- Email: [email protected]
Positive margins after cervical conization as an indicator of residual dysplasia
ONCOLOGY, DYSPLASIA, AND CYTOPATHOLOGY Methods: A case of cervical malignant melanoma treated at our institution was prospectively followed until her death. An extensive MEDLINE search was then performed to obtain all previous case reports on this entity. Information regarding age, clinical presentation, staging, pathology, lymphnode status, treatment, and survival was reviewed. Results: Our patient is a 70-year old white female who presented with a 4-month history of irregular vaginal bleeding. She was diagnosed with malignant melanoma of the cervix, stage IIa, for which she underwent a modified radical hysterectomy, partial vaginectomy, and pelvic and paraaortic lymph node dissection. She received adjuvant radiation therapy to the pelvis, total dose of 4500 cGy. The patient’s survival was 29 months. There have been only 24 published cases of primary cervical melanoma in the medical literature. The patients’ ages ranged from 39 to 78 years old. The main presenting symptom was vaginal bleeding (67%). The majority of the patients, 58%, presented in early stages (Ia to IIa). Treatment was varied, ranging from a simple excision of a mass to radical hysterectomy with lymph node dissection and adjuvant radiation or chemotherapy. Survival was widespread, even within the same stage. Conclusion: Cervical melanoma is a rare disease of which no prospective or retrospective studies exist, only case reports. Treatment controversies exist. We recommend radical surgical excision to obtain negative margins and lymphadenectomy only for grossly positive nodes. The prognosis is poor and unpredictable.
A randomized prospective study of the use of endometrial ablation for prevention of recurrent endometrial polyps in breast cancer patients receiving tamoxifen Motti Goldenberg, Ceana Nezhat, Daniel S. Seidman Department of Ob/Gyn, Sheba Medical Center, TelHashomer, Israel, and Tel-Aviv University, Israel, and Department of Gyn/Ob, Stanford University School of Medicine, Stanford, California, and Center for Special Pelvic Surgery, Atlanta, Georgia Objective: To assess the roles of endometrial ablation in prevention of recurrence of tamoxifen-associated endometrial polyps in breast cancer patients. Design: A randomized prospective study of tamoxifen-treated patients who underwent hysteroscopic removal of endometrial polyps with or without simultaneous resection of the endometrium. Materials and Methods: Twenty consecutive women (aged 43– 61 years) undergoing hysteroscopic removal of tamoxifen-associated endometrial polyps were randomized via a computer-generated random table to undergo or not to undergo concomitant endometrial ablation. All patients had 160
undergone endometrial sampling prior to the procedure. The patients were followed for at least 18 months (range 18 –24 months). The follow-up included transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps while the occurrence of uterine bleeding was noted. Results: In the 10 study group women, who underwent endometrial ablation, only 1 patient had a 1 3 1 cm endometrial polyp diagnosed and removed during the follow-up period. Seven of the study women remained amenorrheic, and 3 experienced spotting a few days every month. In the control group, a recurrent endometrial polyp, necessitating hysteroscopic removal, was diagnosed postoperatively in 6 women (two-tailed Fisher’s Exact test; P , .06). Conclusion: Recurrence of endometrial polyps, one of the most common problems in breast cancer patients receiving long-term treatment with tamoxifen, can be significantly reduced by performing endometrial ablation at the time of hysteroscopic removal of the polyp. The possible risk of occult endometrial cancer is yet to be determined.
