Dysplasia Clinic Research Articles

Detailed account of confounding factors in interpretation of FTIR spectra of exfoliated cervical cells.

The confounding variables that can potentially lead to a misinterpretation of FTIR spectroscopy of exfoliated cervical cells is described. A detailed account of the spectral effects of the following variables in FTIR spectroscopic screening of exfoliated cervical cells is presented: polymorphs; Cell degradation; and impurities such as endocervical columnar cells, metaplastic cells, cervical mucus, red cells, and debris. The interpretation of the spectra of exfoliated cervical cells must be done with subtraction analysis, which includes these factors. This is essential to prevent unacceptable false-positive rates. The above techniques are subsequently applied to two clinic populations: a dysplasia clinic in follow-up patients with negative cytology and two general gynecology clinics with patients with negative cytology. In the dysplasia clinic group 250 sequential patients with negative smears were tested. Thirty had false-positive smears as defined by the IR spectroscopy using the above methodology. Twenty of those patients subsequently had one follow-up and six had a positive abnormal smear. In the community clinic group 656 sequential patients were examined who had negative smears, of which 27 had false-positive FTIR spectra.

Adolescents' Knowledge of Human Papillomavirus and Cervical Dysplasia

Study Objective This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified. Design Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed. Setting The study was conducted at a university-based adolescent dysplasia clinic. Participants Fifty females, ages 15–23 participated in the study: 88% African-American, 12% Caucasian. Results On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood “some” or “most of the time.” Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms “most of the time.” However, 90% had maintained or increased their frequency of Pap tests. Conclusions Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Placement of endosseous implants in children and adolescents with hereditary ectodermal dysplasia

Objective. The purposes of this investigation were to study the feasibility of placing endosseous implants in children and adolescents with ectodermal dysplasia and to assess the position and stability of such implants during growth. This article reports on 6 subjects with long-term follow-up. Study design. A prospective study was commenced in 1991. Patients with hereditary ectodermal dysplasia who were over the age of 5 years and who presented to the University of California San Francisco Ectodermal Dysplasia Clinic for dental treatment were included and maintained in the study. In each case, clinical and radiographic records were obtained before treatment, immediately after implant placement, at delivery of the prosthesis, and subsequently at yearly intervals. Six subjects are reported, 4 as members of the prospective study group and 2 who had been treated before the study began. Results. A total of 41 implants (19 maxillary, 22 mandibular) were placed. The average follow-up after implant placement was 7.8 years (range, 6-11 years), and the average time since restoration was 6 years (range, 5-10 years). Forty implants successfully integrated and have been restored. There was no evidence that implant placement or prosthetic rehabilitation resulted in restriction of transverse or sagittal growth. One mandibular implant, placed in a partially dentate 5-year-old, became submerged because of adjacent alveolar development and required placement of a longer abutment. Four maxillary implants placed in a partially dentate 7-year-old also became submerged and required prosthetic revision and the placement of longer abutments. Conclusions. This preliminary report suggests that endosseous implants can be successfully placed and can provide support for prosthetic restoration in patients with hereditary ectodermal dysplasia. However, vertical dentoalveolar growth results in submergence of the implant relative to the adjacent natural dentition when implants are placed adjacent to erupting permanent teeth. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88: 5-10)

Jugular bulb dehiscence in achondroplasia

Jugular bulb dehiscence—complete absence of a roof over the jugular bulb—is a rare malformation, probably present in ≪1% of the general pediatric population. Of 126 children with achondroplasia evaluated in the Midwest Regional Bone Dysplasia Clinic, four and probably five, were identified as having such dehiscence (at least 3.2% of the children assessed). Identifying this increased incidence in achondroplasia is of some clinical relevance, particularly including risk of difficult to control bleeding at myringotomy. It may also present as otherwise unexplained hearing loss, tinnitus and self audible bruits in these children.

Atypical glandular cells of undetermined significance: implications for management in a dysplasia clinic.

