Invasive inflammatory pseudotumor of uterine cervix: A case report

BACKGROUND

Inflammatory pseudotumor (IPT) of the cervix uteri has been reported in only one patient. Here, we present a case of cervical IPT with bilateral parametrial involvement causing hydroureteronephrosis.

CASE

A 48-year-old, gravida 2, para 1, woman was referred for evaluation of lower abdominal pain and right-sided hydroureteronephrosis. On speculum and colposcopic examinations, the cervix appeared normal. Computed tomography scan revealed a 5 cm x 4 cm mass in the cervix invading both parametria. At laparotomy, the cervix was globally enlarged and both parametria were infiltrated by a tumor of rubbery consistency. After freeing both ureters, the cervix was removed with bilateral parametria and 2-cm vaginal cuff. Histologically, the tumor was characterized by proliferation of fibroblast-like spindle cells and diffuse infiltration of plasma cells and lymphocytes. Immunohistochemical staining showed that the lymphocytes were polyclonal. Immunostaining for smooth muscle actin was negative. The tumor was thus identified as inflammatory pseudotumor. Cervical stroma, bilateral parametria, and subepithelial tissues of the vagina were involved with tumor. However, invasion was not identified in the epithelia of the cervix and vagina or surgical margins of the resected specimen. Postoperative course was uneventful. There is no evidence of recurrent disease 8 months following surgery.

CONCLUSION

The case we present is the second reported case of cervical IPT. It is unique in showing locally aggressive behavior. Surgical resection appears to be the treatment of choice for IPT.

Cervical endometriosis: a diagnostic and management dilemma

Cervical endometriosis is usually a retrospective finding on histology. We describe the diverse symptomatology of the disease, wherein a suspicion of diagnosis may be raised. A series of five patients with cervical endometriosis confirmed on histology was identified. One patient was asymptomatic but examination revealed a mass arising from the cervix. Two patients presented with persistent postcoital bleeding, one patient with intermenstrual bleeding and one patient with both intermenstrual and postcoital bleeding. All patients were followed up with colposcopy and cervical biopsy. Persistence of symptoms determined the mode of treatment which included surgical management in the form of large loop excision of the transformation zone (LLETZ) biopsy in four patients. Cervical endometriosis is a benign condition which may present with symptoms such as persistent post-coital bleeding or intermenstrual bleeding. Colposcopy and cervical biopsy are pivotal to the diagnosis. This condition can be managed expectantly in asymptomatic patients and persistent symptoms may warrant surgery.

Optical coherence tomography: a pilot study of a new imaging technique for noninvasive examination of cervical tissue

OBJECTIVE

Optical coherence tomography (OCT) is a novel noninvasive technique that can map subsurface tissue structure with a resolution of 10 to 20 mum. The objective of this study was to determine whether an OCT imaging system could be used clinically in vivo to image and distinguish features of normal and abnormal cervical tissue.

STUDY DESIGN

Cervical OCT images and biopsy specimens were obtained from consenting volunteers. Images were analyzed quantitatively for intensity of backscattered light from the epithelia and for rates of signal decay of signal over the depth of epithelia (slope). Patients were stratified by menopausal status, and parameters were compared in normal and abnormal cervical samples, as diagnosed by routine histopathologic techniques.

RESULTS

Average epithelial intensities were significantly stronger in the abnormal tissue than in the normal tissue of premenopausal women (P<.0024), but were stronger in the normal tissue of postmenopausal women (P<.062). No significant differences in signal decay rate were detected.

CONCLUSION

OCT images, which contain information about epithelial and stromal structure, can be clinically obtained. Image features of normal and abnormal cervical epithelium differ significantly.

[Chronic endometritis combination with non-inflammatory diseases of the uterine body and cervix]

The biopsies of endometrium and surgical material from 1752 pubertal, reproductive, premenopausal and menopausal age patients were investigated. Chronic endometritis was discovered in all age periods. It was suggested to distinguish the following forms of chronic endometritis: 1) an isolated form, 2) a form associated with inflammatory pathology of other parts of the genital tract, 3) a form associated with non-inflammatory diseases of the corpus and cervix of the uterus. The latter was observed considerably more frequently than other forms. Thus, non-inflammatory lesions of uterine corpus and cervix are factor of risk for development of chronic endometritis.