Positive margins after cervical conization as an indicator of residual dysplasia Melinda Huang, MD, Patrick Anderson, MD Albert Einstein College of Medicine—West Campus, Montefiore Medical Center, Department OB/GYN, Bronx, New York Objective: To determine the significance of positive margins of resection after cervical conization as an indicator of residual dysplasia. Materials and Methods: A retrospective analysis for patients who underwent cervical conization either by loop electrosurgical excision procedure or cold knife conization between 1986 and 1997 at Montefiore Medical Center and North Central Bronx Hospital. The factors evaluated included grade of dysplasia with respect to positive or negative margins and post-procedure follow-up. Differences among groups were evaluated using the x2 and Fisher’s Exact test. Results: Of a total of 179 patients, 99 had positive margins of resection and 80 had negative margins of resection. Twentysix patients had CIN I, of which 10 had positive margins of resection and 16 had negative margins of resection. There were 30 patients with CIN II, of which 13 had positive margins and 17 had negative margins. One hundred fourteen patients had CIN III/carcinoma in situ (CIS), of which 68 had positive margins of resection while 46 had negative margins of resection. Nine patients had microinvasive disease (MIC), of which 8 had positive margins of resection and 1 had negative margin of resection. The correlation between higher grades of dysplasia and the likelihood of having positive margins was noted to be statistically significant (P 5 .02). Patients were followed up from a period of 6 weeks to 5 years. Of the patients with CIN I and positive margins, 5 had a Prim Care Update Ob/Gyns
ONCOLOGY, DYSPLASIA, AND CYTOPATHOLOGY normal post-cone Papanicolaou smear while 2 had an abnormal post-cone Papanicolaou smear. Seven of 9 patients with CIN II and positive margins had normal initial post-procedure Papanicolaou smear while only 2 had abnormal initial post follow-up Papanicolaou smear. Twenty-five patients with CIN III/CIS and positive margins had normal Papanicolaou smears at their initial post-procedure follow-up while 36 patients had an abnormal initial follow-up. Six of 8 patients with MIC and positive margins had documented follow-up. Of these 6, 2 had normal post-procedure Papanicolaou smears while 4 had abnormal post-procedure Papanicolaou smears. This approaches statistical significance. Additionally, the incidence of residual disease was analyzed in hysterectomy specimens with respect to grade of dysplasia. No patients with CIN I and positive margins were treated with hysterectomy. Of the 3 patients with CIN II treated with hysterectomy, 2 had residual dysplasia. Of the 21 patients with CIN II/CIS who underwent hysterectomy, 10 had residual disease. Of the 5 patients with MIC who underwent hysterectomy, 3 had residual disease. Conclusion: The likelihood of positive margins of resection increases with higher dysplasia. The incidence of abnormal initial post-procedure Papanicolaou smear appears to be increased with increasing grade of dysplasia. Interestingly, there does not appear to be an increase in the incidence of residual dysplasia when hysterectomy is performed for positive margin of resection after conization for high grade dysplasia.
Poor correlation of high-grade cervical dysplasia with referral cytology: clinical implications
percentage of cancer cases had preceding HGSIL cytology (6 of 8 cases at least HGSIL, 75%). Conclusion: High-grade cervical neoplasia was more likely to be discovered following colposcopic triage of “minor” Papanicolaou smear abnormalities (ASCUS or LGSIL). The false negative rate of a single Papanicolaou smear to detect dysplasia may be as high as 65% (with specificity at the 90% range) (Fahey MT, Irwig L, Macaskill P. Meta analysis of Pap test accuracy. Am J Epidemiol 1995;141:7:680 –9), making cytology an inaccurate diagnostic replacement for colposcopy. We should rethink the significance of minimally abnormal Papanicolaou smears when designing triage protocols that delay or eliminate colposcopy based on the Bethesda Grading System alone.
Evaluation of the cone biopsy excisor compared with the large loop for electrosurgical excision of cervical lesions Nathan R. Fischer, MD, FACOG Asst. Prof. OB/GYN, University of Connecticut, Attending, Hartford Hospital, St. Francis Hospital and Medical Center, Hartford, Connecticut David Alexandarian, MD, Stephen Gagliardi, MD, John Oglesby, MD, Dennis Scribner, MD, Celedonio Asuncion, MD, Thalia Mesologitis, MD St. Francis Hospital and Medical Center, Hartford, Connecticut Data incorporated from August 1994 to July 30, 1997.
Neal M. Lonky, MD, MPH Kaiser Permanente, Anaheim, and the University of California Irvine School of Medicine, Irvine, California Mashood Sadeghi, MD, Girma Wolde Tsadik, PhD
Objective: To compare a newly designed triangular electrode, the Cone Biopsy Excisor™ to the loop electrode with respect to the margin evaluation, fragmentation, and thermal damage of the conization specimen.
Objective: We questioned the diagnostic utility of cervical cytology by studying whether women with colposcopically guided biopsy proven high-grade cervical dysplasia or cancer had referral cytology results that correlated highly with their disease.