The natural evolution of atypical glandular cells of undetermined significance (AGUS) within a dysplasia clinic population has not yet been studied. The purpose of this study was to determine the outcome of cervico-vaginal smears with the diagnosis of AGUS from dysplasia clinic patients. The cytopathological files of the Ottawa Civic Hospital were reviewed retrospectively from January 1993 to December 1995. In 59 dysplasia clinic patients, AGUS was diagnosed on one or more cervico-vaginal smears. Histological follow-up was available from 34 patients. Cytological follow-up was available on an additional 17 patients. Nineteen patients had clinically significant lesions. In eight patients, squamous intraepithelial neoplasia was diagnosed; in five, adenocarcinoma in situ; in another five, adenocarcinoma; and, in one patient, endometrial hyperplasia with atypia. In 15 patients, follow-up was negative. In a dysplasia clinic population in whom there was a cytological diagnosis of AGUS, we found 32% had significant pathology. Of these patients, 53% had glandular pathology. Based on our experience, histological assessment of the endocervix is suggested in these patients.

Factores de riesgo para cáncer cervicouterino en mujeres de Zacatecas

To determine the sociodemographic characteristics and the reproductive and sexual behavior of participants in the Cervical Cancer Prevention and Control Program and to identify the risk factors for this neoplasm.A case control study was performed among participants in the Cervical Cancer Prevention and Control Program in the state of Zacatecas. The cases consisted of all patients diagnosed and corroborated by histopathology with CIN III and invasive carcinoma of the uterine cervix (251) who were referred to the Dysplasia Clinic (within the same program), during 1993-1995. Controls were women randomly selected from the population which participates in this program, who had negative cervical cytology. One control was selected for each case and paired by age and date, simultaneous to the cervical cytology.Risk of cervical cancer was higher in women with greater number of pregnancies (more than 12 pregnancies) than in women with less than 3 (OR 5.2, CI 95% 2.6-10.5). This is also true of women with greater number of births (12 or more) who have a risk five times higher than women with less than 3. Beginning sexual activity at an early age was associated to the risk of cervical cancer; women who began their sexual activity after the age of 19 had a risk two times lower than those who started before the age of 15. The use of oral contraceptives increased the risk of cervical cancer in relation to the use of non-hormonal contraceptives (OR 1.9, CI 95% 1.3-3.4).In the present study, the risk factors for cervical cancer in the population participating in the prevention and control program were higher in women with high parity, who began sexual activity at an early age and/or who consumed oral contraceptives.

Evaluation of a new instrument designed for directed cervical excision: cone biopsy excisor.

Our objective was to compare a newly designed instrument, the Cone Biopsy Excisor (CBE; Apple Medical Corporation, Bolton, MA), with the standard loop electrosurgical excision procedure (LEEP) for providing a cervical conization specimen with the best achievable margin quality for histological evaluation. Patients referred to the dysplasia clinics at Hartford Hospital, St. Francis/Mt. Sinai Hospital and the University of Connecticut Health Center/New Britain General Hospital were randomized to either the CBE procedure or LEEP. To be included in the study, patients had to meet at least one of the following criteria: biopsy-proven cervical intraepithelial neoplasia grade 2 or 3, unsatisfactory colposcopy, positive endocervical curettage, or one or more degrees of cytohistological discrepancy. Exclusion criteria included pregnancy, undiagnosed uterine bleeding, acute cervicitis, or biopsy-proven invasive carcinoma. Forty-seven patients were randomized to the CBE and 48 to LEEP. To obtain the cervical specimen, third- and fourth-year obstetricalgynecological residents used Force II Valley Lab Generators (Valley Lab, Boulder, CO) at a blend one setting (80/20 blend of cutting and coagulation). Wattage ranged from 25 to 45, according to the size of the instrument used. Pathological reports were reviewed by the author to determine the amount of fragmentation and for tissue diagnosis. Slides of the specimens were evaluated by two blinded gynecological pathologists. The slides were analyzed for margin quality and thermal damage. A thermal damage score was assigned, evaluating the number of cells affected and the depth of damage. This scoring system, designed by the pathologists, ranged from 3 (least thermal damage) to 9 (greatest thermal damage). Of 47 CBE cases and 48 LEEP cases, 41 (87%) and 8 (17%), were single specimens X (1) = 44.6; (p < .0001). The mean number of specimens submitted to pathology per case was 1.2 (+/- 0.6) in the CBE group and 2.3 (+/- 0.9) in the LEEP group (t - 6.89;p < .001). Margins obliterated by thermal artifact included 3 of 47 (6%) in the CBE group and 16 of 48 (33%) in the LEEP group (X (1) = 9.16;p < .003). Mean thermal damage score was 4.1 (± 0.9) in the CBE group and 6.1 (± 1.8) in the LEEP group (t = 6.77; p < .001). The Cone Biopsy Excisor provides a cervical specimen that exhibits less fragmentation and less thermal damage and has margins that are less likely to be indeterminate than that provided by standard LEEP.