Effect of the sampling sequence on the quality of Papanicolaou smear

The aim of the study was to determine whether the order of cell collection (ie, obtaining either endocervical first or ectocervical cells first) has an effect on the quality of the Papanicolaou smear. 1129 smears were obtained using an Ayre spatula and an endocervical brush. In 564 cases, the endocervical brush was used first, and in 565 cases, the spatula was used first. The number of smears obscured by blood, the smears without endocervical component, and the smears with poor fixation were compared between the two groups. More smears were partially obscured by blood when brush was used first (78, 13.8% compared with 48, 8.5%, P = 0.004). No endocervical component was found in seven (1.2%) smears from the brush-first group compared with five (0.9%) of the spatula-first group, which is an insignificant difference. There were no significant differences in the number of poor-fixated smears, too-thick smears, and satisfactory smears but limited by inflammation between the two methods. The quality of the Papanicolaou smear can be improved by using the Ayre spatula first followed by the endocervical brush. Fewer smears will be contaminated by blood which may result in more squamous intraepithelial lesions being detected.

Extragenital endometriosis--a clinicopathological review of a Glasgow hospital experience with case illustrations

The clinicopathological characteristics of 34 cases of extragenital endometriosis (mean age 33.74) presenting to surgeons over a 9-year period at Glasgow Royal Infirmary were reviewed. A total of 379 cases of endometriosis were diagnosed by histology during the period, giving an 8.9% prevalence of extragenital manifestations. Eleven (32.3%) cases were in the intestinal tract, two (5.9%) in the urinary tract and 21 (61.8%) were in other sites, including pfannenstial scar, inguinal canal, umbilicus and perineum; 52.9% presented to gynaecologists and mean time to diagnosis was 24.54 months (CI: 13.2 - 35.8). Pain was the most common presentation in 76.5% but this was cyclical, reported in only 41.2%. Palpable mass was found in 41.2%, especially in pfannenstial scar (26.5%), suggesting iatrogenic cause. Histology remains the cornerstone of diagnosis and several of the case histories describe delay and diagnostic confusion. Endometriosis is rarely fatal, but continues to challenge patients and clinicians in all specialities in presentation and diagnosis.

Cervical stump necrosis and septic shock after laparoscopic supracervical hysterectomy

The decision to retain or remove the cervix when performing laparoscopic hysterectomy remains a topic of debate. A 38-year-old woman with multiple sclerosis underwent laparoscopic supracervical hysterectomy (LASH) for menometrorrhagia. Two weeks later, she was seen at our institution with septic shock. She underwent an exploratory laparotomy and was found to have cervical stump necrosis and peritonitis. Trachelectomy was performed. The postoperative course was prolonged by persistent fever, pleural effusion, and abscess collections. Although rare, cervical stump necrosis is a possible complication of LASH.

Laser CO2 conization in postmenopausal age: risk of cervical stenosis and unsatisfactory follow-up

OBJECTIVE

To assess chances of adequate cyto-colposcopic follow-up after laser conization performed in postmenopausal screening population by the evaluation of postoperative cervical stenosis and unsatisfactory colposcopy rates.

PATIENTS AND METHODS

One thousand two hundred eighteen patients were submitted to laser CO2 conization for cervical intraepithelial neoplasia (CIN). Incidence and risk factors for cervical stenosis and unsatisfactory follow-up were retrospectively evaluated comparing fertile with postmenopausal patients.

RESULTS

Global incidences of postoperative unsatisfactory colposcopy and cervical stenosis were 46.2% and 7.1%. These rates were higher in postmenopausal patients compared with fertile ones, revealing a statistical correlation between unsatisfactory follow-up and postmenopausal status at the time of conization. Association between CIN relapse and cervical stenosis was significantly higher in postmenopausal group (66.7% vs. 8.6%; P <0.05), where two cases of recurrence were detected only after hysterectomy, because of an insurmountable cervical stenosis. Univariate and multivariate analysis revealed HRT use as the only significant factor in influencing postoperative cervical stenosis.

CONCLUSION

Conization is still considered as the standard treatment for CIN at any woman's age, when excisional management is indicated, but all postmenopausal patients should be counseled about the possibility of postoperative stenosis that could exclude an adequate follow-up, configuring a failure of the conservative treatment. HRT use is associated with a low risk of stenotic complications; therefore, if possible, users should be encouraged to continue therapy at least 1 year after laser conization.