Methods: After approval by the Institutional Review Boards of Hartford Hospital, St. Francis Hospital, and New Britain General Hospital/University of Connecticut, patients were randomly assigned to undergo conization with the Cone Biopsy Excisor or with the large loop. Inclusion criteria included biopsy proven CIN II, CIN III, inadequate colposcopy, positive endocervical curettage, or cytohistological discrepancy. Exclusion criteria included pregnancy, undiagnosed uterine bleeding, and invasive carcinoma. The procedures were performed by senior residents on clinic patients at the respective institutions. In addition, after FDA approval November 18, 1996, private OB/GYN practitioners performed cases and added those results to the study. Seventy-eight patients were randomized to the Cone Biopsy Excisor, while 77 patients were randomized to the loop electrosurgical excision procedure (LEEP). To obtain the surgical specimen, Force 2 Valley Lab generators were used with wattage ranging from 35 to 50 according to the size of the instrument chosen, 40/60 blend of coagulation, and cutting current. Pathology reports were reviewed to determine the amount of fragmentation that occurred during the procedure and for
Methods: All women with any cytologic abnormality or visible lower tract lesion(s) are referred for colposcopic examination. Ten thousand visits to our colposcopy clinic were prospectively collected, tracked, and reviewed, which revealed 566 cases of high-grade dysplasia and 8 cancers on biopsy. The proportion of high grade disease that was discovered by high grade cytology was measured. Results: The diagnosis of high grade cervical disease was not preceded by high-grade cytology (HGSIL) or “rule out cancer” cytology result (n 5 95, 16.8%) in the majority of cases (P , .0001, x2). High-grade disease was more often preceded by low-grade cytology (LGSIL) (n 5 224, 39.5%), followed by atypical Papanicolaou smears (ASCUS) (n 5 220, 38.9%) and visible cervical or vaginal lesion(s) (n 5 27, 4.8%). A very high Volume 5, Number 4, 1998
161
A randomized prospective study of the use of endometrial ablation for prevention of recurrent endometrial polyps in breast cancer patients receiving tamoxifen Motti Goldenberg, Ceana Nezhat, Daniel S. Seidman Department of Ob/Gyn, Sheba Medical Center, TelHashomer, Israel, and Tel-Aviv University, Israel, and Department of Gyn/Ob, Stanford University School of Medicine, Stanford, California, and Center for Special Pelvic Surgery, Atlanta, Georgia Objective: To assess the roles of endometrial ablation in prevention of recurrence of tamoxifen-associated endometrial polyps in breast cancer patients. Design: A randomized prospective study of tamoxifen-treated patients who underwent hysteroscopic removal of endometrial polyps with or without simultaneous resection of the endometrium. Materials and Methods: Twenty consecutive women (aged 43– 61 years) undergoing hysteroscopic removal of tamoxifen-associated endometrial polyps were randomized via a computer-generated random table to undergo or not to undergo concomitant endometrial ablation. All patients had 160
undergone endometrial sampling prior to the procedure. The patients were followed for at least 18 months (range 18 –24 months). The follow-up included transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps while the occurrence of uterine bleeding was noted. Results: In the 10 study group women, who underwent endometrial ablation, only 1 patient had a 1 3 1 cm endometrial polyp diagnosed and removed during the follow-up period. Seven of the study women remained amenorrheic, and 3 experienced spotting a few days every month. In the control group, a recurrent endometrial polyp, necessitating hysteroscopic removal, was diagnosed postoperatively in 6 women (two-tailed Fisher’s Exact test; P , .06). Conclusion: Recurrence of endometrial polyps, one of the most common problems in breast cancer patients receiving long-term treatment with tamoxifen, can be significantly reduced by performing endometrial ablation at the time of hysteroscopic removal of the polyp. The possible risk of occult endometrial cancer is yet to be determined.
Positive margins after cervical conization as an indicator of residual dysplasia Melinda Huang, MD, Patrick Anderson, MD Albert Einstein College of Medicine—West Campus, Montefiore Medical Center, Department OB/GYN, Bronx, New York Objective: To determine the significance of positive margins of resection after cervical conization as an indicator of residual dysplasia. Materials and Methods: A retrospective analysis for patients who underwent cervical conization either by loop electrosurgical excision procedure or cold knife conization between 1986 and 1997 at Montefiore Medical Center and North Central Bronx Hospital. The factors evaluated included grade of dysplasia with respect to positive or negative margins and post-procedure follow-up. Differences among groups were evaluated using the x2 and Fisher’s Exact test. Results: Of a total of 179 patients, 99 had positive margins of resection and 80 had negative margins of resection. Twentysix patients had CIN I, of which 10 had positive margins of resection and 16 had negative margins of resection. There were 30 patients with CIN II, of which 13 had positive margins and 17 had negative margins. One hundred fourteen patients had CIN III/carcinoma in situ (CIS), of which 68 had positive margins of resection while 46 had negative margins of resection. Nine patients had microinvasive disease (MIC), of which 8 had positive margins of resection and 1 had negative margin of resection. The correlation between higher grades of dysplasia and the likelihood of having positive margins was noted to be statistically significant (P 5 .02). Patients were followed up from a period of 6 weeks to 5 years. Of the patients with CIN I and positive margins, 5 had a Prim Care Update Ob/Gyns
ONCOLOGY, DYSPLASIA, AND CYTOPATHOLOGY normal post-cone Papanicolaou smear while 2 had an abnormal post-cone Papanicolaou smear. Seven of 9 patients with CIN II and positive margins had normal initial post-procedure Papanicolaou smear while only 2 had abnormal initial post follow-up Papanicolaou smear. Twenty-five patients with CIN III/CIS and positive margins had normal Papanicolaou smears at their initial post-procedure follow-up while 36 patients had an abnormal initial follow-up. Six of 8 patients with MIC and positive margins had documented follow-up. Of these 6, 2 had normal post-procedure Papanicolaou smears while 4 had abnormal post-procedure Papanicolaou smears. This approaches statistical significance. Additionally, the incidence of residual disease was analyzed in hysterectomy specimens with respect to grade of dysplasia. No patients with CIN I and positive margins were treated with hysterectomy. Of the 3 patients with CIN II treated with hysterectomy, 2 had residual dysplasia. Of the 21 patients with CIN II/CIS who underwent hysterectomy, 10 had residual disease. Of the 5 patients with MIC who underwent hysterectomy, 3 had residual disease. Conclusion: The likelihood of positive margins of resection increases with higher dysplasia. The incidence of abnormal initial post-procedure Papanicolaou smear appears to be increased with increasing grade of dysplasia. Interestingly, there does not appear to be an increase in the incidence of residual dysplasia when hysterectomy is performed for positive margin of resection after conization for high grade dysplasia.