Risk of Sexual Abuse Among Adolescents with Cervical Dysplasia

<h3>Background</h3> Adolescents with cervical dysplasia are known to be at risk for other STDs; many have initiated intercourse at a young age. This study was undertaken to assess the risk of a history of sexual abuse/vaginal or rectal penetration in this population. <h3>Methods</h3> One hundred twenty-two adolescents (ages 12–21) were seen in a hospital-based adolescent dysplasia clinic for evaluation of abnonnal Pap smears and genital condylomata from September 1991 until September 1993. As part of an initial screening intake evaluation, demographic data and infonnation about past sexual experiences, STDs, contraceptive use, and general health was obtained. These adolescents clinic were asked if they had ever been sexually abused. In particular, the question was worded: "Have you ever been forced to have sex when you didn't want to?" <h3>Results</h3> The mean age was 16.8; 70% were African American, 45% were Medicaid/25% self pay. Thirty-two percent of adolescent dysplasia patients reported a past history of forced vaginal or rectal penile penetration. This percentage does NOT include adolescents who reported fondling. The mean age of initiation of sexual intercourse was 13.9 years. Dysplasia patients reported a mean of 3.6 sexual partners, with six girls reporting 7 or more partners. A history of STDs other than genital warts/dysplasia was reported by 66% of dysplasia patients. <h3>Conclusions</h3> Adolescent females with cervical dysplasia represent a high risk population. They are at high risk for having experienced other STDs as well as past sexual abuse. Adolescents with a history of cervical dysplasia should be questioned about past experiences of sexual abuse. Conversely, patients with a history of sexual abuse should have regular Pap smears perfonned. Sexual abuse during or prior to adolescence is potentially a risk marker/factor for sexual behaviors which put an adolescent at risk for cervical dysplasia and other STDs.

The reliability of high-risk adolescent girls' report of their sexual history

The purposes of this study were to determine the consistency in sexually active adolescent girls' self-report of sexual history and to examine their perceptions of providing sexual history information in an interview. Twenty-two adolescent girls (86% black and 14% white) were recruited from an outpatient dysplasia clinic to be interviewed 2 weeks apart. The interview consisted of questions regarding sexual history and whether they viewed their age at first intercourse as too young, too old, or appropriate. After the second interview they were asked whether there were any questions for which they thought other teenagers would be tempted not to tell the truth and any questions that were too embarrasing. Significant correlations between visits were seen for each sexual history variable. Girls described number of sexual partners and sexually transmitted disease history as questions to which adolescents might not be truthful. As part of sexual history taking, health care providers should explore with adolescent girls their perceptions of their history and address any concerns the girls have that might lead to inaccuracies or prevent the girls from obtaining appropriate anticipatory guidance.

Detecting structural changes at the molecular level with Fourier transform infrared spectroscopy. A potential tool for prescreening preinvasive lesions of the cervix.