Distribution of Immune Cell Subsets and Cytokine-Producing Cells in the Uterine Cervix of Human Papillomavirus (HPV)-Infected Women

The aim of this study was to characterize the immune system profile in the uterine cervix of 17 human papillomavirus (HPV)-infected women, compared with 17 whom were coinfected with HIV-1. Five histologically normal cervices in immunocompetent women were used as controls. HPV infection was associated with a marked increase in cells expressing interleukin (IL)-6, interferon gamma (IFN-gamma), and tumor necrosis factor alpha (TNF-alpha). Coinfection by HPV and HIV-1 led to decreased expression of IL-6, TNF-alpha, and IFN-gamma. However, coinfection led to increased numbers of cells expressing IL-4, IL-10, and IL-8. Compared with the histologically normal cervices, increased numbers of macrophages (CD68, RFD7) and T lymphocytes (CD4, CD8) were seen in HPV-infected cervices; coinfection with HIV-1 was associated with a higher number of CD8 cells and lower number of CD68 cells. HPV DNA localized exclusively to the dysplastic squamous cells, whereas HIV-1 RNA was detected mainly in CD68-positive stromal cells. In conclusion, this study shows differential expression of various cytokines and classes of inflammatory cells, relative to HIV-1 infection and HPV coinfection, which may relate to the risk of transmission of HIV-1 and increased risk of cervical cancer in these women.

Rapid review of liquid-based smears as a quality control measure

The objective of this study was to investigate the effectiveness of a standardized method of rapid review (RR) of monolayer preparations for the identification of abnormalities, the presence of an endocervical component and infectious agents. A total of 200 ThinPrep (Cytyc, Boxborough, MA) slides representing the spectrum of abnormalities commonly encountered in cervical/vaginal cytologic specimens was retrieved from archive. The study set comprised 129 cases within normal limits (WNL); 36 low-grade epithelial abnormalities (LGEA); 28 high-grade epithelial abnormalities (HGEA), including 2 endocervical adenocarcinomas in situ (AIS) and 7 carcinomas. Eighteen false negative (FN) cases were also included for study. Originally missed on initial review, these cases were found to be abnormal on quality control review (17 LGEA; 1 AIS). Commonly encountered infectious agents were represented and included Candida albicans, Trichomonas vaginalis, herpes simplex virus, and Actinomyces. The slides were reviewed using a standardized method of RR (turret technique, for 60 sec) by three experienced screeners masked to the original reference diagnosis. Median sensitivity for LGEA was 70% (range, 67-72%); HGEA, 69% (range, 54-80%); and FN, 65% (range, 56-78%). Specificity remained high, median specificity for LGEA was 95%; HGEA, 97%; and FN, 100%. There was no significant overcalling of any diagnostic category. The chi-square test at P < 0.05 showed no significant difference between RR and full manual rescreen of the ThinPrep smears in this study. While no statistical difference was proven, the sensitivity measurements for all categories of abnormality were moderate due to the high proportion of atypical cases included into the study set. Abnormalities on the monolayer preparations frequently displayed fewer, smaller groups of disaggregated cells with rounded cytoplasmic outlines that were difficult to discern on RR. Interobserver variation was noted. Monolayers with a paucity of diagnostic cells and those displaying subtle nuclear atypia were often overlooked.

Citologia oncológica, captura de híbridos II e inspeção visual no rastreamento de lesões cervicais

Avaliar as alterações na citologia oncológica, na captura híbrida II e na inspeção visual com ácido acético (IVA) a 5% em 684 mulheres atendidas em uma unidade de saúde, e avaliar o desempenho e a concordância entre os exames. Procurar descrever as características sócio-demográficas e reprodutivas (SDR) destas mulheres e sua associação com a presença de doença. As mulheres foram submetidas à coleta de citologia, captura e IVA, e as com exame positivo foram submetidas à colposcopia com biopsia, se necessário. Foi calculado o desempenho dos testes e a associação dos fatores SDR com o diagnóstico histológico foi avaliada por intermédio do cálculo do odds ratio. Embora 198 mulheres apresentassem pelo menos um teste alterado, apenas 21 apresentaram lesão histológica. A sensibilidade dos testes foi semelhante enquanto as especificidades da IVA e da citologia foram maiores que a da captura híbrida II. Apenas a ausência de citologia esteve associada à presença de doença. O desempenho da citologia foi maior que o da IVA, que foi maior que o da captura. A ausência de citologia foi associada com doença histológica.

Prevalence and management of abnormal pap smear in antenatal care clinic at Thammasat University Hospital

OBJECTIVE

To investigate the prevalence of abnormal Papanicolaou smear in pregnant patients who attend the Antenatal Care Clinic at Thammasat University Hospital.

