currently being done.

Triage by HPV-DNA testing: is it useful in women with persistent minor smear abnormalities?

Background.  This study was carried out to evaluate the efficacy of HPV‐DNA (Human Papilloma Virus) testing as a triage strategy for persistent borderline and mild cytological abnormalities.

Bilateral hematosalpinx in a case of ectopic pregnancy: a clinical dilemma

A 31-year-old woman with a positive pregnancy test and a transvaginal ultrasound scan result that was suggestive of a right tubal ectopic pregnancy underwent a laparoscopy, which showed bilateral hematosalpinx. In the presence of active bleeding and deteriorating hemodynamic status of the patient, a minilaparotomy was performed that revealed a right-sided hematosalpinx and a left-sided ectopic gestation.

How significant is a cervical smear showing glandular dyskaryosis

OBJECTIVE To evaluate the incidence, outcome and predictive value of cytology showing glandular dyskaryosis. PARTICIPANTS Fifty-seven women with a smear diagnosis of glandular dyskaryosis registered between January 1997 and December 2001. SETTING Colposcopy and cytopathology units in a large district general hospital. RESULTS Sixty smears in 57 women showing glandular dyskaryosis were identified from a cohort of 135,120 smears, giving an incidence of 0.05%. Hospital records were available for 50 women. Final diagnosis included 13 cases of cervical glandular intraepithelial neoplasia (CGIN), 4 microinvasive cervical adenocarcinomas, 2 undifferentiated tumours, 1 microinvasive squamous carcinoma, 21 cases of CIN and 13 cases of endometrial pathology (8 endometrial cancers). Twelve women had coexistent squamous and glandular disease. Forty-five out of 50 women had significant pathology (positive predictive value 90%). Colposcopy was seen to be of limited value in assessment of smears showing glandular dyskaryosis. Only 1 out of 13 glandular lesions was diagnosed by colposcopy. CONCLUSION Smears showing glandular dyskaryosis are associated with significant pathology in 90% of cases and malignancy in 32% of cases. Hence, women with a smear showing glandular dyskaryosis should be referred urgently to a colposcopy clinic and flagged up as suspected cancer. Glandular dyskaryosis should be included in the national referral criteria for suspected gynaecological cancer.

Primary ovarian pregnancy with a levonorgestrel intrauterine system

A 26-year-old woman para 2+0 presented to the accident and emergency department with vaginal bleeding and lower abdominal pain. Her symptoms followed the insertion of a levonorgestrel intrauterine system (LNG IUS) (Mirena®) for contraception 13 weeks prior to presentation. She had continued to bleed irregularly since the insertion of the LNG IUS and had visited her general practitioner (GP) on two occasions when she was reassured that irregular vaginal bleeding and spotting are common side effects of the LNG IUS. She subsequently developed a constant dull lower abdominal pain and went to her GP who removed the LNG IUS and prescribed her a course of antibiotics. The patient presented to the accident and emergency department when her pain did not subside after 1 week. A urine pregnancy test was positive and a quantitative serum beta human chorionic gonadotrophin (s-hCG) subunit measurement was 331000 mIU/ml. A transvaginal ultrasound scan showed a bulky retroverted uterus with a heterogeneous endometrium measuring 19 mm. There was no visible intrauterine pregnancy. (excerpt)

Laparoscopic excision of a large paraovarian cyst presenting with acute lower abdominal pain.

Bonney J. (1925) Myomectomy as treatment for uterine fibroids. Lancet, ii, 1060 – 1062. Buttram V.C. and Reiter R.C. (1981) Uterine leioyomata: etiology, symptomatology and management. Fertility and Sterility, 36, 433 – 445. Day Baird D., Dunson D.B., Hill M.C., Cousins D. and Schectman J.M. (2003) High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. American Journal of Obstetrics and Gynecology, 188, 100 – 107. Iverson R.E., Chelmow D., Strohbehn K., Waldman L., Evantash R.G. and Aronson M.P. (1999) Myomectomy fever: testing the dogma. Fertility and Sterility, 72, 104 – 108. Ravina J., Herbreteau D., Ciraru-Vigneron N., Bouret J.M., Houdart E., Aymard A. and Merland JJ. (1995) Arterial embolisation to treat uterine myomata. Lancet, 346, 671 – 672. Semm K. (1979) New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy, 11, 85 – 93.

Asymptomatic vasculitis of the uterine cervix in presence of cervical intraepithelial neoplasia grade III

Case reportA 34-year-old woman was diagnosed to have a high-grade cervical intraepithelial neoplasia and was treated by large loop excision of the transformation zone. Histology of the excised cone confirmed the diagnosis but also showed evidence of vasculitis of medium-sized vessels of the cervix. The woman was referred to a physician to rule out underlying systemic disease. Extensive laboratory and clinical screening was negative.DiscussionThe clinical significance and management of asymptomatic isolated vasculitis of the uterine cervix are discussed.