To study cervical exfoliated cells with Fourier transform infrared spectroscopy (FTIR). Consecutive samples from 133 women attending the Dysplasia Clinic, Ottawa Civic Hospital, were collected in balanced electrolyte solution. After centrifugation, two smears were prepared for routine screening. The remainder of the pellet was frozen for FTIR spectroscopic study. In 120 samples, adequate material was available for spectroscopic study. All smears from 17 women with normal spectra were within normal limits (WNL). One hundred three spectra were abnormal. The corresponding smears were interpreted as: 41 low grade squamous intraepithelial lesions, 20 high grade squamous intraepithelial lesions, 6 atypical squamous cells of undetermined significance, 17 cases with benign cellular changes, and 19 WNL. Ten of 17 cases with benign cellular changes had characteristic spectra consistent with inflammatory changes. FTIR spectroscopy is a highly sensitive technique for detecting cervical abnormalities and a potential tool for prescreening preinvasive lesions of the cervix.

Improving compliance among women with abnormal papanicolaou smears

To determine whether a clinic-based intervention, consisting of motivational brochures and a tracking system, increases adherence to recommendations for treatment in women with abnormal Papanicolaou smears. Three pairs of clinics--two family planning clinics, two family practice clinics, and two dysplasia clinics--were randomized within pairs either to provide the intervention or to maintain usual contact procedures with women having abnormal Papanicolaou smears. Baseline adherence rates were assessed through chart review during 3 randomly selected months of the previous year. Intervention clinics received the tracking system and motivational brochures, which were sent to women on notification of their cervical abnormalities. Comparison clinics also used the tracking system but did not include the brochures when notifying women of their abnormalities. Adherence rates were assessed prospectively for approximately 100 consecutive nonpregnant women with abnormal Papanicolaou smears (inflammatory benign atypia, or cervical intraepithelial neoplasia I, II, or III) at each clinic. Within clinics, baseline adherence rates ranged from 34-69% for atypia and 33-88% for dysplasia. For dysplasia patients, the overall analysis indicated a significant increase in adherence for the intervention clinics (P = .03); however, for atypia patients, the observed difference was not statistically significant (P = .23). Extensive analyses of the data from family planning clinics indicated that women receiving the intervention were more likely to obtain follow-up treatment (odds ratio [OR] 2.6, 95% confidence interval 1.15-5.85). There was a suggestion that the intervention could have a greater effect among African-American women (OR 15.7) compared with white women (OR 1.8) (P = .09). White women, those with dysplasia, nonsmokers, and nulliparas were most likely to adhere to treatment recommendations. A motivational brochure can enhance adherence to treatment recommendations among women with abnormal Papanicolaou smears. Future studies should focus on techniques for enhancing adherence among more resistant participants.

A Study of Women Who Appear to Default from Management of an Abnormal Pap Smear

A study of nonattendance at a Dysplasia Clinic found that 20% of women who had an appointment in 1988 failed to attend the clinic during the next 18 months. Most of the nonattendance was among women who had previously been assessed at the Dysplasia Clinic. Only 6% of the nonattending women had cytological/histological evidence of CIN which remained untreated. If all women who did not default from attendance at the Dysplasia Clinic were correctly managed, then 1% of all women who have appointments made for the Dysplasia Clinic were potentially receiving inadequate management for lesions considered to have a precancerous potential. A questionnaire to the women who failed to attend these appointments identified pregnancy and seeking management elsewhere as the most commonly stated reasons for the nonattendance.

Barrier methods of contraception and cervical intraepithelial neoplasia

This North Carolina-based case-control study examined risk factors for cervical intraepithelial neoplasia (GIN). Cases were 103 women with biopsy-confirmed CIN II or III who were recruited from a referral dysplasia clinic. Controls were 258 family practice patients with normal cervical cytology. All subjects were interviewed regarding their sexual and reproductive history, Pap smear screening, active and passive cigarette exposures, and contraceptive use patterns. When compared with controls, cases were half as likely to have ever used barrier methods of contraception; the adjusted odds ratio was 0.5 (95% CI 0.2–0.9). The risk of CIN II III decreased further with increasing years of barrier method use. Recency, latency, and age at first barrier method use were all associated with a reduced risk of CIN. Men and women should carefully consider the range of benefits of barrier method use as a means to reduce their risk of unwanted pregnancies, sexually transmitted diseases, and cervical neoplasia.