MATERIAL AND METHOD

Pregnant patients who attended the antenatal care clinic at Thammasat University Hospital from August 2003 to December 2003 were recruited for Papanicolaou test. Patients who had abnormal results of equally or over "abnormal squamous/glandular cells of undetermined significance" were assigned for colposcopy and colposcopic biopsy to confirm the result.

RESULTS

From 500 Papanicolaou smear performed, there were only four patients who had abnormal Pap tests, which were: 2 ASC-US and 2 LSIL. The prevalence of abnormal Pap smear in pregnant patients who attended the antenatal clinic at Thammasat University Hospital was 0.8 percent.

CONCLUSION

The prevalence of abnormal Papanicolaou smear in pregnant patients attending antenatal care clinic at Thammasat University Hospital was quite low in compares with other literature.

Vesicocervical fistula: rare complication of cesarean section demonstrated by magnetic resonance imaging

We report a rare complication of cesarean section in a 46-year-old woman presenting with incontinence. The patient was noted at cystoscopy to have a lesion on the posterior wall of the bladder. Histologic examination of the biopsied lesion demonstrated endocervical tissue, and subsequent magnetic resonance imaging revealed a vesicocervical fistula. She was treated by open excision of the fistula and repair of the bladder and cervix with omental interposition. Only 16 cases of vesicocervical fistulas have been previously reported, and this is the first to demonstrate the finding on magnetic resonance imaging.

The relative distribution of oncogenic types of human papillomavirus in benign, pre-malignant and malignant cervical biopsies

The aim of the present investigation was to define the spectrum of oncogenic types of human papillomavirus (HPV) present in benign, pre-malignant (low-grade and high-grade squamous intraepithelial lesions, LSIL and HSIL) and malignant cervical lesions. The study comprises 215 HPV-positive biopsies, analysed with PCR, followed by sequence analyses of the HPV DNA. Fifeteen oncogenic types of HPV were identified. In 170 benign or pre-maligant alterations, the most common being HPV 16 (51%), HPV 31 (8%), HPV 18 (7%) and HPV 45 (6%). HPV 33, 35, 51, 56, 58, 66, and 70 occurred in about 1-4%. The prevalence of HPV 39, 52, 56, 59 and 73 was <1%. All the observed types of HPV, except 39 and 52, occurred in SIL lesions. The most common oncogenic HPV types (16 and 18), occurring in 45 invasive squamous carcinomas, comprised 76 per cent of the tumours, whereas less frequent HPV types (31, 33, 52, 56, 67, 70 and 73) were each found in about 2-4%. Double HPV infections were not observed. In conclusion, a total of 15 different oncogenic HPV types were identified, of which 13 types were present in pre-malignant cervical lesions and 9 in malignant lesions. This information may have some relevance when HPV analyses are considered as an adjunct to the organised screening of cervical cancer and for those working with the development of HPV vaccines for the prevention of cervical cancer.

Pseudo-tumoral lesions of the cervix

Pseudo-tumoral lesions of the cervix implies some reactive, non-neoplastic changes (metaplasia, hyperplasia, inflammation) that, occasionally, are wrong interpreted as precancerous or malign lesions. Even some can present architectural or cytological abnormal aspects, these are different from the one noted in carcinomas or the precursor lesions of carcinomas. Them recognition is indispensable in order to avoid the diagnose errors and the super evaluation of these benign lesions.

Mullerian adenosarcoma with sarcomatous overgrowth of the cervix presenting as cervical polyp: a case report and review of the literature

An aggressive variant of adenosarcoma, mullerian adenosarcoma with sarcomatous overgrowth (MASO) in the cervix is extremely rare. This variant contains obvious, high-grade sarcoma in addition to a low-grade form. In this report, we describe a case of MASO of the uterine cervix and review the clinical and pathological features of these tumors. The patient was a 37-year-old woman with a cervical polypoid mass, which was morphologically considered as a benign endocervical polyp. Microscopically, polypoid cervical mass showed diffuse and dense malignant spindle cell proliferation around the benign endocervical glands and also an area of markedly anaplastic and pleomorphic spindle cell proliferation, so called, sarcomatous overgrowth. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymph node dissection were performed. The patient has been followed-up and neither chemotherapy nor other adjuvant therapies have been administered. At present, she has been clinically free of disease for 9 months since she received surgery. It is extremely rare that MASO of the uterine cervix is presented in premenopausal woman. Gynecologists and pathologists should be aware of the difficulties associated with a delay in the diagnosis of MASO when the tumor is present as a benign looking cervical polyp.

