Theresa Freeman-Wang

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.

Colposcopy in special circumstances: Pregnancy, immunocompromise, including HIV and transplants, adolescence and menopause

The true value of colposcopy in pregnancy is under debate; the examination may be more difficult depending on the gestation at which a woman presents. Cervical intraepithelial neoplasia does not have an accelerated progression during pregnancy, and treatment is usually deferred until postpartum. The prevalence of cervical intraepithelial neoplasia is greater in women with immune compromise. Those with human immunodeficiency have a higher prevalence, more persistence and less regression of human papillomavirus-related infections. Cervical cancer remains an AIDS-defining illness. Women who have had renal transplants also have a higher risk of developing cervical intraepithelial neoplasia. By contrast, other chronic illnesses that require immunosuppressant therapy do not seem to show this added risk. In young women, human papillomavirus infection is common and cervical intraepithelial neoplasia is also evident, but regression of these lesions is frequent and so conservative review may be appropriate. At the menopause, colposcopy is often unsatisfactory. The use of human papillomavirus testing for triage of low-grade cytological abnormalities may benefit this age group.

Post-coital bleeding: a rare and unusual presentation of cervical endometriosis

Introduction: Often due to benign conditions such as cervical ectopy, post-coital bleeding is a distressing symptom for the patient. However, for the clinician, the identification of the etiology is important in order to effect proper treatment. Case report: We present a case referred to the colposcopy clinic because of post-coital bleeding and a smear report of ‘groups of benign glandular cells of endometrial origin’. Colposcopy was normal but histology of an excised haemorrhagic nodule revealed endometriosis with resolution of symptoms. Conclusion: Cervical endometriosis should be considered in the differential diagnosis of post-coital bleeding with no obvious ectopy or malignancy.

Cervical cancer prevention and screening: the role of human papillomavirus testing

An organised screening programme has reduced the incidence of cervical cancer in the UK. Cervical screening aims to detect and treat premalignant, low‐ or high‐grade disease. Oncogenic or high‐risk human papillomaviruses (HR‐HPV) account for over 99.7% of cervical cancer cases; the most common subtypes are HPV‐16, 18, 31, 33 and 45. HPV vaccination was introduced as part of the childhood vaccination programme in 2008 and will probably save 400 lives per year. HPV testing is useful: in triage of women with borderline or low‐grade cytology; as a test of cure after treatment, in the management of uncertainty, and in primary HPV screening.

Cervical cancer diagnosed after simple hysterectomy for persistent abnormal cervical smears: a clinical dilemma.

review of granulosa cell tumours of the ovary cases in KKH. Singapore Medical Journal, 42, 203 – 207. Cooke I., O’Brien M., Charnock F.M., et al. (1995) Inhibin as a marker for ovarian cancer. British Journal of Cancer, 71, 1046 – 1050. Cronje H.S., Niemand I., Bam R. and Woodruff J.D. (1999) Review of the granulosa – theca cell tumours from the Emil Novak Ovarian Tumour Registry. American Journal of Obstetrics and Gynecology, 180, 323 – 327. Gershenson D.M., Morris M., Burke T.W., et al. (1996) Treatment of poor-prognosis sex cord – stromal tumours of the ovary with combination bleomycin, etoposide and cisplatin. Obstetrics and Gynecology, 87, 527 – 531. Lauszus F.F., Petersen A.C., Greisen J. and Jakobsen A. (2001) Granulosa cell tumour of the ovary: a population-based study of 37 women with stage 1 disease. Gynecologic Oncology, 81, 456 – 460. Moodley M., Moodley J. and Chikosi A.B. (2000) Ovarian carcinoma, pericardial metastasis and human immunodeficiency virus infection. International Journal of Gynecological Cancer, 10, 82 – 83. Santala M., Suvanto-Luukkonen E., Kyllonen A., et al. (2001) Hyperprolactinemia complicating juvenile granulosa cell tumour of the ovary. Gynecologic Oncology, 82, 389 – 391. Sayegh R.A., DeLellis R., Alroy J., et al. (1999) Masculinizing granulosa cell tumour of the ovary in a postmenopausal woman. A case report. Journal of Reproductive Medicine, 44, 821 – 825. Wolf J.K., Mullen J., Eifel P.J., et al. (1999) Radiation treatment of advanced or recurrent granulosa cell tumour of the ovary. Gynecologic Oncology, 73, 35 – 41. Wu L., Zhang W. and Li L. (2000) Prognostic factors in granulosa cell tumour of the ovary. Zhonghua Fu Chan Ki Za Zhi, 35, 673 – 676.

Persistent minor smear abnormalities: is large loop excision of the transformation zone (LLETZ) the solution?

This prospective observational study was carried out to evaluate the efficacy of large loop excision of the transformation zone (LLETZ) as a management strategy for women with four or more smears showing borderline changes or mild dyskaryosis. A total of 102 women with four or more smears showing minor abnormalities and no colposcopic evidence of high-grade disease opted to undergo LLETZ in preference to continued cytological surveillance. Histology of the LLETZ specimens showed 11 cases of CIN2/3, one CGIN, 32 CIN1 and 10 HPV changes. In 97 of the 102 (95%) women, the follow-up cervical smear reverted to negative.

Cytologists should be aware of these guidelines just as colposcopists should understand cytology

atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H): characteristics and histologic outcomes. Cancer 2006;108:298–305. 8. Shafi MI, Luesley DM, Jordan JA, Dunn JA, Rollason TP, Yates M. Randomised trial of immediate versus deferred treatment strategies for the management of minor cervical cytological abnormalities. Br J Obstet Gynaecol 1997;104:590–4. 9. Cullimore J, Scurr J. The abnormal glandular smear: cytologic prediction, colposcopic correlation and clinical management. J Obstet Gynaecol 2000;20:403–7. 10. Jordan J, Arbyn M, Martin-Hirsch P, et al. European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, Part 2. Cytopathology 2009;20 (in press). 11. Adams M, Jasani B, Fiander A. Human papilloma virus (HPV) prophylactic vaccination: Challenges for public health and implications for screening. Vaccine 2007; 25: 3007–13.