Self-reported health concerns and sexual behaviors in adolescents with cervical dysplasia: A pilot study

A group of 46 women attending an adolescent dysplasia clinic were surveyed regarding the reported impact of cervical dysplasia on sexual beliefs and behaviors. The adolescents reported being concerned about their future health and having changed their sexual practices. There were no clear relationships between demographic variables or sexual attitudes and changes. The adolescents' self-reports of their behavior were not consistent; those adolescents who reported safer sex practices did not have lower rates of sexually transmitted diseases postbiopsy. The results of this study indicate the important but complex impact of sexually transmitted disease on adolescents and suggests that this impact on adolescents may be different from that on adults.

Cervical intraepithelial neoplasia III in an adolescent with bowenoid papulosis

Bowenoid papulosis (BP) is a cutaneous condition of the external genitalia seen primarily in young adults. Evidence supports an etiologic role of human papillomavirus (HPV), particularly type 16. HPV-16 is also associated with an increased risk for cervical intraepithelial neoplasia (CIN) and invasive carcinoma. A 17-year-old female, referred to the adolescent dysplasia clinic with a diagnosis of condyloma acuminatum, was presented. She had multiple smooth, shiny, brown 3- to 4-mm papules on the external genitalia. Biopsy confirmed BP. Colposcopic examination of the cervix and biopsy showed CIN III. The patient's sexual partner was examined colposcopically, and no suspicious lesions were seen. The patient underwent laser vaporization of her external genital and cervical lesions. At the time of treatment, some of the initial BP lesions had spontaneously regressed. This case highlights the need to evaluate females with BP for possible CIN, to examine sexual partners, and to use ablative therapy, as there is the potential of malignant progression in BP.

Evaluation of a nonisotopic probe for detection of Chlamydia trachomatis in endocervical specimens

A nonisotopic probe (Gen-Probe PACE; Gen-Probe, Inc., San Diego, Calif.) for detection of Chlamydia trachomatis in endocervical specimens was evaluated in 344 women attending a dysplasia clinic or an obstetrics clinic and 158 women who visited an emergency room. For each patient, the probe, a tissue cell culture, and a direct immunofluorescent-antibody test (DFA; MicroTrak; Syva Co., Palo Alto, Calif.) were used. C. trachomatis was detected in 54 specimens by at least one method. Forty-four, 44, and 37 specimens were positive by culture, probe, and DFA, respectively, and 31 were positive by all three methods. Considering culture-positive plus both probe- and DFA-positive results as the "gold standard," we determined the overall sensitivity, specificity, and positive and negative predictive values of the probe to be 80, 98, 82, and 98%, respectively. These values were 94, 98, 84, and 99%, respectively, in emergency room patients and 71, 98, 80, and 97%, respectively, in clinic patients. The sensitivities, specificities, and negative predictive values of the DFA and probe were comparable. The positive predictive values of the DFA in all patients and in emergency room and clinic patients were 97, 100, and 95%, respectively. Given the number of probe-positive results that were not confirmed by culture, we do not recommend using the Gen-Probe PACE to screen for C. trachomatis in women with a low to moderate risk for infection.