Vesicocervical fistula: an unusual complication of vesicovaginal [corrected] fistula repair

A rare case of vesicocervical fistula following repair of a vesicovaginal fistula is presented. The patient complained of cyclical menouria since the first repair done 15 years ago and gradually worsening urinary incontinence. A laparoscopic assisted repair of the fistula was performed and the patient is fully continent at 12-months follow up.

Sonographic cervical length in threatened preterm labor in a South African population

OBJECTIVE

In a previous study conducted in the UK we demonstrated that only 8% of women with threatened preterm labor deliver within 7 days. Furthermore, delivery within 7 days occurred in less than 1% of women presenting with a sonographically measured cervical length > or = 15 mm, compared to 37% in those with cervical length < 15 mm. In this study we investigate the potential value of cervical length in the prediction of outcome of threatened preterm labor in a South African population.

METHODS

We examined 63 women with singleton pregnancies presenting with regular and painful uterine contractions at 24-36 (mean, 31) weeks of gestation. Women in active labor, defined by the presence of cervical dilatation > or = 3 cm, and those with ruptured membranes were excluded. On admission to the hospital a transvaginal scan was performed to measure the cervical length. The subsequent management was determined by the attending obstetrician. The primary outcome was delivery within 7 days of presentation.

RESULTS

Delivery within 7 days of presentation occurred in 20/63 (32%) pregnancies, including 20 of the 30 (67%) cases with cervical length < 15 mm and none of the 33 cases with cervical length > or = 15 mm. Logistic regression analysis demonstrated that the only significant contributor in the prediction of delivery within 7 days was cervical length (odds ratio 0.67; 95% CI 0.54-0.85; P = 0.001) with no significant independent contribution from maternal age, gestational age, body mass index, parity, use of antibiotics, previous history of preterm delivery, cigarette smoking, contraction frequency or use of tocolytics.

CONCLUSION

In this South African population, which had a high incidence of delivery within 7 days of presentation with threatened preterm labor, sonographic measurement of cervical length is equally effective as in a lower-risk population in distinguishing between true and false labor.

Prevalence of human papillomavirus infection and correlation with cervical lesions in Japanese women

PURPOSE

To investigate the prevalence of human papillomavirus (HPV) infection in patients attending a gynecologic outpatient department, and to correlate the infection status with the presence or absence of uterine cervical lesions and the grades assessed by cytological or histological examinations.

METHODS

Five hundred and seventy-two subjects were studied. In all subjects, HPV detection by the hybrid capture method and a cervical cytological examination were performed

RESULTS

The HPV-positive rate in subjects with normal cytology was 12.3%. The detection rate was high (21.7%) in subjects aged in the twenties and low in the forties, and HPV was not detected in subjects aged in the sixties and seventies. When HPV-positive rates were examined according to cytological or histological grades, the rates were higher in subjects with abnormal cytology (P < 0.01) or cervical intraepithelial neoplasia (CIN) or squamous cell carcinoma compared with those with normal cytology.

CONCLUSION

Diagnosis of HPV infection is also important for the prediction of progression to CIN and cervical cancer.

Histopathological changes of cervical tissue in women with systemic sclerosis

Systemic sclerosis is a connective tissue disease that can affect almost any organ of the body. The clinical aspects of systemic sclerosis on the reproductive system have been studied in large series, and an increased rate of cesarean section has been reported. For this reason, in the present study the histopathological features of cervical specimens of hysterectomyzed women with systemic sclerosis were evaluated. An increased frequency of vascular and stromal abnormalities in cervical specimens of women with systemic sclerosis were observed. Vascular medial hypertrophy, intimal thickening, and fibrosis were more often encountered in the cervical specimens of the patients with systemic sclerosis. Some of the histopathological features also showed correlation with the clinical profile of the disease. The patients with vascular medial hypertrophy in their cervical specimens were older, had a higher Rodnan score, and had longer duration of the disease. In contrast to vascular medial hypertrophy, periadventitial edema was found in the cervical specimens of the patients who were younger, had a lower Rodnan score, and had shorter duration of the disease. It was concluded that the problems that are seen in common obstetric and gynecological practices in patients with systemic sclerosis may be explained by these tissue abnormalities.