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1/35. Recurrent osseous metaplasia of the cervix after loop electrosurgical excision.

    BACKGROUND: Osseous metaplasia of the uterus is a rare pathologic entity usually affecting the endometrial cavity without cervical extension. It has been reported after abortion, in cases of chronic endometritis, and as a result of metabolic disorders as hypervitaminosis D, hyperparathyroidism, hypercalcemia, and hyperphosphatemia. CASE: A woman developed osseous metaplasia of the cervix shortly after loop electrosurgical excision procedure (LEEP) for severe cervical dysplasia. Normal transvaginal ultrasonograms before the LEEP, and failure to detect osseous metaplasia after histologic review of the tissue obtained from that procedure indicate that the osseous metaplasia had been induced by the LEEP. The heterotopic bone formation rapidly recurred after initial removal. Her serum calcium, phosphorus, and vitamin d levels were normal. CONCLUSION: LEEP may result in healing with metaplastic bone formation. ( info)

2/35. Abnormal cervicovaginal smears due to endometriosis: a continuing problem.

    endometriosis may be challenging when identified on cervicovaginal smears (CVS), leading to an incorrect interpretation of high-grade squamous intraepithelial lesion (HSIL), or atypical glandular cells of undetermined significance (AGUS) including adenocarcinoma in situ (AIS). awareness of cervical endometriosis, particularly in predisposed patients, is crucial for a correct diagnosis. While cervical endometriosis has been reported to be a diagnostic pitfall of glandular abnormalities, its characteristic features are still not well-established. This may partially be attributed to the varied cytomorphologic features endometriosis shows, depending on menstrual cycle hormonal changes. We describe our experience with three examples where CVS were interpreted as either AGUS or HSIL, which led to a hysterectomy in 2 of 3 patients. Cervical endometriosis needs to be considered with other well-known benign conditions that mimic glandular abnormalities, including cervicitis, tubal metaplasia, lower uterine segment sampling, and microglandular hyperplasia. Published series and our own experience lead us to suggest that these smears will continue to present diagnostic difficulties. ( info)

3/35. Imiquimod: potential risk of an immunostimulant.

    A 19-year-old woman with severe HLA B27 spondyloarthropathy whose disease was controlled on cyclosporin, methotrexate and prednisolone had human papillomavirus infection and developed cervical dysplasia and a large number of cutaneous and vulval warts. These were not responsive to cryotherapy, salicylic acid or cimetidine, so she was treated with topical imiquimod 5% cream. Two weeks after starting this treatment she had a significant flare of her spondyloarthropathy. She was so ill that she stopped using the imiquimod cream. She had full resolution of her warts after 3 weeks' treatment with imiquimod cream, but her spondyloarthropathy took more than 3 months to improve, despite significant augmentation of her immunosuppression. This case highlights the potential risk of using imiquimod cream (an immunostimulant) in a patient who has a condition requiring immunosuppression, such as autoimmune disease or an organ transplant. ( info)

4/35. Double cervix with bilateral and synchronous HSIL associated with different high-risk HPV types. A case report.

    BACKGROUND: High grade squamous intraepithelial lesion (HSIL) of the cervix is well known to be associated with human papillomavirus (HPV) infection. HSIL and invasive carcinomas occurring synchronously in genital malformations, such as a double cervix, have been reported. It has been postulated that the field effect phenomenon of HPV infection is responsible for this synchronous infection. However, there is no information in the literature on the specific types of HPV causing the concomitant lesions in cases with a double cervix. CASE: A 33-year-old nulligravida with a double cervix and a single uterine corpus was diagnosed with bilateral HSIL on Papanicolaou-stained ThinPrep slides (Cytyc Corp., Boxborough, massachusetts, U.S.A.). A bilateral loop electrosurgical excision procedure cone biopsy revealed HSIL involving both cervices. dna extracted from the HSIL lesions was analyzed by a polymerase chain reaction-based assay for the presence of HPV. High-risk HPV type 33 was identified in the right cervix, while HPV type 35 was present in the left. CONCLUSION: Demonstration of high-risk HPV types bilaterally supported the etiologic role of HPV infection in the synchronous and bilateral occurrence of HSIL in this case of a double cervix. The HPV types were different in the right and left cervices. ( info)

5/35. Human papillomavirus type 31 dna detected in part of the dysplasia but in no part of the squamous metaplasia in a specimen taken from one patient.