Cervical dysplasia and human papillomavirus: Evaluation in an adolescent dysplasia clinic

Thirty patients with cervical dysplasia on Pap smear were seen in a dysplasia clinic within a division of adolescent medicine. The mean age was 16.9 years. Of the abnormal Pap smears, 47% were obtained during routine visits. The mean age for first intercourse was 14.6 (range 12–17 years), and mean number of sexual partners 3.3 (range 1–6). One or more sexually transmitted diseases were reported in 67%, with Chlamydia cervicitis in 53%. Colposcopic examination of the vulva, vagina, and cervix was undertaken, followed by cervical biopsies and endocervical curettage. Biopsy results included mild or moderate dysplasia (43%); condyloma without dysplasia (37%); and no evidence of cervical condyloma or dysplasia (20%). Colposcopy revealed vulvar and/or vaginal condyloma in 83%. In evaluating patients with abnormal Pap smears, it is difficult to distinguish patients with dysplasia on biopsy from those with only condyloma on the basis of demographic data. Adolescents are developing higher rates of cervical dysplasia and, with abnormal cytology, require careful colposcopy and biopsy.

The value of an adolescent dysplasia clinic

Patients with cervical dysplasia on Pap smear were referred from a division of adolescent medicine to a newly established adolescent dysplasia clinic. Ages ranged from 13 to 22 with a mean of 17.7 years; 79% were black and 21% were white. Of the abnormal Pap smears, 43% were obtained during routine visits and the remainder, prompted by genital symptoms. Compliance with the initial referral to the adolescent dysplasia clinic was facilitated by the location of the specialty clinic in the same setting as the general pediatrics adolescent clinic. Of the first 30 patients evaluated by colposcopy, all ultimately returned for treatment. Noncompliance was 20–23%, as measured by failure to keep an initially scheduled appointment for colposcopy, or a subsequent appointment for cryotherapy, or topical treatment of associated vulvar and vaginal condyloma. Sexually active adolescents require frequent Pap smears and colposcopy as indicated. A dysplasia service within a division of adolescent medicine can provide the milieu for optimal management.

Mutagenic Mucus in the Cervix of Smokers&lt;xref ref-type="fn" rid="FN2"&gt;2&lt;/xref&gt;

A pilot study was conducted to determine whether any relationship exists between mutagenicity of a women's uterine cervical mucus and her current smoking status. Cervical fluids obtained from 78 premenopausal women seen between July 1983 and March 1984 at the University of California, San Francisco Dysplasia (and diethylstilbestrol) Clinic or in a private practice were tested for mutagenicity by means of the Ames-Salmonella microsomal test. Of 36 current smokers, 14 (39%) had positive tests as compared to 5 of 42 nonsmokers (12%). The odds ratio (OR) estimate was 4.7 with 95% confidence limits (CL) of 1.6-14.2. Secretions from 14 of 32 (44%) women who had smoked during the day of the sample collection--within the previous 7 hours--were positive on the laboratory test, whereas none of the 4 women was positive who had smoked 8 hours or more before the specimens were obtained. Fluids from women with dysplasia or carcinoma in situ were more likely to be mutagenic than were those from other women, although this finding may be due to chance (OR = 2.0 with 95% CL of .70-5.9). This relationship between smoking and mutagenic cervical fluids offers evidence that might help to explain the association between cervical cancer and cigarette smoking noted in previous epidemiologic studies.

The Emotional Impact of Abnormal Pap Smears on Patients Referred for Colposcopy

There has been no investigation of the emotional impact of abnormal Pap smears, although anecdotal reports suggest the majority of women have strong emotional reactions to the event and, in some cases, refuse subsequent diagnosis and treatment on the basis of their concerns. In order to ensure patient compliance, it is necessary to identify and deal with the difficulties these patients may experience. Fifty women referred to the Ottawa Civic Hospital Dysplasia Clinic for colposcopically directed biopsies following abnormal Pap smears were asked to describe their concerns about abnormal Paps, to rate the intensity of these concerns on a 10-point scale, and to suggest interventions which would have helped them to be less apprehensive. Four areas of patient concern emerged: fear of cancer (reported by 100% of the patients), fear of loss of reproductive/sexual function (68%), fear of medical procedures (65%), and a fear described by many patients as "bodily betrayal" (62%). On the basis of these findings, suggestions are made for improving the emotional management of CIN patients.