Poor correlation of high-grade cervical dysplasia with referral cytology: clinical implications
percentage of cancer cases had preceding HGSIL cytology (6 of 8 cases at least HGSIL, 75%). Conclusion: High-grade cervical neoplasia was more likely to be discovered following colposcopic triage of “minor” Papanicolaou smear abnormalities (ASCUS or LGSIL). The false negative rate of a single Papanicolaou smear to detect dysplasia may be as high as 65% (with specificity at the 90% range) (Fahey MT, Irwig L, Macaskill P. Meta analysis of Pap test accuracy. Am J Epidemiol 1995;141:7:680 –9), making cytology an inaccurate diagnostic replacement for colposcopy. We should rethink the significance of minimally abnormal Papanicolaou smears when designing triage protocols that delay or eliminate colposcopy based on the Bethesda Grading System alone.
Evaluation of the cone biopsy excisor compared with the large loop for electrosurgical excision of cervical lesions Nathan R. Fischer, MD, FACOG Asst. Prof. OB/GYN, University of Connecticut, Attending, Hartford Hospital, St. Francis Hospital and Medical Center, Hartford, Connecticut David Alexandarian, MD, Stephen Gagliardi, MD, John Oglesby, MD, Dennis Scribner, MD, Celedonio Asuncion, MD, Thalia Mesologitis, MD St. Francis Hospital and Medical Center, Hartford, Connecticut Data incorporated from August 1994 to July 30, 1997.
Neal M. Lonky, MD, MPH Kaiser Permanente, Anaheim, and the University of California Irvine School of Medicine, Irvine, California Mashood Sadeghi, MD, Girma Wolde Tsadik, PhD
Objective: To compare a newly designed triangular electrode, the Cone Biopsy Excisor™ to the loop electrode with respect to the margin evaluation, fragmentation, and thermal damage of the conization specimen.
Objective: We questioned the diagnostic utility of cervical cytology by studying whether women with colposcopically guided biopsy proven high-grade cervical dysplasia or cancer had referral cytology results that correlated highly with their disease.
Methods: After approval by the Institutional Review Boards of Hartford Hospital, St. Francis Hospital, and New Britain General Hospital/University of Connecticut, patients were randomly assigned to undergo conization with the Cone Biopsy Excisor or with the large loop. Inclusion criteria included biopsy proven CIN II, CIN III, inadequate colposcopy, positive endocervical curettage, or cytohistological discrepancy. Exclusion criteria included pregnancy, undiagnosed uterine bleeding, and invasive carcinoma. The procedures were performed by senior residents on clinic patients at the respective institutions. In addition, after FDA approval November 18, 1996, private OB/GYN practitioners performed cases and added those results to the study. Seventy-eight patients were randomized to the Cone Biopsy Excisor, while 77 patients were randomized to the loop electrosurgical excision procedure (LEEP). To obtain the surgical specimen, Force 2 Valley Lab generators were used with wattage ranging from 35 to 50 according to the size of the instrument chosen, 40/60 blend of coagulation, and cutting current. Pathology reports were reviewed to determine the amount of fragmentation that occurred during the procedure and for
Methods: All women with any cytologic abnormality or visible lower tract lesion(s) are referred for colposcopic examination. Ten thousand visits to our colposcopy clinic were prospectively collected, tracked, and reviewed, which revealed 566 cases of high-grade dysplasia and 8 cancers on biopsy. The proportion of high grade disease that was discovered by high grade cytology was measured. Results: The diagnosis of high grade cervical disease was not preceded by high-grade cytology (HGSIL) or “rule out cancer” cytology result (n 5 95, 16.8%) in the majority of cases (P , .0001, x2). High-grade disease was more often preceded by low-grade cytology (LGSIL) (n 5 224, 39.5%), followed by atypical Papanicolaou smears (ASCUS) (n 5 220, 38.9%) and visible cervical or vaginal lesion(s) (n 5 27, 4.8%). A very high Volume 5, Number 4, 1998
161