Diama Bhadra Vale

The top hat procedure does not impact the management of women treated by LEEP in cervical cancer screening

To describe Top-hat results and their association with margin status and disease relapse in a referral facility in Brazil. A retrospective study of 440 women submitted to LEEP to treat HSIL, in which 80 cases were complemented immediately by the top hat procedure (Top-hat Group - TH). TH Group was compared to women not submitted to Top-hat (NTH). The sample by convenience included all women that underwent LEEP from January 2017 to July 2020. The main outcome was the histological result. Other variables were margins, age, transformation zone (TZ), depth, and relapse. The analysis used the Chi-square test and logistic regression. The TH Group was predominantly 40 and older (NTH 23.1% vs. TH 65.0%, p<0.001). No difference was found in having CIN2/CIN3 as the final diagnosis (NTH 17.0% vs. TH 21.3%, p=0.362), or in the prevalence of relapse (NTH 12.0% vs. TH 9.0%, p=0.482). Of the 80 patients submitted to top hat, the histological result was CIN2/CIN3 in eight. A negative top hat result was related to a negative endocervical margin of 83.3%. A CIN2/CIN3 Top-hat result was related to CIN2/CIN3 margin in 62.5% (p=0.009). The chance of obtaining a top hat negative result was 22.4 times higher (2.4-211.0) when the endocervical margin was negative and 14.5 times higher (1.5-140.7) when the ectocervical margin was negative. The top hat procedure did not alter the final diagnosis of LEEP. No impact on relapse was observed. The procedure should be avoided in women of reproductive age.

Depth of Invasion of 13 mm or Greater Accurately Predicted the Risk of Having a Node Positivity in Lymphadenectomy for Squamous Vulvar Cancer

ABSTRACT Aim To analyze factors related to lymph node involvement in patients with squamous vulvar cancer undergoing lymphadenectomy and wide local excision at the University Hospital in Campinas, Brazil. Methods A retrospective study involving 56 women treated between 2010 and 2022. The primary outcome was inguinal lymph node involvement (positive or negative). Clinical, operative, and pathologic variables were analyzed by appropriate tests. Kaplan–Meier curves were used to determine overall survival rate (OS). A receiver operating characteristic (ROC) curve was created to determine the optimal value of the depth of invasion for predicting node positivity. Results Of the 56 women who underwent surgery, node involvement was positive in 18 (32.1%). Where node was positive, the tumors were over 5 cm in 22.2% (versus 2.7%, p  = 0.035), had an depth of invasion equal to or deeper than 13 mm (13 mm+) in 62.5% (versus 14.3%, p  &lt; 0.001), lymphovascular invasion in 33.3% (versus 11.8%, p  = 0.024), presented disease progression in 44.4% (versus 11.8%, p  = 0.019), and death in 77.8% (versus 31.6%, p  = 0.001). The 5‐year OS was 57.1% in the node‐negative and 8.6% in the node‐positive group, with most events occurring within the first 24 months. Depth of invasion 13 mm + increased the risk of node‐positivity 11 times (11.37;1.85–69.82), showing a predictive negative value of 83.3%, and accuracy of 78.4%. Conclusion The 13.0 mm cutoff for depth of invasion was independently associated with the risk of having a positive node, with an accuracy of 78.4%. The 5‐year OS was 8.6% in the node‐positive group, with most events within the first 24 months.

Screen-and-treat approach in managing cervical cancer precursor lesions: An observational study with 524 women

To detect factors related to overtreatment with the "Screen-and-treat" approach (S&T) in women with suspicious cervical precancerous lesions. A retrospective observational study of 524 women with high-grade squamous intraepithelial lesions (HSIL) or more severe (HSIL+) in cytology, treated by the Large Loop Excision of the Transformation Zone (LLETZ): 161 without a previous biopsy (S&T group) and 363 with a previous biopsy (biopsy group) from January 2017 to July 2020. The main outcome was a diagnosis of LLETZ: negative (negative or low-grade squamous intraepithlelial lesion LSIL) or HSIL+. A negative diagnosis was interpreted as "overtreatment." Results were analyzed as a function of the S&T approach (whether previous biopsy or not). Variables were obtained from medical records, and were compared with Chi-square or Fisher's exact test (p, p-value), to estimate the chances of a logistic regression analysis (Odds Ratio, OR, or admitting a Confidence Interval (CI) of 95 %). No differences were observed in groups regarding menopausal status, smoking, hormonal contraceptive use, colposcopy findings, LLETZ diagnosis, and recurrence. Comparing biopsy vs S&T groups, the frequency of women over 40 years was 28.4 % vs 39.7 % (p = 0.011), and transformation zone type 3 was 12.2 vs 26.8 % (p < 0.001), respectively. In women managed by S&T, when compared to a LLETZ diagnosis, an HSIL+ result was more frequent in women presenting with TZ 1 (93.1 % TZ1 vs 78.5 % TZ2 vs 73.8 % TZ3, p = 0.008) and in women with abnormal colposcopy (92.9 % abnormal vs 38.1 % negative, p < 0.001). Multiple regression analysis found that women with negative colposcopic findings presented a higher risk for negative LLETZ diagnosis (LSIL/Negative final histology) (18.6; 6.18-56.02). No difference was observed in the LLETZ diagnosis in women who did or did not use the S&T approach: it was adequate for women referred by cytological HSIL along with high-grade colposcopic findings.