    Using in situ hybridization, human papillomavirus (HPV 6, 16, 18, 31, 33) DNAs were detected in a cervical severe dysplasia accompanied by squamous metaplasia. It was found that, only HPV 31 dna was harbored in the cervical severe dysplasia, but HPV DNAs were not identified in a lesion of squamous metaplasia. The in situ hybridization method will be of use, therefore, when dysplasia with squamous metaplasia or other lesions are examined for HPV dna. In a cervical smear, HPV 31 dna could be detected on the nuclei of dysplastic cells, so this method is applicable to cervical smears. If squamous metaplasia is to be considered as a precursor lesion to cervical dysplasia, the HPV dna harbored in the dysplasia must also be detected in the accompanying squamous metaplasia. Our results suggested that not all squamous metaplasias were involved with HPV, as far as we were able to detect using five types of HPV dna probe. ( info)

6/35. Is early postradiation dysplasia almost associated with poor prognosis? A case report and review of the literature.

    Following radiotherapy for cervical carcinoma, abnormal cytologic changes have been reported in a number of publications. These reactions occur at varying periods of time following irradiation and do not necessarily reflect the presence of invasive cancer. On the basis of cytologic and histopathologic features, these reactions were determined as postradiation dysplasia (PRD). PRD has been reported to occur in 18.7-26% of patients treated by radiotherapy for cervical cancer. In the literature, it was reported that patients diagnosed with PRD less than 3 years after the initial diagnosis of cervical cancer had a mean survival rate of 33.8% as compared with a 100% 5-year survival rate in patients with a delayed (>3 years) onset of period. We present a case of stage IIIB cervical squamous cell carcinoma with PRD detected 6 months after radiotherapy. The patient is still tumor free 8 years after radiotherapy. In the light of this patient, we review the literature and discuss the relationship of PRD with survival in the cervical carcinomas. ( info)

7/35. Preventing cervical cancer by treating genital warts in men. Why male sex partners need androscopy.

    The increased incidence of cancer of the genitourinary and anorectal areas has been directly related to the coexistence of genital human papillomavirus infection. The diagnosis and treatment of condyloma acuminatum in men is important not only to prevent cancer but also to decrease the reservoir of virus that is being transferred to women. Screening with androscopy (examination of male genitals with a colposcope after a vinegar solution has been applied to the skin) is indicated for all men who are at risk for this infection. Treatment options include chemical application, cryosurgery, laser therapy, and interferon injections. To be effective, treatment must include both sexual partners. ( info)

8/35. Rapidly progressive squamous cell carcinoma of the cervix coexisting with human immunodeficiency virus infection: clinical opinion.

    The acquired immune deficiency syndrome (AIDS) has been characterized by aggressive malignancies and infections with unusual presentations. There is a well-documented association between cervical dysplasia and the development of cervical carcinoma, and more recent evidence of an association between cervical dysplasia and hiv infection. The course of coexistent hiv infection and cervical cancer has not been well described. We report a patient with hiv infection and a stage IIIB squamous cell carcinoma of the cervix who, despite adequate treatment, had rapid disease progression as well as metastasis to an unusual iliopsoas muscle site in association with an abscess. As hiv becomes more prevalent in the female population, an increased frequency of rapidly progressive cervical carcinoma may be forthcoming. Improved life expectancy of hiv-infected patients due to modern medication is anticipated, causing a cervical neoplasm to have a more prominent effect on prognosis. Close surveillance with frequent Pap smears and colposcopies as well as aggressive management of cervical dysplasia and carcinoma in hiv-infected patients is suggested as is thorough patient counseling. ( info)

9/35. Distinguishing tubal metaplasia from endocervical dysplasia on cervical Papanicolaou smears.

    Tubal metaplasia is a benign endocervical lesion. There may be confusion, however, in distinguishing tubal metaplasia from endocervical gland dysplasia on Papanicolaou smear. We present a case in which a cervical smear diagnosis initially reported as endocervical atypia was corrected to a diagnosis of tubal metaplasia upon cytologic review, thus altering patient management. The presence of terminal bars and cilia are the most helpful features in the cytologic recognition of tubal metaplasia. The evaluation of endocervical gland dysplasia suggested by Papanicolaou smear may include diagnostic conization; therefore, to prevent unnecessary intervention, it is important to distinguish endocervical gland dysplasia from tubal metaplasia. ( info)

10/35. Carcinoma of the cervix in a pregnant woman with negative Pap smears and colposcopic examination.

    A case is reported of squamous cell carcinoma of the cervix developing in a pregnant woman while manifesting five consecutive false-negative Pap smears and colposcopic appearance suggestive of dysplasia. Pap smears and colposcopic examinations are helpful in diagnosing dysplastic and early cancerous lesions of the uterine cervix. We describe a case where both Pap smears and colposcopy failed to diagnose an early occult invasive lesion in the cervix of a pregnant woman who manifested only CINIII by colposcopy, while the Pap smear was falsely negative on five consecutive occasions. ( info)
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