Prognosis determination of endocervical adenocarcinomas morphologically reclassified as HPV associated or HPV independent

AbstractObjectiveTo evaluate the prognosis of endocervical adenocarcinomas after reclassification according to the morphologic type based on the 2020 World Health Organization Classification.MethodsA retrospective longitudinal study with cases admitted at the University of Campinas, Brazil, from 2013 to 2020. The sample included 140 cases morphologically reclassified: 100 cases as adenocarcinoma HPV‐associated (HPVA), 17 as HPV‐independent (HPVI), and 23 non‐HPVA/HPVI. Clinic and pathologic variables were evaluated. Analyses were performed by χ2, Fisher exact, and Mann–Whitney U tests, Kaplan–Meier curves, Log‐rank test, and Cox regression.ResultsCompared with the HPVA group, advanced stage (FIGO Stage II+) was more frequent in the HPVI group (P = 0.009), which also showed older patients (P = 0.032), and a higher proportion of deaths (P = 0.006). The median overall survival (OS) differed between groups: 73.3 months in HPVA and 42.4 months in HPVI (P = 0.005). At the multivariate analysis, the risk of death was 6.7 (95% confidence interval 1.9–23.0) times higher in patients diagnosed in advanced stages.ConclusionHPVI cases were more frequent in older patients, presenting at more advanced stages and with worse OS. The morphology‐based approach of the new WHO classification appears to be prognostically valuable and applicable in lower‐ and middle‐income settings.

The value of the endocervical margin status in LEEP: analysis of 610 cases

To describe the results of 610 patients who underwent LEEP and evaluate factors related to a negative margin. A retrospective study of patients treated by LEEP at a colposcopy referral service in Campinas, Brazil, 2017-2019. Patients were referred to treat high-grade squamous intraepithelial lesion or adenocarcinoma in situ suspected by cytology and colposcopy (screen-and-treat) or by biopsy. Descriptive analysis was performed by frequencies as a function of the status of the margins (negative or positive). Factors associated with margin status were assessed by regression. The endocervical, ectocervical or both margins were negative in 82.4%, 75.7% and 65.9%, respectively. Age, sexual debut, parity, menopause status, smoking and hormonal contraception showed no difference in the proportion of negative margins. Both margins were negative in 66.1% of patients with transformation zone type(TZ) 1, 73.1% of TZ 2, and 54.7% of TZ 3 (p = 0.015). The endocervical negative margin was obtained in 78.0% of patients submitted to excision I (loop 10 mm) and 82.5% to excision II (loop 15 mm) (p = 0.016). Having the sexual debut at 18 years or older or being submitted to an excision type II doubled the chance of negative endocervical margin (1.98;1.04-3.77 and 1.95; 1.18-3.21, respectively). The proportion of negative endocervical margin was 78% in excision I and 86% in excision II. Sexual onset and excision type II increased the chance of obtaining a negative endocervical margin.

Cervical Cancer Screening with HPV Testing: Updates on the Recommendation

AbstractThe present update is a reassessment of the 2018 ‘Guidelines for HPV-DNA Testing for Cervical Cancer Screening in Brazil’ (Zeferino et al.)9, according to the changes observed in new international guidelines and knowledge updates. The most relevant and recent guidelines were assessed. Questions regarding the clinical practice were formulated, and the answers considered the perspective of the public and private sectors of the Brazilian health system. The review addressed risk-based strategies regarding age to start and stop screening, the use of cytology and colposcopy to support management decisions, treatment, follow-up strategies, and screening in specific groups, including vaccinated women. The update aims to improve the prevention of cervical cancer and to reduce overtreatment and the misuse of HPV testing.

Implementing plans for global elimination of cervical cancer

Cervical cancer screening in Brazilian Amazon Indigenous women: Towards the intensification of public policies for prevention

BackgroundIndigenous women are vulnerable to cervical cancer. Screening is a strategy to reduce the burden of the disease.ObjectiveTo evaluate the prevalence profile of cervical cancer screening cytological results in Brazilian indigenous women by age and frequency of tests compared to non-indigenous women.MethodsA cross-sectional study evaluating the prevalences of screening test results in indigenous women assisted in the Brazilian Amazon from 2007 to 2019 (3,231 tests), compared to non-indigenous women (698,415 tests). The main outcome was the cytological result. Other variables were frequency, age groups, and population. The frequency was categorized as "1sttest", the first test performed by the women in their lifetime, or "screening test," tests from women who had previously participated in screening. Analyzes were based on prevalences by age group and population. We used Prevalence Ratios (PR) and 95% Confidence Intervals for risks and linear regression for trends.ResultsData from the 1sttest showed a higher prevalence of Low-grade Squamous Intraepithelial Lesion (LSIL) in indigenous women. Peaks were observed in indigenous under 25, 35 to 39, 45 to 49, and 60 to 64. The prevalence of High-grade Squamous Intraepithelial Lesion or more severe (HSIL+) was low in both groups in women younger than 25. The indigenous HSIL+ prevalence curve showed a rapid increase, reaching peaks in women from 25 to 34 years, following a slight decrease and a plateau. In screening tests, HSIL+ was more prevalent in indigenous from 25 to 39 (PR 4.0,2.3;6.8) and 40 to 64 (PR 3.8,1.6;9.0). In indigenous, the PR of HSIL+ results in screening tests over 1sttests showed no screening effect in all age groups. In non-indigenous, there was a significant effect toward protection in the age groups over 25.ConclusionThis screening study of indigenous women from diverse ethnicities showed a higher prevalence of cytological LSIL and HSIl+ than in non-indigenous women. The protective screening effect in reducing HSIL+ prevalence was not observed in indigenous.